Focus on Wounds and the Healing Process (Relates to Chapter 13, “Inflammation and Wound Healing,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Wound Healing Regeneration Replacement of lost cells and tissues with cells of the same type The final phase of the inflammatory response is healing. Healing includes the two major components of regeneration and repair. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Wound Healing Regeneration Ability to regenerate depends on cell type. Constantly dividing cells that rapidly regenerate Skin, bone marrow, lymphoid organs, as well as mucous membrane cells of the urinary, reproductive, and GI tracts Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Wound Healing Regeneration Replacement of lost cells and tissues with cells of the same type Stable cells such as liver, bone, kidney, and pancreas regenerate in response to injury. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Wound Healing Regeneration Permanent cells such as neurons and skeletal and cardiac muscle do not divide. Neurons are replaced by glial cells or stem cells. Skeletal and cardiac muscle will be repaired with scar tissue. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Wound Healing Repair Healing as a result of lost cells being replaced with connective tissue More common than regeneration More complex than regeneration Occurs by primary, secondary, or tertiary intention Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Types of Wound Healing Types of wound healing. A, Primary intention. B, Secondary intention. C, Tertiary intention. Fig. 13-4. Types of wound healing. A, Primary intention. B, Secondary intention. C, Tertiary intention. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Wound Healing Repair Primary intention Includes three phases Initial phase Granulation phase Maturation phase and scar contraction Primary intention healing takes place when wound margins are neatly approximated, such as in a surgical incision or a paper cut. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Wound Healing Repair Initial phase Lasts 3 to 5 days Edges of incision are aligned. Blood fills the incision area, which forms matrix for WBC formation. Acute inflammatory reaction occurs. The area of injury is composed of fibrin clots, erythrocytes, neutrophils (both dead and dying), and other debris. Macrophages ingest and digest cellular debris, fibrin fragments, and RBCs. Extracellular enzymes derived from macrophages and neutrophils help digest fibrin. As the wound debris is removed, the fibrin clot serves as a meshwork for future capillary growth and migration of epithelial cells. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Wound Healing Repair Granulation phase Lasts 5 days to 3 weeks Fibroblasts migrate to site. Wound is pink and vascular. Surface epithelium begins to regenerate. {See next slide of figure} Although wound is pink and vascular, the wound is friable, at risk for dehiscence, and resistant to infection. In a superficial wound, re-epithelialization may take 3 to 5 days. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Before and After Granulating A, Wound clean but not granulating (note lack of red cobblestone appearance), suggesting heavy bacterial contamination or other impediments to wound healing. B, Same wound granulating after 1 week of topical antibiotic use (note healthy red cobblestone appearance). Fig. 13-5. A, Wound clean but not granulating (note lack of red cobblestone appearance), suggesting heavy bacterial contamination or other impediments to wound healing. B, Same wound granulating after 1 week of topical antibiotic use (note healthy red cobblestone appearance). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Wound Healing Repair Maturation phase and scar contraction Begins 7 days after injury and continues for several months/years Fibroblasts disappear as wound becomes stronger. Mature scar forms. This is the reason abdominal surgery discharge instructions limit lifting for up to 6 weeks. Active movement of the myofibroblasts causes contraction of the healing area, helping to close the defect and bring the skin edges closer together. The scar may be more painful at this phase than in the granulation phase. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Wound Healing Repair Secondary intention Wounds that occur from trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss. Edges cannot be approximated. Results in more debris, cells, and exudate The inflammatory reaction may be greater than in primary healing. This results in more debris, cells, and exudate. The debris may have to be cleaned away (debrided) before healing can take place. The process of healing by secondary intention is essentially the same as healing by primary intention. The major differences are the greater defect and the gaping wound edges. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Wound Healing Repair Tertiary intention Delayed primary intention due to delayed suturing of the wound Occurs when a contaminated wound is left open and sutured closed after the infection is controlled It also occurs when a primary wound becomes infected, is opened, is allowed to granulate, and is then sutured. Tertiary intention usually results in a larger and deeper scar than results from primary or secondary intention. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Wound Classification Classified by Cause Surgical or nonsurgical Acute or chronic Depth of tissue affected Superficial, partial thickness, full thickness A superficial wound involves only the epidermis. Partial-thickness wounds extend into the dermis. Full-thickness wounds have the deepest layer of tissue destruction because they involve the subcutaneous tissue and sometimes even extend into the fascia and underlying structures such as the muscle, tendon, or bone. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Wound Classification Classified by Color Red Yellow Black May have two or more colors The red-yellow-black classification can be applied to any wound allowed to heal by secondary intention, including surgically induced wounds left to heal without skin closure because of a risk for infection. A wound may have two or three colors at the same time. In this situation, the wound is classified according to the least-desirable color present. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Delay of Healing Nutritional deficiencies Inadequate blood supply Corticosteroid drugs Infection Smoking {See Table 13-8} Nutritional deficiencies may include vitamin C, protein, and zinc. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Delay of Healing Mechanical friction on wound Advanced age Obesity Diabetes mellitus Poor general health Anemia {See Table 13-8} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Complications of Healing Adhesions Contractures Dehiscence Evisceration Excess granulation tissue Fistula formation {See Table 13-9} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Complications of Healing Infection Hemorrhage Hypertrophic scars Keloid formation {See Table 13-9} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Assessment Assess on admission and on a regular basis. Identify factors that may delay healing. Record the consistency, color, and odor of any drainage, and report if abnormal for the situation. Staphylococcus and Pseudomonas species are common organisms that cause purulent, draining wounds. {See next slide for wound measurement figure} If a wound fails to heal in a timely manner, assess and identify factors that may delay healing. The patient should be referred to a health care provider who specializes in wound management. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Wound Measurement Wound measurements are made in centimeters. The first measurement is oriented from head to toe, the second is from side to side, and the third is the depth (if any). If any tunneling (when cotton-tipped applicator is placed in wound, there is movement) or undermining (when cotton-tipped applicator is placed in wound, there is a “lip”) is noted around the wound, this is charted with respect to a clock, with 12 o’clock being toward the patient’s head. This wound would be charted as a full-thickness, red wound, 7 cm x 5 cm x 3 cm, with a 3-cm tunnel at 7 o’clock and a 2-cm undermining from 3 o’clock to 5 o’clock. Fig. 13-9. Wound measurements are made in centimeters. The first measurement is oriented from head to toe, the second is from side to side, and the third is the depth (if any). If there is any tunneling (when cotton-tipped applicator is placed in wound, there is movement) or undermining (when cotton-tipped applicator is placed in wound, there is a “lip” around the wound) this is charted in respect to a clock with 12 o’clock being toward the patient’s head. This wound would be charted as a full-thickness, red wound, 7 cm × 5 cm × 3-cm, with a 3-cm tunnel at 7 o’clock and 2 cm undermining from 3 o’clock to 5 o’clock. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Diagnoses Impaired skin integrity Impaired tissue integrity Risk for infection Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Implementation Care varies depending on Causative agent Degree of injury Patient’s condition Superficial skin injuries may only need cleansing. Adhesive strips or tissue adhesives may be used instead of sutures. The treatment plan can include covering these wounds with a film dressing to provide a moist healing environment and wound protection from trauma. Deeper skin wounds can be closed by suturing the edges together. If the wound is contaminated, it must be converted into a clean wound before healing can occur normally. Debridement of a wound that has multiple fragments or devitalized tissue may be necessary. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Implementation Purposes of wound management Cleaning a wound Treating infection Protecting clean wound from trauma Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Implementation Sutures/fibrin sealant help closure. Primary intention wounds may be covered with dry dressing. Drains may be inserted. Topical antimicrobials/antibacterials should be used with caution. Most commonly, sutures are used to close wounds because suture material provides the mechanical support necessary to sustain closure. In contrast, fibrin sealant is a biologic tissue adhesive that can function as a useful adjunct to sutures. Example of drain: The Jackson-Pratt drainage device is a suction drainage device consisting of a flexible plastic bulb connected to an internal plastic drainage tube (see next slide for figure). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Jackson-Pratt Drainage Device Fig. 13-10. Jackson-Pratt drainage device. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Implementation Secondary intention wound care depends on etiology and type of tissue in the wound. The red-yellow-black concept of wound care presented in Table 13-7 provides a method of dressing selection based on the wound tissue color. Examples of types of wound dressings are presented in Table 13-10. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Implementation Red Wounds Protect the wound Gentle cleaning, if needed A dressing material that keeps the wound surface clean and slightly moist is optimal to promote epithelialization. Transparent film or adhesive semipermeable dressings (e.g., OpSite, Tegaderm) are occlusive dressings that are permeable to oxygen. The wound then is usually covered with a sterile dressing. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Implementation Yellow wounds Dressing that absorbs exudate and cleanses the wound surface Hydrocolloid dressings Black Wounds Debridement of nonviable, eschar tissue Yellow Wounds After these preparations are saturated with exudate, they should be removed by washing with sterile saline or water. The quantities of wound secretions determine the number of dressing changes. Hydrocolloid dressings (i.e., DuoDerm) are designed to be left in place for up to 7 days, or until leakage occurs around the dressing. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Implementation Negative-pressure wound therapy Suction removes drainage and speeds healing. Monitor serum protein levels, F&E balance, and coagulation studies. Wound types suitable for this therapy include acute or traumatic wounds, surgical wounds that have dehisced, pressure ulcers, and chronic ulcers. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Implementation Hyperbaric O2 Delivery of O2 at increased atmospheric pressure Allows O2 to diffuse into serum Last 90 to 120 minutes, with 10 to 60 treatments It can be given systemically with the patient placed in an enclosed chamber (or the injured limb), where 100% O2 is administered at 1.5 to 3 times the normal atmospheric pressure. Elevated O2 levels stimulate angiogenesis, kill anaerobic bacteria, and increase the killing power of WBCs and certain antibiotics (e.g., fluoroquinolones, aminoglycosides). Hyperbaric O2 therapy accelerates granulation tissue formation and wound healing. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Implementation Drug therapy Becaplermin (Regranex) Nutritional therapy Diet high in protein, carbohydrates, and vitamins with moderate fat Becaplermin should be used only when the wound is free of devitalized tissue and infection. It should not be used if cancer is suspected in the wound. Individuals at risk for wound-healing problems are those with malabsorption problems (e.g., Crohn’s disease, GI surgery, liver disease), deficient intake or high energy demands (e.g., malignancy, major trauma or surgery, sepsis, fever), and diabetes. Vitamins needed include C, B-complex, and A. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Implementation Infection prevention Do not touch recently injured area. Keep environment free from possibly contaminated items. Antibiotics may be given prophylactically. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Implementation Infection control Culture should be done. Concurrent swab specimens obtained from Wound exudate Z-technique Levine’s technique The culture should be taken before the first dose of antibiotic is given. Cultures can be obtained by needle aspiration, tissue culture, or swab technique. The Z-technique involves rotating a culture swab over the cleansed wound bed surface in a 10-point Z-track fashion. Levine’s technique involves rotating a culture swab over a cleansed 1-cm2 area near the center of the wound, using sufficient pressure to extract wound fluid from deep tissue layers. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Implementation Psychologic implications Fear of scar or disfigurement Drainage or odor concerns Be aware of your facial expressions while changing dressing. When you are changing a dressing, inappropriate facial expressions can alert the patient to problems with the wound or your ability to care for it. Wrinkling your nose may convey disgust to the patient. You should also be careful not to focus on the wound to the extent that the patient is not treated as a total person. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Patient Teaching Teach signs and symptoms of infection. Note changes in wound color or amount of drainage. Provide medication teaching. Because patients are being discharged earlier after surgery and many have surgery as outpatients, it is important that the patient, the family, or both know how to care for the wound and perform dressing changes. Wound healing may not be complete for 4 to 6 weeks or longer. Drug-specific side effects and adverse effects, as well as methods to prevent side effects, should be reviewed with the patient. Awareness of the necessity to continue the drugs (i.e., antibiotics) for the specified time is an important point to teach the patient. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Audience Response Question Ibuprofen (Advil, Motrin) is prescribed for a patient after casting for a simple fracture of the radius. The nurse instructs the patient to take the drug every 6 hours around the clock for the first 24 to 48 hours to 1. Stimulate the synthesis of new bone tissue. 2. Relieve pain to promote uninterrupted sleep. 3. Prevent a cycle of fever, chills, and sweating. 4. Prevent swelling of soft tissue at the fracture site. Answer: 4 Rationale: The primary purpose for the administration of ibuprofen is to decrease inflammation; the medication is a nonsteroidal antiinflammatory medication. Ibuprofen also has analgesic properties. The medication’s action is inhibition of prostaglandin synthesis. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Audience Response Question A basic principle of wound management for all open wounds is to 1. Protect new granulation and epithelial tissue. 2. Apply topic antimicrobials to prevent wound infection. 3. Remove wound exudate with frequent dressing changes. 4. Use occlusive dressings to prevent wound contamination. Answer: 1 Rationale: Wounds that are clean and granulating and re-epithelializing should be kept slightly moist and protected from further trauma. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 40

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study 71-year-old woman had open abdominal surgery. The incision was not closed. Wound needs to close by secondary intention. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study She is overweight and diabetic. Her wound has become infected. She is still in the hospital but wants to go home. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Discussion Questions What are her risk factors for wound infections? What is her priority of care? What teaching should be done with her before she goes home? Obesity, diabetes, age To facilitate wound healing with good wound care, activity and ambulation to increase circulation, and good nutrition Proper wound care and diet Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.