1. Wounds and the Healing Process
Chapter 12
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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.
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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
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Types of Wound Healing
Types of wound healing. A, Primary intention. B, Secondary intention. C, Tertiary intention.
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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.
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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 migration.
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.
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Wound Healing
Repair
Granulation phase
Fibroblasts migrate to site and secrete collagen.
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.
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8. 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). B.
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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.
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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.
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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.
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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.
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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 (see Table 12-7).
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.
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14. Complications of Healing
The shape and location of the wound determine how well the wound will heal.
Certain factors can interfere with wound healing and lead to complications.
{See Table 12-8.}
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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.
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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.
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17. Nursing Implementation
Wound management and type of dressing depends on
Type, extent, and character of wound
Phase of healing
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.
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18. Nursing Implementation
Purposes of wound management
Cleaning a wound
Treating infection
Protecting clean wound from trauma
The purposes of wound management include (1) cleaning a wound to remove any dirt and debris from the wound bed, (2) treating infection to prepare the wound for healing, and (3) protecting a clean wound from trauma so it can heal normally.
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19. Nursing Implementation
Primary intention wounds may be covered with dry dressing.
Drains may be inserted.
Topical antimicrobials/antibacterials should be used with caution.
For wounds that heal by primary intention, it is common to cover the incision with a dry, sterile dressing that is removed as soon as the drainage stops or in 2 to 3 days.
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).
Topical antimicrobials and antibacterials (e.g., povidone-iodine [Betadine], Dakin’s solution [sodium hypochlorite], hydrogen peroxide [H2O2], and chlorhexidine [Hibiclens]) should be used with caution in wound care because they can damage the new epithelium of healing tissue and delay healing.
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20. Jackson-Pratt Drainage Device
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21. 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 12-7 provides a method of dressing selection based on the wound tissue color.
Examples of types of wound dressings are presented in Table
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22. Nursing Implementation
Red Wounds
Protect the wound
Gentle cleaning, if needed
Red Wounds
Clean wounds that are granulating and re-epithelializing should be kept slightly moist and protected from further trauma until they heal naturally. Do not let a wound dry out. Dryness is an enemy of wound healing. “Airing out” a wound is a great mistake. Wounds need a moist environment to heal.
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.
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23. Nursing Implementation
Yellow Wounds
Dressing that absorbs exudate and cleanses the wound surface
Hydrocolloid dressings
Black Wounds
Debridement of nonviable, eschar tissue
Yellow Wounds
The amount 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.
Black Wounds
The immediate treatment of a black wound is debridement of the nonviable, eschar tissue. The debridement method used depends on the amount of debris and the condition of the wound tissue.
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24. Nursing Implementation
Negative-pressure wound therapy (vacuum-assisted wound closure)
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.
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25. Negative-Pressure Wound Therapy
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26. Nursing Implementation
Hyperbaric O2 therapy (HBOT)
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.
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27. Nursing Implementation
Nutritional Therapy
Diet high in protein, carbohydrates, and vitamins with moderate fat
Becaplermin (Regranex), a recombinant human platelet-derived growth factor gel, actively stimulates wound healing and 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.
Vitamin C is needed for capillary synthesis and collagen production by fibroblasts.
The B-complex vitamins are necessary as coenzymes for many metabolic reactions.
Vitamin A is also needed in healing because it aids in the process of epithelialization. It increases collagen synthesis and tensile strength of the healing wound.
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28. Nursing Implementation
Infection prevention
Do not touch recently injured area.
Keep environment free from possibly contaminated items.
Antibiotics may be given prophylactically.
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29. 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.
Be careful not to focus on the wound to the extent that the patient is not treated as a total person.
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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.
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