Wound Healing

Types of healing

There are 2 types of healing: Primary intention, where the tissue surfaces have been closed and there is minimal or no issue loss There is also delayed primary intention healing, aka tertiary healing. In this case, wounds are left open for 3-5 days to allow edema or infection to resolve or to permit exudate to drain. The wound is then properly closed.  Secondary intention, where the wound is extensive and the edges cannot, or should not, be closed. There is extensive tissue loss. It differs from primary in 3 ways: Repair time is longer Scarring is greater Susceptibility to infection is greater

Phases of Wound Healing

There are 3 phases of wound healing: Inflammatory phase. It starts after injury and lasts 3-6 days. Vascular and cellular responses intended to remove any foreign substances and dead and dying tissue occurs. There are 2 major processes that occur during this phase: Hemostasis. Vasoconstriction of larger blood vessels occur, the injured blood vessels retract, and fibrin is deposited. Blood clots form in the area. Blood clots provide a matrix of fibrin that acts as framework for cell repair. A scab will form. This scab aids in hemostasis and inhibits contamination of the wound.  Epithelial cells migrate into the an serve as a barrier between the body and the environment by preventing the entry of microorganisms.  Phagocytosis. Neutrophils move into the interstital space, and are replaced by macrophages. The macrophages engulf microorganisms and cellular debris and secrete an angiogenesis factor. The angiogenesis factor stimulates the formation of epithelial buds at end of injured blood vessels.  Proliferative phase. Extends from day 3 or 4  to about day 21 post injury. Fibroblasts synthesize collagen, which adds tensile strength to the wound. Capillaries grow across the wound, fibroblasts move into the wound and deposit fibrin. Fragile granulation tissue forms from the growing capillary network. Epithelial cells migrate over the granulation tissue and fill the wound.  Alternatively, if the wound doesn't close by epithelialization, the area becomes covered with an eschar. Initially, wounds healing by secondary intention will secrete blood tinged drainage. If they are not covered by epithelial cells, they will be covered with a thick, gray, fibrinous tissue that becomes dense scar tissue.  Maturation phase. Starts at day 21 and can extend to 1 or 2 years post injury. Fibroblasts continue to synthesize collagen, collagen fibers reorganize, and the wound is remodeled and contracted. 

Preventing Impaired Wound Healing

Nutrition: Patient requires a diet rich in protein, carbohydrates, lipids, vitamins A and C, and minerals such as iron, zinc, and copper.  Malnourished patients should improve nutritional status before surgery. Obese clients are at risk for infection and slower healing r/t adipose tissue having a minimal blood supply. Lifestyle: Exercise: Patients who exercise regularly are likely to heal more quickly due to blood bringing oxygen and nourishment to wound.  Smoking: Risk for delayed healing r/t arteriole constriction and reduced amount of functional hemoglobin. Medications: Anti-inflammatories and anti-neoplastic drugs may interfere w/healing Prolonged antibiotic use can cause resistance, increasing risk for wound infection,

Clinical manifestations of impaired healing

Exudate: Material that has escaped from blood vessels during the inflammatory process and deposited into tissue or on tissue surface. There are 3 types and one... Subtype, I guess: Serous: Accompanies mild inflammation and presents clear or straw colored. Thin, watery, with few cells. Purulent: Thicker, consists of large quantity of cells and necrotic debris. Opaque or milky, but they can vary in color from blue to green to yellow. Depends on organism. This is commonly known as pus. The formation of this exudate is called suppuration. Sanguineous (hemorrhagic): Large amounts of RBCs, indicating severe capillary damage. If bright, it indicates fresh bleeding; if dark, it indicates older bleeding. More frequently seen in open wounds. Mixed types: This is the subtype. Serosanguineous: Consists of clear and blood tinged drainage. Commonly seen in surgical incisions. Purosanguineous: Consists of pus and blood. Often seen in a new wound that's infected. 

Lifespan & Culture Considerations

Older adults: More likely to have chronic diseases that hinder healing. Increased risk of nutritional deficiencies. May reduce numbers of RBCs and leukocytes, impeding delivery of oxygen and inflammatory response.  Normal cellular and molecular change Delayed inflamamtory response, fewer macrophages, decreased phagocytic activity.  Slowed cell renewal and collagen synthesis Collagen tissue becomes less flexable and more susceptible to damage. Healing process is slowed, but quality of healing is the same.  Chronic illnesses: Reduced liver function, which decreases synthesis of clotting factors. Diabetes- impair oxygen delivery. Chronic lung disease- impair oxygen delivery. Cardiovascular disease- impair oxygen delivery. Atherosclerosis- impairs blood flow to wounds. Atrophy of capillaries- impairs blood flow to wounds. 

Collaboration

Should focus on promoting health and preventing infection. Teach how to recognize signs of infection and other signs of impaired healing Contact provider immediately if symptoms develop. If healing is impaired, focus on addressing anything life threatening first. Then shift back to the aforementioned goal.  Pain management may be needed. Surgical debridement: Wound is filled with salene solution, topical anesthetic is applied. Forceps grip necrotic tissue, which is then cut away with a scalpel or laser. The presence of slough, eschar, or necrotic tissue indicates ineffective healing. Appropriate for wounds with a lot of infected or necrotic tissue.  May be used for wounds that abscess Escharotomy: Surgical removal of eschar. Incisions are made along the damaged area to release pressure; the tissue swelling causes incisions to spread and exposes underlying tissues and structures.    Treats full-thickness wounds that encircle or nearly encircle a body part and have formed an eschar.  These wounds are often caused by burns. Must be done b/c eschar is inelastic, which restricts blood flow and extracellular fluids and can lead to fluid accumulation and increased pressure inferior to the wound. This pressure can cause compartmental tissue damage.  Client is usually sedated during procedure. Medications: Prophylactic antibiotic treatment, antibiotic ointment, and analgesics for pain.  Antibiotics, if an infection is present.  Growth factors nay be given to promote healing if healing is impaired.  Usually topical gels applied directly to wound.  Nonpharmacological treatment: Normal healing: Infection prevention measures. Compression bandages and hoisery Diets high in protein, carbohydrates, and vitamins, Impaired healing: Vaccum assisted closure of wound. Hyperbaric oxygen therapy (improves oxygenation in nonhealing wounds) Introduction of stem cells into the wound, Skin or tissue grafts. Biosurgery with sterile maggots. 

Nursing process

Goals: Promotion of healing Prevention of infection and other complications Requires care and aseptic procedures during hospitalization. Teaching about ongoing wound care at home.  Client should know how to clean, dress, and promote healing. Client should also know signs of complication.  Assessment for untreated wounds: Location and extent of tissue damage; measurement of length, width, and depth of wound. Inspection for bleeding. Inspection for foreign bodies. Determining last tetanus shot (if wound is contaminated)  Assessing associated features (i.e.: fractures, internal bleeding) Assessment for treated wounds: Observing appearance, size, and draining. Observing for swelling, pain, and status of drains and tubes. Estimating amount of drainage: How much of the dressing is saturated? When wounds are undermined, gently expose undermined area w/thin, flexible probe. Once end of tract is reached, gently raise probe so bulge created by end can be seen and its length can be measured. Do not use cotton tipped swab. It can leave fibers in wound.  Sinus tracts are often caused by infection and have significant damage. Treatment includes antibiotics, irrigation surgical incision to open and drain it, and vacuum therapy.  Diagnosis: Be aware that if impairment is severe, the client is immunosuppressed, or the wound was caused by trauma, the risk for infection is greater. Also be aware that Impaired skin integrity is generally r/t wounds that do not penetrate the dermis. Impaired tissue integrity applies to wounds that extend subcutaneously.  Planning: Goal for impaired tissue integrity is to maintain skin integrity and avoid potential related risks. Implementation: 4 major areas in which the nurse can help: Maintaining moist wound healing Dressing and frequency of change should support moist wound bed conditions. Beds that are too dry or disturbed often fail to heal,  Providing sufficient nutrition and hydration. Have client take in at least 2,500 mL a  day unless contraindicated.  Ensure client recieves vitamins C, A, B, and B5, as well as the mineral zinc. A dietician consult may be helpful. Preventing infection: 2 main aspects Preventing microorganisms from entering wound. Prevenitng spread of bloodborn pathogens between client and others. Proper positioning.  Position client to keep pressure off wound.  Change positions without shear or friction damage. Assist the client in being as mobile as possible. Activity enhances circulation.  If client is immobile, ROM exercises and a turning schedule should be implemented.  Evaluation Regular evaluation is important when client is at risk for impaired tissue integrity.