Focus on Wounds and the Healing Process (Relates to Chapter 13, “Inflammation and Wound...

Focus on Wounds and Focus on Wounds and thethe

Healing ProcessHealing Process

Focus on Wounds and Focus on Wounds and thethe

Healing ProcessHealing Process(Relates to Chapter 13,

“Inflammation and Wound Healing,” in the textbook)

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

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Wound HealingWound HealingWound HealingWound Healing

•Regeneration Replacement of lost cells and

tissues with cells of the same type


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•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


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•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.


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•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.


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•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 HealingTypes of Wound HealingTypes of Wound HealingTypes of Wound Healing


Fig. 13-4. Types of wound healing. A, Primary intention. B, Secondary intention. C, Tertiary intention.

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•Repair Primary intention

• Includes three phases• Initial phase•Granulation phase•Maturation phase and scar

contraction


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•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.


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•Repair Granulation phase

• Lasts 5 days to 3 weeks• Fibroblasts migrate to site.• Wound is pink and vascular.• Surface epithelium begins to regenerate.


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Before and After Before and After GranulatingGranulating

Before and After Before and After GranulatingGranulating


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).

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•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.


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•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


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•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


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Wound ClassificationWound ClassificationWound ClassificationWound Classification

•Classified by Cause

• Surgical or nonsurgical• Acute or chronic

Depth of tissue affected• Superficial, partial thickness, full thickness


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Wound ClassificationWound ClassificationWound ClassificationWound Classification

•Classified by Color

• Red• Yellow• Black• May have two or more colors


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Delay of HealingDelay of HealingDelay of HealingDelay of Healing

•Nutritional deficiencies• Inadequate blood supply•Corticosteroid drugs• Infection •Smoking


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Delay of HealingDelay of HealingDelay of HealingDelay of Healing

•Mechanical friction on wound

•Advanced age•Obesity •Diabetes mellitus•Poor general health •Anemia


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Complications of HealingComplications of HealingComplications of HealingComplications of Healing

•Adhesions•Contractures•Dehiscence•Evisceration•Excess granulation tissue•Fistula formation


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Complications of Healing Complications of Healing Complications of Healing Complications of Healing

• Infection•Hemorrhage•Hypertrophic scars•Keloid formation


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Nursing AssessmentNursing AssessmentNursing AssessmentNursing Assessment

•Assess on admission and on a regular basis.

• Identify factors that may delay healing.


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Wound MeasurementWound MeasurementWound MeasurementWound Measurement


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.

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Nursing DiagnosesNursing DiagnosesNursing DiagnosesNursing Diagnoses

• Impaired skin integrity• Impaired tissue integrity•Risk for infection


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Nursing Implementation Nursing Implementation Nursing Implementation Nursing Implementation

•Care varies depending on Causative agent Degree of injury Patient’s condition


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Nursing ImplementationNursing ImplementationNursing ImplementationNursing Implementation

•Purposes of wound management Cleaning a wound Treating infection Protecting clean wound from

trauma


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•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.


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Jackson-Pratt Drainage Jackson-Pratt Drainage DeviceDevice

Jackson-Pratt Drainage Jackson-Pratt Drainage DeviceDevice


Fig. 13-10. Jackson-Pratt drainage device.

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•Secondary intention wound care depends on etiology and type of tissue in the wound.


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•Red Wounds Protect the wound Gentle cleaning, if needed


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•Yellow wounds Dressing that absorbs

exudate and cleanses the wound surface

Hydrocolloid dressings•Black Wounds

Debridement of nonviable, eschar tissue


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•Negative-pressure wound therapy Suction removes drainage

and speeds healing. Monitor serum protein levels,

F&E balance, and coagulation studies.


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•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


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•Drug therapy Becaplermin (Regranex)

•Nutritional therapy Diet high in protein,

carbohydrates, and vitamins with moderate fat


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• Infection prevention Do not touch recently injured

area. Keep environment free from

possibly contaminated items. Antibiotics may be given

prophylactically.


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• Infection control Culture should be done. Concurrent swab specimens

obtained from• Wound exudate• Z-technique• Levine’s technique


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•Psychologic implications Fear of scar or disfigurement Drainage or odor concerns Be aware of your facial

expressions while changing dressing.


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Patient TeachingPatient TeachingPatient TeachingPatient Teaching

•Teach signs and symptoms of infection.

•Note changes in wound color or amount of drainage.

•Provide medication teaching.


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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 to1. 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.

Audience Response Question


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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.

Audience Response Question


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•71-year-old woman had open abdominal surgery.

•The incision was not closed.

•Wound needs to close by secondary intention.


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•She is overweight and diabetic.

•Her wound has become infected.

•She is still in the hospital but wants to go home.


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Discussion QuestionsDiscussion QuestionsDiscussion QuestionsDiscussion Questions

1. What are her risk factors for wound infections?

2. What is her priority of care?

3. What teaching should be done with her before she goes home?


Focus on Wounds and the Healing Process (Relates to Chapter 13, “Inflammation and Wound...

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