A wound is a disruption in the continuity of cells—anything that causes cells that would normally be connected to become separated. Wound healing is the restoration of that continuity. Several effects may result with the occurrence of a wound: immediate loss of all or part of organ functioning, sympathetic stress response, hemorrhage and blood clotting, bacterial contamination, and death of cells. The most important factor in minimizing these effects and promoting successful care is careful asepsis.
A biological process, wound healing begins with trauma and ends with scar formation. There are two types of tissue injury: full and partial thickness. Partial thickness injury is limited to the epidermis and superficial dermis with no damage to the dermal blood vessels. Healing occurs by regeneration of epithelial tissue. Full thickness injury involves loss of the dermis and extends to deeper tissue layers and disrupts dermal blood vessels. Wound healing involves the synthesis of several types of tissue and scar formation.
The three phases of repair are lag, proliferative, and remodeling. Directly after injury, hemostasis is achieved with clot formation. The fibrin clot acts like a highway for the migration of cells into the wound site. Within the first four hours of injury, neutrophils begin to appear. These inflammatory cells kill microbes, and prevent the colonization of the wound. Next the monocyte, or macrophage, appears. Functions of these cells include the killing of microbes, the breakdown of wound debris, and the secretion of cytokines that initiate the proliferative phase of repair. Synthetic cells, or fibroblasts, proliferate and synthesize new connective tissue, replacing the transitional fibrin matrix. At this time, an efficient nutrient supply develops through the arborization (terminal branching) of adjacent blood vessels. This ingrowth of new blood vessels is called angiogenesis. This new very vascularized connective tissue is referred to as granulation tissue.
The first phase of repair is called the lag or inflammatory phase. The inflammatory response is dependent upon the depth and volume of tissue loss from the injury. Characteristics of the lag phase include acute inflammation and the initial appearance and infiltration of neutrophils. Neutrophils protect the host from microorganisms and infection. If inflammation is delayed or stopped, the wound becomes susceptible to infection and closure is delayed.
The proliferative phase is the second phase of repair and is anabolic in nature. The lag and remodeling phase are both catabolic processes. The proliferative phase generates granulation tissue. In this process, acute inflammation releases cytokines, promoting fibroblast infiltration of the wound site, then creating a high density of cells. Collagen is the major connective tissue protein produced and released by fibroblasts. The connective tissue physically supports the new blood vessels that form and endothelial cells promote ingrowth of new vessels. These new blood vessels are necessary to meet the nutritional needs of the wound healing process. The mark of wound closure is when a new epidermal cover seals the defect. The process of wound healing continues under-neath the new surface. This is the remodeling or maturation phase and is the third phase in healing.
The first principle of wound care is the removal of non-viable tissue including necrotic (dead) tissue, slough, foreign debris, and residual material from dressings. Removal of non-viable tissue is referred to as debridement; removal of foreign matter is referred to as cleansing. Chronic wounds are colonized with bacteria, but not necessarily infected. A wound is colonized when a limited number of bacteria are present in the wound and are of no consequence in the healing process. A wound is infected when the bacterial burden overwhelms the immune response of the host and bacteria grow unchecked. Clinical signs of infection are redness of the skin around the wound, purulent (pus-containing) drainage, foul odor, and edema.
The second principle is providing a moist environment. This has been shown to promote re-epitheliazation and healing. Exposing wounds to air dries the surface and may impede the healing process. Gauze dressings provide a moist environment as long as they are kept moist
Anabolic—Metabolic processes characterized by the conversion of simple substances into more complex compounds.
Catabolic—Metabolic processes characterized by the release of energy through the conversion of complex compounds into simple substances.
Dermis—The thick layer of skin below the epidermis.
Epidermis—The outermost layer of the skin.
Exudate—Fluid, cells, or other substances that are slowly discharged by tissue, especially due to injury or inflammation.
Fibrin—The fibrous protein of blood clots.
Fibroblast—An undifferentiated connective tissue cell that is capable of forming collagen fibers.
Neutrophil—A type of white blood cell.
Scar—Scar tissue is the fibrous tissue that replaces normal tissue destroyed by injury or disease.
in the wound. These are referred to as wet to dry dressings. Generally a saline soaked gauze dressing is loosely placed into the wound and covered with a dry gauze dressing to prevent drying and contamination. It also supports autolytic debridement (the body's own capacity to lyse and dissolve necrotic tissue), absorbs exudate, and traps bacteria in the gauze, which are removed when the dressing is changed.
Preventing further injury is the third principle of wound care. This involves elimination or reduction of the condition that allowed the wound to develop. Factors that contribute to the development of chronic wounds include losses in mobility, mental status changes, deficits of sensation, and circulatory deficits. Patients must be properly positioned to eliminate continued pressure to the chronic wound. Pressure reducing devices, such as mattresses, cushions, supportive boots, foam wedges, and fitted shoes can be used to keep pressure off wounds.
Providing nutrition, specifically protein for healing, is the fourth principle of healing. Protein is essential for wound repair and regeneration. Without essential amino acids, angiogenesis, fibroblast proliferation, collagen synthesis, and scar remodeling will not occur. Amino acids also support the immune response. Adequate amounts of carbohydrates and fats are needed to prevent the amino acids from being oxidized for caloric needs. Glucose is also needed to meet the energy requirements of the cells involved in wound repair. Albumin is the most important indicator of malnutrition because it is sacrificed to provide essential amino acids if there is inadequate protein intake.
Effective wound care begins with an assessment of the entire patient. This includes obtaining a complete health history and a physical assessment. Assessing the patient assists in identifying causes and contributing factors of the wound. When examining the wound, it is important to document its size, location, appearance, and the surrounding skin. The health care professional also examines the wound for exudate, necrotic tissue, signs of infection, and drainage, and documents how long the patient has had the wound. It is also important to know what treatment, if any, the patient has previously received for the wound.
Actual components of wound care include cleaning, dressing, determining frequency of dressing changes, and reeavaluation. Removing dead tissue and debris that impedes healing, is the goal of cleaning the wound. When cleaning the wound, protective goggles should be worn and sterile saline solution should be used. Providone iodine, sodium hypochlorite, and hydrogen peroxide should never be used, as they are toxic to cells.
Gentle pressure should be used to clean the wound if there is no necrotic tissue. This can be accomplished by utilizing a 60 cc catheter tip syringe to apply the cleaning solution. If the wound has necrotic tissue, more pressure may be needed. Whirlpools can also be used for wounds having a thick layer of exudate. At times, chemical or surgical debridement may be needed to remove debris.
Dressings are applied to wounds for the following reasons: to provide the proper environment for healing, to absorb drainage, to immobilize the wound, to protect the wound and new tissue growth from mechanical injury and bacterial contamination, to promote hemostasis, and to provide mental/physical patient comfort. There are several types of dressings and most are designed to maintain a moist wound bed:
- Alginate: made of non-woven fibers derived from seaweed, alginate forms a gel as it absorbs exudate. It is used for wounds with moderate to heavy exudate or drainage, and is changed every 12 hours to three days, depending on when the exudate comes through the secondary dressing.
- Composite dressings: combining physically distinct components into a single dressing, composite dressings provide bacterial protection, absorption, and adhesion. The frequency of dressing changes vary.
- Foam: made from polyurethane, foam comes in various thicknesses having different absorption rates. It is used for wounds with moderate to heavy exudate or drainage. Dressing change is every three to seven days.
- Gauze: available a number of forms including sponges, pads, ropes, strips and rolls, gauze can be impregnated with petroleum, antimicrobials, and saline. Frequent changes are needed because gauze has limited moisture retention properties, and there is little protection from contamination. With removal of a dried dressing, there is a risk of wound damage to the healing skin surrounding the wound. Gauze dressings are changed two to three times a day.
- Hydrocolloid: made of gelatin or pectin, hydrocolloid is available as a wafer, paste, or powder. While absorbing exudate, the dressing forms a gel. Hydrocolloid dressings are used for light to moderate exudate or drainage. This type of dressing is not used for wounds with exposed tendon or bone, or third-degree burns, and not in the presence of bacterial, fungal, or viral infection, active cellulitis or vasculitis, because it is almost totally occlusive. Dressings are changed every three to seven days.
- Hydrogel: composed primarily of water, hydrogel dressings are used for wounds with minimal exudate. Some are impregnated in gauze or non-woven sponge. Dressings are changed one or two times a day.
- Transparent film: an adhesive waterproof membrane that keeps contaminants out while allowing oxygen and water vapor to cross through, it is used primarily for wounds with minimal exudate. It is also used as a secondary material to secure non-adhesive gauzes. Dressings are changed every three to five days, if the film is used as a primary dressing.
- Hematoma: dressings should be inspected for hemorrhage at intervals during the first 24 hours after surgery. A large amount of bleeding is to be reported immediately. Concealed bleeding sometimes occurs in the wound, beneath the skin. If the clot formed is small, it will be absorbed by the body, but if large, the wound bulges and the clot must be removed for healing to continue.
- Infection: the second most frequent nosocomial (hospital acquired) infection in hospitals is surgical wound infections with Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa. Prevention is accomplished with meticulous wound management. Cellulitis is a bacterial infection that spreads into tissue planes. Systemic antibiotics are usually prescribed. If the infection is in an arm or leg, elevation of the limb reduces dependent edema and heat application promotes blood circulation. Abscess is a bacterial infection that is localized and characterized by pus. Treatment consists of surgical drainage or excision with the concurrent administration of antibiotics.
- Dehiscence (disruption of surgical wound) and evisceration (protrusion of wound contents): this condition results from sutures giving way, infection, distention, or cough. Pain results and the surgeon is called immediately. Prophylactically, an abdominal binder may be utilized.
- Keloid: refers to excessive growth of scar tissue. Careful wound closure, hemostasis, and pressure support are used to ward off this complication.
The goals of wound care include reducing risks that inhibit wound healing, enhancing the healing process, and lowering the incidence of wound infections.
Health care team roles
Members of the health care team actively work to reduce patients' exposure to infections, as well as to administer prescribed treatments and patient education, which includes teaching home wound care.
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René A. Jackson, RN