Ch3 - Factors Affecting Wound Healing - Wound Healing

What is the preferred fuel source of active cells?

Carbohydrates

What is a good predictor of wound healing in relation to wound dimensions?

Changes in one surface area overtime can assist with predicting wound healing. A 20-40% decrease in wound surface area within 2 to 4 weeks of initiating treatment is a good indicator that the wound is responding to wound management interventions.

How many microbes are present in intact healthy tissue?

Normal, intact skin may have a bacterial count of up to 10^3 microbes/gram of tissue.

The presence of oxygen is critical to all three phases of old healing. What is oxygen specifically required for?

Oxygen is required for phagocytosis, collagen synthesis, fiberglass replication, growth factor of production, angiogenesis, and epithelialization.

What should a clinician consider in relation to wound healing when treating an immunocompromised patient?

Patients who are immunocompromised will have altered wound healing and limited reserves to repair injured tissues. Immunocompromised patients have an increased risk of infection due to their immune systems being ineffective.

When should pain medication be administered?

Treatment time should correspond with medication's peak action period to maximize effectiveness.

What 3 things must a clinician always consider when predicting the time to wound healing?

Wound characteristics, and both local and systemic factors.

List wound shape in order of slowest healing to fastest healing time.

(slowest) Circular wounds, square or rectangular wounds, linear wounds (fastest)

How does smoking negatively impact wound healing?

1. Decreases tissue perfusion: Vasoconstrictor, Increases risk for peripheral vascular disease, Increases risk of intermittent claudication 2. Reduces tissue oxygenation: Carbon monoxide > 200X greater affinity for oxygen than hemoglobin = displaces oxygen on RBCs, Hydrogen cyanide interferes with cellular oxygen metabolism, Increases risk of COPD 3. Delays normal cellular response to wounding: Increased platelet aggregation and clot strength, Decreases fibroblast proliferation and their production of extracellular matrix and growth factors, Decreases erythrocyte proliferation, Decreases lymphocyte chemotaxis and function, Increases levels of catabolic enzymes and MMPs, Decreases myofibroblast contraction, Slows epidermal regeneration, Smoking cessation leads to immediate improvements in above + these gains continue to increase over time

How does lack of physical activity affect wound healing?

1. Increased risk of adverse health conditions/comorbidities including CAD, CVA, cancer (breast colon, colorectal, endometrial, and ovarian), obesity, diabetes, depression, and anxiety. 2. Increases morbidity and mortality. 3. Decreases strength, flexibility, mobility, endurance, and physical function.

What is the effect of alcohol abuse on wound healing?

1. Malnutrition 2. Increases risk of injury *Less likely to seek medical care

Age-related changes make aging skin ______(4 things)______ compared to young skin.

1. More fragile 2. More prone to injury 3. Slower to repair and regenerate after injury. 4. More susceptible to infection (it is also harder to detect infection)

Deterrence to expedite wound healing can be divided into 5 major categories. What are these categories?

1. characteristics related to the wound itself 2. local factors within the wounded area 3. systemic factors related to the individual with the open wound 4. patient adherence 5. inappropriate wound management

Why is it important to keep a healing wound moist, but not too moist?

A dry wound progresses through the phases of inflammation more slowly than a moist wound. If a wound is allowed to air dry it dehydrates within 2-3 hours leaving a crust consisting of dead cells, proteins such as vibrant, and breeze, 0.2-0.3 mm thick on top of the wound bed (this process is called desiccation). Desiccation retards healing by creating a physical barrier to epithelialization, thus delaying healing. Covering wounds maintains moist environment by trapping and fluids that have been shown to contain growth factors and enzymes important to the healing process. Too much moisture will also delay wound healing and cause the wound and periwound to become macerated. Macerated skin, is more fragile and friable than healthy skin. If not controlled. maceration can lead to an increase in wound size.

What is meant by a high wound bioburden and how does it adversely affect wound healing?

A high wound bioburden = high concentrations of microorganisms. These microorganisms compete with body cells for oxygen and energy by secreting cytotoxic substances.

What is an acute wound?

A wound induced by surgery or trauma otherwise healthy individual.

What is a chronic wound?

A wound induced by varying causes, whose progression through the phases of healing is prolonged or arrested for any reason.

What systemic factors affect wound healing?

Age, in adequate nutrition, comorbidities, medication, and lifestyle choices

What are risk factors for malnutrition?

Alcohol abuse, drug abuse, and obesity.

What is one easy way of promoting a patient's circulation that also tends to patient comfort?

Ensure that the patient is sufficiently warm, during transport, and during treatment. Blankets and heat lamps can be helpful adjuncts especially in whirlpool areas.

If carbohydrates are not present, what will the body use as a secondary fuel source? Why is this detrimental to dealing?

Amino acids from protein. Protein is required for cellular repair and regeneration, protein depletion will impair inflammation, immune response, proliferation, and maturation and remodeling

When should a clinician suspect a wound is infected?

An infection should be suspected if the cardinal signs of inflammation or disproportionate to the size and extent of a wound.

How can healthcare professionals positively affect malnourished patients?

By providing appropriate nutritional support and lifestyle education. A screening of the gastrointestinal system and a nutritional assessment should be included in the systems review of all patients with, or at risk for, open wounds.

Acute wounds follow a predictable course of healing. Why are chronic wounds relatively unpredictable?

Chronic wounds are not self-limiting. Once upon fails to progress through the normal phases of wound healing, time since onset cannot be used as a predictor for time to wound healing. A clinician can assist a patient's wound into moving forward through phases of wound healing, only then can predictions be made.

Which inflammatory mediators are of high concentration in chronic wounds? What has decreased concentration? How is this combination detrimental to wound healing?

Chronic wounds exhibit an increase in the number of inflammatory mediators such as tumor necrosis factor (TNF) alpha and and matrix metalloproteases (MMPs), as well as a decrease in the number of tissue inhibitors of matrix metalloproteases (TIMPs). This imbalance leads to an increased breakdown of the extracellular matrix and inhibits granulation tissue formation and reduces/arrests epithelialization, which is recognized clinically as a nonadvancing wound edge.

How does a chronic wound's microflora differ from an acute wound?

Chronic wounds have a greater number and variety of microflora. When the amount of microbes present reach critical levels, healing will be impaired.

How are circulation and wound healing influenced by the sympathetic nervous system?

Circulation is controlled by the sympathetic nervous system, the fight or flight branch of the autonomic nervous system. Cold, fear, and pain can all trigger the sympathetic nervous system, Thereby causing peripheral vasoconstriction and potentially slowing the wound healing process.

What local factors affect wound healing?

Circulation, sensation, mechanical stress

How is patient compliance different from patient adherence?

Compliance - implies a one-way interaction in which an omniscient clinician directs the patient to follow certain procedures and the patient complies solely because the clinician said to do so. Adherence - implies that the patient freely chooses to follow suggested guidelines. This is considered the more appropriate term.

How does necrotic tissue or the presence of foreign bodies affect wound healing?

Epithelial cells can only migrate over viable tissue, necrotic tissue impedes wound healing and promotes infection. Dead tissue within a wound bed can change a colonized wound into an infected wound by providing food for the microbes present. Foreign bodies or debris within a wound bed may also contribute to infection and perpetuate the inflammatory response.

What anatomical and functional changes secondary to aging, impair wound healing?

Decreased macrophage function - leads to slowed immune response. Impaired fibroblast function - decreases collagen synthesis and strength. Cellular turnover decreases - making repair and regeneration slower. Epidermal and dermal atrophy due to decreased dermal vasculature and interdigitations - makes skin thinner and more prone to skin tears and blisters. Pain perception decreases - Minor trauma may go unrecognized. Decrease in Inflammatory response - Slows the healing process. Vascular responsiveness is decrease - affecting the ability of inflammatory cells to reach the injured area. Presbyopia - Age related deterioration of eye sight - May increase risk of falling or bumping into objects.

What lifestyle changes/interventions can be made to address poor nutrition?

Dietician, Urban planning to correct food deserts, Creation of community markets, Mandate high nutrition value meals in the NSLP (National School Lunch Program), Support for public services including SNAP (Supplemental Nutrition Assistance Program) and WIC (Women, Infants, and Children)

Older age is an independent predictor of poor outcomes and delayed healing in the case of chronic ulcers. What adjunct can be used to accelerate wound healing?

Electrical stimulation should be considered if healing is delayed.

What are interventions for someone who has impaired circulation is caused by pain?

Explain interventions, Provide rationale, if patient can comprehend, Distraction, Pain medication, Accept steady improvements when patient tolerance precludes complete resolution during a particular session

What are interventions for someone who has impaired circulation is caused by fear?

Explain interventions, Provide rationale, if patient can comprehend, Distraction, Provide a nonthreatening environment, Antianxiety medications

Inadequate nutrition is a changeable systemic factor. Why is it never too late to change your diet for the better?

Fortunately, a patient's recent food intake seems to be more important than food consumed over the course of weeks or even months.

What are nonverbal signs that a patient is in pain?

Groaning, fidgeting, physically withdrawing, noncompliance, or refusal of care. *Clinicians should not push past a patient's pain tolerance.

Why is having normal macrocirculation or the presence of pulses not indicative of prognosis for wound healing?

Inadequate microcirculation - blood flow to the smaller arterials and capillaries - as seen in PVD and DM could be detrimental to wound healing and cannot be assessed by taking a pulse.

What is the ideal temperature for wound healing?

Maintaining a normothermic wound environment between 37-38°C has been shown to improve wound healing. At these temperatures, the vasculature dilates, tissues are less vulnerable to infection, and tissue oxygen levels are increased.

When is a wound considered infected?

If a wound culture contains greater than 10^5 microbes/gram of tissue.

How can pour nutrition influence wound healing?

Increased risk of adverse health conditions such as obesity and diabetes, Abnormal wound healing

What occurs when a wound has an adequate blood flow?

Increases the risk of infection and slows the healing process.

How does infection impair wound healing?

Infection prolongs inflammation and promotes wound dehiscence.

Why is allowing a wet-to-dry dressing to dry out a bad idea?

It impairs wound healing by: allowing desiccation (removal of moisture and growth factors key to wound healing) and removal of dry gauze will damage granular tissue and is a common cause of chronic inflammation. **Regardless of etiology or severity, wounds heal faster when a warm, moist environment is maintained.

What factors contribute to nonadherence?

It is helpful to relate some of the potential problems with adherence to a communication model in which: the patient is the receiver of information, the task is the message, and the clinician is the sender. More commonly, nonadherence seems to be unintentional due to misunderstanding, or poor eyesight limiting skin inspection, or just plan forget fullness. Some nonadherence is intentional because of real or perceived barriers (i.e., wearing a boot for a wound that the patient thinks is ugly). A patient's prior experiences can have a profound effect on current actions (Ex. why should I do what you say when the last time i did nothing and the wound still healed, or oppositely - I did what you said an I still had to amputate my foot). Poor continuity of care, such as frequent changes in health care providers or inconsistent approaches to healing, detracts from patient adherence - clinicians should strive for a coordinated, consistent, interdisciplinary approach to patient care.

What should a clinician do if they suspect nonadherence?

It is important to provide the patient with objective evidence of nonadherence (the presence of dog hair and dirt within the wound bed), state the ramifications of this behavior (delayed wound heal-ing and infection), and restate the intended behavior (keep the wound covered at all times except for dressing changes).

How can improper suturing or edema delay wound healing?

It places excessive tension on wound edges

What are interventions for someone who has impaired circulation is caused by being cold?

Keep wound covered except for dressing changes, Blankets, Heat lamps

What extrinsic factors have been linked to initiating and perpetuating both neuropathic ulcers and pressure injuries?

Mechanical stressors including: pressure, shear, and friction. *Minimizing adverse mechanical stress is on balloons will enhance healing.

What wound characteristics are known to affect the rate of wound healing?

Mechanism of onset, time since onset, wound location, wound dimension, temperature, wound hydration, necrotic tissue or foreign bodies, and infection.

What are 3 examples of nonadherence?

Missing appointments, not performing at home program, or early self-discharge

What does microflora of normal skin include?

Normal skin microflora include: Staphylococcus, Microboccus, Peptococcus, Streptococcus, Acinetobacter, and yeast.

What interventions can be implemented to address a sedentary lifestyle?

Regular exercise; Behavioral counseling; Fitness trackers; Personal trainer; Community and private fitness facilities; Required physical health and education in schools for all ages; Support for local health initiatives such as sidewalks, bike lanes, parks, and urban wilderness areas

How does periwound edema impede healing?

Restricts BF Ex) Venous insufficiency ulcers

How can sensory deficits be damaging and lead to pressure injury development?

Sensory deficits cause a failure to recognize and relieve pressure, irritation, or overt trauma. Without adequate sensation, individuals have no signal to warn of tissue damage. This can lead to delayed identification of tissue trauma and indirectly retard wound healing due to continued trauma to an injured area.

What is a good intervention for chronic wounds?

Serial debridement -decreases wound bioburden and appears to stimulate wound healing in chronic wounds.

How can short-term and long-term use of NSAIDs influence wound healing

Short-term use or in therapeutic dosages -minimal evidence suggests NSAIDs delay wound healing by influencing the inflammatory phase. Long-term use - May be associated with a decrease in tensile strength and particularly non-selective (non-COX-2 inhibitors) results in delayed and abnormal bone healing.

Those with activity limitations such as change of positions while lying, the inability to shift weight while sitting, or extremely limited walking/sitting tolerance is associated with an increased risk of what?

Skin breakdown and delayed repair. *This statistic includes those with strength deficits

What are some interventions for patients who smoke?

Smoking cessation programs, Support groups, Counseling

How do steroids impair wound healing?

Steroids at doses greater than 30 to 40 mg per day impair all phases of wound healing. Steroids suppress inflammation in the immune system, decreased angiogenesis and epithelialization, and slow cell proliferation. Steroids also decrease collagen synthesis, wound contraction, and wound tensile strength

What interventions can help a patient who abuses alcohol?

Support groups, Counseling, Inpatient treatment programs

How can a clinician facilitate patient adherence?

The clinician should emphasize that past experience does not dictate future outcomes. The clinician should highlight the control the patient has over the current situation and specifically how action, or lack of action, can affect outcomes. **Self-efficacy is associated with adherence. The patient should be told why (Ex. it is important to change the dressing this frequently [because the antimicrobial is ineffective after 8 hours] or what the potential consequences of nonadherence are [delayed wound closure, infection, sepsis, etc.]) The patient should be educated as to how to reach this goal (step-by-step instructions). By providing concrete evidence of intervention success, adherence can be increased.

How do antineoplastics drugs used in chemotherapy delay wound healing?

They are designed to disrupt the cell cycle.

How can medications, including angiotensin-converting enzyme (ACE) inhibitors, allopurinol, and several antibiotics negatively impact the skin?

They are known to cause skin reactions including rashes, Vasculitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis.

Intrinsic factors such as tissue perfusion or oxygenation can impair wound healing. Name some disease processes affecting tissue perfusion or oxygenation.

Tissue perfusion: Peripheral vascular disease Oxygenation: Anemia and chronic obstructive pulmonary disease (COPD)

How should a clinician intervene if necrotic tissue, foreign bodies, or debris is present in a wound bed?

To facilitate healing and decrease the risk of infection, both necrotic tissue and breeze should be meticulously debris did from the wound bed if the wound bed has adequate vascular supply to support wound healing.

What are interventions for someone who has impaired circulation is caused by impaired macro- or microcirculation?

Vascular consult, Medical management

Cells within chronic wounds are senescent. What does this mean?

While still metabolically active, these cells proliferate at a reduced rate, synthesize fever proteins, respond less to chemical mediators, and migrate much slower than cells within an acute wound that are not senescent.

Whirlpool treatment is over used. When is it appropriate to use a whirlpool?

Whirlpool treatment may be appropriate for some wounds with thick exudate, slough, or necrotic tissue. **However, because it increases edema, traumatizes granulating tissue, and retards epithelialization, whirlpool is contraindicated on clean wounds.

When should antibiotics be prescribed?

With the exceptions of bite wounds and deep hand puncture wounds, systemic antibiotics should be reserved for cases with signs of systemic infection or ascending cellulitis. In addition, the prescribed antibiotic should be chosen based on the results of available wound cultures.

How does temperature affect wound healing?

Wound and environmental temperature affects healing. Wound healing at 30°C has been reported to be faster than 20°C. As temperature decreases to 12°C, one tensile strength also decreases.

What wound dimensions affect the rate of healing?

Wound shape, size, and depth

How does wound location factor into healing time?

Wounds heal slower if they are located: in areas with decrease vascularity, over bony prominences secondary to increased tissue tension, where the skin is thicker since there is more tissue to rebuild. Because wound healing can occur through regeneration from epidermal appendages, wounds in areas with fewer epidermal appendages resurface more slowly.

What medications (supplements, vitamins, hormones, herbs/natural medications) appear to aid in wound healing?

Zinc, vitamin A, vitamin C, Estrogen, thyroid hormones, hemorrheologic agents (such as pentoxifylline), Topical nitroglycerin and (possibly) phenytoin - Improve local circulation. Honey, turmeric, goldenseal - have antioxidant or antimicrobial effects which appear to increase the rate of wound healing. Bacitracin, neomycin, sulfur sulfadiazine - promote re-epithelialization. Short term use of the least cytotoxic agent may assist with resolving local infection and biofilms, does facilitating wound healing (if used too frequently = these drugs are known to decrease wound contraction, and inhibit epithelialization)

When does an acute wound require intervention?

infected wounds, vascular wounds, surgical wounds, and burns