Chapter 11: Inflammation & wound healing

Wound tunneling vs undermining

-undermining: wound is spread out underneath the skin that surrounds the visible part of the sore. So,wound is bigger than what appears at first glance -tunneling: a portion of the wound that continues to travel

Types of wound dressing: Antimicrobials

-used on partial and full thickness wounds, over surgical incisitons or around tracheostomies (acticoat, curity AMD, lodoflex, silversorb, silvercel)

Types of debridement:Mechanical debridement

-wet to dry dressings: open-mesh guaze is moistened with NS, lightly packed into wound surgace and outer layer allowed to dry. wound debris adheres to dressing and then dressing is removed -wound irrigation: make certain bacteria are not accidentally driven into wound with high irrigation pressure

Types of wound dressing: Hydrogels

-donate moisture to dry wound and maintain a moist environment -can rehydrate wound tissue -require secondary dressing -Used on dry wounds, wounds with minimal drainage or necrotic wounds (aquasite, curasol, intrasite, purilon, solosite)

Types of debridement: enzymatic debridement

-drugs applied topically to dissolve necrotic tissue and then covered with moist dressing -process can be slow and thick eschar may have to be scored with scalpel

Types of wound dressing: Alginates

-easy to use on irregular shaped wound -generally require secondary dressing -used on wounds with mod-heavy exudates (pressure ulcers, infected wounds) (algisite, kalginate, melgisorb, sorbsan)

Primary intention

-healing takes place when wound margins are neatly approximated, such as in a surgical incision or a paper cut -Initial phase -Granulation phase -Maturation phase and scar contraction

Factors that may delay healing: corticosteroid drugs

-impair phagocytosis by WBC, inhibit fibroblast proliferation and fxn, depress formation of granulation tissue, inhibit wound contraction

Wound healing complications: Hypertropic Scars

-inappropriately large, raised red and hard scars -occur when overabundance of collagen is produced during healing

Factors that may delay healing: infection

-increase inflammatory response and tissue destruction

Wound healing complications: Infection

-increase risk when wound contains necrotic tissue or blood supply is decreased, immune fxn decreased, undernutrition, multiple stressers and hyperglycemia in diabetes

Levine's technique

-involves rotating a culture swab over a cleansed 1cm2 area near center of wound (sample of clean tissue needed too) -use sufficient pressure to extract wound fluid from deep tissue layers -sample must be sent to lab within 1 hour

Wound healing complications: Excess Granulation Tissue ("proud flesh")

-may protrude above surface of healing wound -if granulation tissue is cauterized/cut off, healing continues as normal

Factors that may delay healing: smoking

-nicotine, a potent vasoconstrictor, impedes blood flow to healing areas

Wound healing complications: Contractions

-normal part of healing until excessive -can result in deformity, shortening of muscle/scar tissue resulting from excessive fibrous tissue formation

Wound healing complications: Evisceration

-occurs when wound edges separate to the extent that intestines protrude through wound

Types of wound dressing: Gauze

-provide absorption of exudates, most often combined with another kind of dressing -can be used in almost any kind of wound: cleansing, packing and covering

Types of debridement: Surgical debridement

-quick method of debridement to prevent, control or remove infection -used when large amounts of nonviable tissue are present -prepares wound bed for healing, skin grafting or flaps

Types of debridement: autolytic debridement

-semiocclusive or occlusive dressings used to soften dry eschar by autolysis -assess area around wound for maceration when using these dressings

Regeneration

Replacement of lost cells and tissues with cells of same type

Materials used to close wounds?

-adhesive strips (steri-strips, butterflies) -sutures (stitches) -tissue adhesives (fibrin sealants)

Wound healing complications: Adhesions

-bands of scar tissue that form btw or around organs -occur in abd cavity or btw the lungs and pleura -adhesions in abd may cause intestinal obstruction

Factors that may delay healing: obesity

-decreases blood supply in fatty tissue

Types of wound dressing: transparent films

-Use with caution over superficial wounds -In fragile wounds, can reslut in further tissue loss -can draw in moisture, increasing risk of infection -Used on dry, uninfected wounds or wounds with minimal drainage (bioclusive, OpSite, Suresite, Tegaderm, transeal)

Skin Tear

-Wound caused by shear, friction, and/or blunt force -Results in separation of skin layers -Common in older adults and critically or chronically ill adults

Wound healing complications: Dehiscence

-separation and disruption of previously joined wound edges -usually occurs when primary healing site bursts open -may be caused by: infection, granulation tissue not strong, obesity (adipose tissue has less blood supply and may slow healing), pocket of fluid (seroma, hematoma) developing btw tissue layers and preventing edges of wound from coming together

Factors that may delay healing: advanced age

-slows collagen synthesis by fibroblasts, impairs circulation, requires longer time for epithelialization of skin, alters phagocytic and immune response

Factors that may delay healing: anemia

-supplies less O2 at tissue level

Types of wound dressing: Hydrocolloids

-support debridement and prevent secondary infections -used on wounds with light to mod drainage (bursemed, comfeel, duoderm, primacol)

Negative-pressure wound therapy

-treat acute or traumatic wounds, surgical wounds that have dehisced, pressure ulcers, and chronic ulcers -Suction removes drainage and speeds healing -Monitor serum protein levels, fluid and electrolyte balance, and coagulation studies -pulls excess fluid from wound, reduces bacterial load, encourages blood flow into wound base

Repair

-Healing as a result of lost cells being replaced with connective tissue -More common/complex than regeneration -Occurs by primary, secondary, or tertiary intention

Wound Healing: Assessment

-Assess on admission and on a regular basis -characteristics of the wound and surrounding area: location, size (longest length and widest width), depth, undermining and tunneling, wound margin (e.g., normal, macerated (edges softening due to exposure to moisture), erythema), and wound base (e.g., eschar (piece of dead tissue cast off from skin surface), slough (liquidfying necorsis-yellow, cream, tan), exudate). -Identify factors that may delay healing -Record the consistency, color, and odor of any drainage and report if abnormal for the situation

Primary intention: 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 -Active movement of the myofibroblasts causes contraction of the healing area, helping to close the defect and bring the skin edges closer together -More painful than granulation phase -reason abdominal surgery discharge instructions limit lifting for up to 6 weeks

Wound healing complications: Hemorrhage

-Bleeding normal immediately after tissue injury and ceases with clot formation -abnormal caused by suture failure, clotting abnormalities, dislodged clot, infection or erosion of blood vessel by foreign object

Wound Classification

-Cause: Surgical or nonsurgical, Acute or chronic -Depth of tissue affected: Superficial, partial thickness, full thickness

Infection control

-Culture and sensitivity should be done (done before first dose of antibiotics) -Concurrent swab specimens obtained using Levine's technique

Nursing implementation: Contaminated wound

-Debridement may be necessary -Absorption or hydrocolloid dressing may be used

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 -results in a larger and deeper scar than results from primary or secondary intention

Nutritional Therapy

-Diet high in protein, carbohydrates, and vitamins with moderate fat, increase fluids -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: -Vitamin C: capillary synthesis and collagen production by fibroblasts. -B-complex vitamins: coenzymes for many metabolic reactions. Vitamin A: aids in the process of epithelialization. Increases collagen synthesis and tensile strength of the healing wound.

Infection prevention

-Do not touch recently injured area -Keep environment free from possibly contaminated items -Antibiotics may be given prophylactically

Nursing implementation: Clean wounds

-Dressing material that keeps wound surface clean and slightly moist is optimal to promote epithelialization -Transparent film may be used -superficial skin injuries may only need cleansing -Clean wounds that are granulating and re-epithelializing should be kept slightly moist and protected -Dryness is an enemy of wound healing -Topical antimicrobials and antibactericidals used with caution

Psychologic implications

-Fear of scar or disfigurement -Drainage or odor concerns -Be aware of your facial expressions while changing dressing

Primary intention: Granulation phase

-Fibroblasts migrate into site and secrete collagen -Wound is pink and vascular -Surface epithelium begins to regenerate -the wound is friable, at risk for dehiscence, and resistant to infection

Wound healing complications: Keloid formation

-Great protrusion of scar tissue that extends beyound wound edges and may form tumor-like masses of scar tissue -Pernament without any tendency to subside -Patients often complain of tenderness, pain and hyperparesthesia (excessive sensitivity) especially in early stages

Primary intention: 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: 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

Types of wound dressing: nonadherent dressing

-Minimally absorbent -used for minor wounds or as secondary dressing (adaptic, vaseline gauze, xeorform)

Purposes of wound management

-Protecting a clean wound -Cleaning a wound -Treating infection

Patient Teaching

-Teach signs and symptoms of infection -Note changes in wound color or amount of drainage -Provide medication teaching

Wound Measurement: how to

-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.

Factors that may delay healing: Nutritional deficit

-Vitamin C: delays formation of collagen fibers and cap development -protein: decrease supply of amino acids for tissue repair -zinc: impairs epithelization

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 -same healing as primary intention. Differences are the greater defect and the gaping wound edges

Wound

-a break or opening into the skin

Becaplermin (Regranex)

-a recombinant human platelet-derived growth factor gel, actively stimulates wound healing. -used to treat diabetic foot ulcers. -should be used only when the wound is free of dead tissue and infection. It should not be used if cancer is suspected in the wound

Jackson-Pratt drain

-a suction drainage device consisting of a flexible plastic bulb connected to an internal plastic drainage tube

Types of wound dressing: foams

-able to hold large amounts of exudate -often used on new wounds (Allevyn, cutimed, hydrocell, lyofoam, mepilex, polymem)

Hyperbaric O2 therapy (HBOT)

-accelerates granulation tissue formation and wound healing -Delivery of O2 at increased atmospheric pressure -Allows O2 to diffuse into serum -Last 90 to 120 minutes, with 10 to 60 treatments -Elevated O2 levels stimulate angiogenesis, kill anaerobic bacteria, and increase the killing power of WBCs and certain antibiotics

Factors that may delay healing: poor general health

-causes generalized absence of factors necessary to promote wound healing

Factors that may delay healing: diabetes mellitus

-decrease collagen synthesis, delays cap growth, impairs phagocytosis (result of hyperglycemia), reduces supply of O2 and nutrients secondary to vascular disease

Factors that may delay healing: inadequate blood supply

-decreases supply of nutrients to injured area, decreases removal of exudative debris, inhibits inflammatory response

Factors that may delay healing: mechanical friction on wound

-destroys granulation tissue, prevents apposition of wound edges

Wound healing complications: Fistula formation

abnormal passage between organs or hallow organ and skin