Wound Healing- A Process Almost All RNs Encounter. June 5th, 2. 01. 2 By Jennifer Olin, BSN, RNSummer fun and all that comes with it can mean ice cream and fireworks or it can mean scraped knees and bandages. With all the baseball games, hanging out, and swimming in the lakes or at the beach, and riding bikes down mountain trails, injuries happen. When those abrasions, lacerations, punctures, and incisions are taken care of there is a very definite healing process. In fact, there are three types of healing, distinguished by just how much skin and tissue has been lost: Primary Intention Healing – This occurs where the tissue surfaces have been approximated (closed). This can be with stitches, or staples, or skin glue (like Derma bond), or even with tapes (like steri- strips). This kind of closure is used when there has been very little tissue loss. It is also called “primary union” or “first intention healing.” An example of wound healing by primary intention is a surgical incision. Second Intention Healing – A wound that is extensive and involves considerable tissue loss, and in which the edges cannot be brought together heals in this manner. This is how pressure ulcers heal. Secondary intention healing differs from primary intention healing in three ways. The repair time is longer. The scarring is greater. The chances of infection are far greater. Tertiary Intention Healing – This type of wound healing is also known as “delayed” or “secondary closure” and is indicated where there is a reason to delay suturing or closing a wound some other way, for example when there is poor circulation to the injured area. Universal Healing Tao Free information. A Taoist Approach to Internal Cleansing Urine Therapy, Massages, Cosmic Detox, Cosmic Cleansing, Urine Therapy for fasting for.What is the role of fruits and vegetables? While the health-related benefits of a diet rich in fruits and vegetables is known to most, the scientific literature in. Wound Healing-A Process Almost All RNs Encounter. By Nancy Collins, PhD, RD, LD/N, FAPWCA, and Allison Schnitzer Nutrition is a critical factor in the wound healing process, with adequate protein intake essential to. At low doses, nicotine can favor faster wound healing, while in larger doses it has the opposite effect. Active ingredient: Antihemophilic Factor (recombinant): nominally 250 IU, 500 IU, 1,000 IU, or 2,000 IU per vial; powder for IV infusion after reconstitution; plasma. Home Remedies for Sick Birds and Optimum Avian Nutrition. Stress, pollution, prescription drugs, the overuse of antibiotics and a poor diet all contribute to the ill. These wounds are closed later. An example of a wound healing by tertiary intention is an abdominal wound that is initially left open to allow for drainage but is later closed. Promoting Wound Healing. Any type of wound undergoes considerable stress while in the healing process. For example, there may be physical stressors such as strain on sutures from coughing or sneezing; simple movement of the offended body part can cause undue trouble at the site and disrupt the wound layers. One nursing responsibility is protecting the wound and promoting healing. It takes from 2. 4 to 7. If a wound is going to become infected, it usually occurs three- to- six days after the incident but can take up to 3. Centers for Disease Control and Prevention in their Criteria For Defining A Surgical Site Infection (SSI). A clean surgical wound usually doesn’t regain strength against normal stress for 1. For other types of wounds, depending on the severity, those numbers can be greater or lesser. Ongoing observation for the wound identifies early signs and symptoms of stress such as infections. Factors Affecting Wound Healing. There are a number of factors to take into consideration when waiting for a wound to heal. Any one or a combination of these can multiply how long it will take for a patient to fully recover from a wound of any type, superficial or deep. Developmental Considerations – Healthy children and adults heal more quickly than the elderly. Older adults are more likely to have chronic diseases, such as peripheral vascular disease, which impairs blood flow. Reduced liver function or diabetes are can also impair healing times. Also, with aging, skin loses its flexibility and scar tissue is less elastic. Nutrition – Wound healing places a lot of demands on the body. Clients need a diet rich in protein, carbohydrates, lipids, vitamins A & C, and minerals, such as iron, zinc, and copper. Obese patients are at an increased risk of wound infection and slower healing because adipose tissue usually has an inadequate blood supply. Lifestyle – People who exercise regularly tend to have better circulation and are more likely to heal quickly because blood brings oxygen and nourishment to the wound. Smoking reduces the amount of functional hemoglobin (the iron- containing oxygen- transport protein) in the blood which limits the oxygen- carrying capacity of the blood. Smoking also has been linked to clot formation in the circulatory system. Medications – Patients who are on anti- inflammatory drugs, (such as steroids or aspirin), heparin or antineoplastic agents (such as medications used in chemotherapy) often suffer delayed healing. Also prolonged use of antibiotics can make a person more likely to develop a wound infection. Infection – Wound infections slow healing. There may be infectious agents involved at the time of injury, they may be acquired during surgery or come from exposure later in the healing process. Complications. If any of the aforementioned factors occur while someone is trying to heal from a wound there are a number of complications which can arise: Hemorrhage – Some escape of blood from a wound site is normal. However, if there is persistent bleeding it may be caused by a dislodged clot or erosion of a blood vessel or a even a slipped ligature. Internal hemorrhage is often detected by swelling or distention in the area around the wound or even by symptoms more serious such as a rapid, thread pulse, increased respirations, sweating, restlessness, and/or clod, clammy skin. Hematoma – Sometimes patients will develop a collection of blood right underneath the skin. A hematoma may appear as a swelling that is reddish- blue in color. A large hematoma may be dangerous because it can place pressure on blood vessels and obstruct blood flow. Dehiscence with Possible Evisceration – Dehiscence is the partial or total rupturing of a wound. Evisceration is the protrusion of internal viscera through an incision. These complications are most often involve the layers of the abdomen. A number of factors, including obesity, poor nutrition, multiple trauma, failure of sutures, excessive coughing, vomiting, and dehydration, heighten a patient’s risk of dehiscence. This is most likely to occur four to five days after the wound has been repaired, before the body has had time to deposit sufficient collagen in the wound site. As nurses we see wounds at all stages of repair. It is important to recognize the different types of wound healing that are occurring, where in the process the patient has progressed to, and if they are not healing well we must assess why and take the appropriate measures to help the process along. Abnormal wound healing . Chronic wounds are defined as those that do not appear to follow the normal healing process in less than 4 weeks. These wounds are most commonly located on the lower leg, foot, and pelvic region. Healing is more difficult because the aetiology of the wound is harder to determine, and the measures to reverse the medical abnormalities are often complex. Knowledge about the science of wound healing is expanding. In the near future we can anticipate new therapies for slow or abnormally healing wounds that will be based on genetics and immunology. More effective biological dressings and growth factors are already available and are proving useful for selective patients. Keloids and hypertrophic scars. Hypertrophic scars and keloids are thickened scars due to excessive synthesis of collagen after an acute injury. The terms overlap, but in general hypertrophic scars develop within the boundary of the original wound and regress in time whereas keloids extend beyond the wound boundary and tend to remain elevated. Hypertrophic scars follow known injury such as surgery, laceration, abrasion or deep inflammatory skin disease such as acne. They are more likely if there is excessive tension on the wound, tissue infection or electrosurgery. Keloids may also arise spontaneously and sometimes continue to slowly grow for many years. Hypertrophic scars and keloids most frequently arise in young adults and are particularly prevalent in black- skinned individuals. They are equally common in males and females. Although often asymptomatic, these scars may also be pruritic and/or tender. They are firm or hard, skin- coloured to bright red, smooth, elevated nodules. Keloids may have claw- like extensions far beyond the original wound. They are particularly frequently seen on earlobes, shoulders, upper back and anterior chest. The histology of a hypertrophic scar is whorled fibrous tissue with haphazardly arranged fibroblasts. Keloids have similar features with thick eosinophilic bands of collagen. Management is challenging. Susceptible individuals should avoid cosmetic procedures such as excision of benignnaevi and body piercing. Any surgical procedure should be undertaken with careful attention to optimum conditions for healing. Active treatment of hypertrophic and keloid scars attempts to reduce collagen formation and actively destroy it by inducing collagenase. Treatment may include: Intralesional corticosteroid injections. Triamcinolone acetonide 1. The injections are easier after pre- treatment by cryotherapy to induce tissue oedema. Scar dressings. Silicone gel pads, polyurethane self- adherent plasters and pressure dressings are helpful. Topical applications containing mucopolysaccharides, silicone or other agents. These are easy to use but of unproven efficacy. Surgery. Excision or laser ablation of the scar may result in a recurrence that is larger than the original. It may be indicated if it can achieve a reduction in wound tension and if followed immediately by other active measures that induce collagenase. Radiotherapy. Recurrence is reduced and delayed by irradiation of the scar after surgical excision. Vascular laser. Laser treatment reduces the redness, irritation and thickness of some scars. It may be repeated. Phototherapy with UVA- 1 (3. This is under investigation for the treatment of several fibrotic skin disorders but is not currently available in New Zealand. Imiquimod. This immune response modulator may reduce recurrence rates of hypertrophic scars after surgery. Impaired wound healing. Many intrinsic and extrinsic factors can impair wound healing. Local factors. Growth factors. Oedema. Ischaemia. Hypoxia. Infection. Regional factors. Arterial insufficiency. Venous insufficiency. Neuropathy. Systemic factors. Inadequate perfusion. Metabolic disease. Miscellaneous factors. Nutritional state. Pre- existing illness. Exposure to X- radiation. Smoking. Drugs. Smoking. The association between poor surgical outcome and smoking has been recognised for a long time. Smoking increases the risk of wound infection, graft or flap failure, tissue necrosis and haematoma formation. The pathogenesis is unclear but involves: Arteriolar vascoconstriction and cellular hypoxia. Decreased collagen synthesis. Delayed revascularisation. Systemic factors that impair wound healing. Aging. There are age and sun- induced changes in the structure and function of the skin resulting in thinner, less elastic tissue that bruises easily. However, these changes have little impact on acute wound healing. Chronic wounds are prevalent in the elderly but poor healing is related to co- morbid conditions rather than age alone. Ageing results in dysfunctional molecular mechanisms that affect the ability to repair damaged cells and tissues. This may lead to neoplastic transformation of a normal cell into one with unlimited growth potential i. Neoplasia prevents normal healing processes; ulceration is characteristic for basal and squamous cell carcinomas. Inadequate nutrition. Carbohydrates, protein and amino acids, fatty acids, minerals and vitamins are required for normal wound healing. Abnormal nutritional states may arise because of: Inadequate diet (consider anorexia nervosa, poor self- care in the elderly, psychiatric disease, drug and alcohol abuse)Specific metabolic disorders such as inborn errors of amino acid metabolism. Inadequate absorption of nutrients. Inadequate tissue distribution. Drug effects. Delayed wound healing occurs in patients with hypovitaminosis A (retinol). In contrast, excessive granulation tissue may arise in hypervitaminosis A or in patients treated with synthetic retinoids (isotretinoin or acitretin). Scurvy is due to deficiency of vitamin C (ascorbic acid). Cutaneous features include poor wound healing, follicularhyperkeratosis, . In the skin, lack of essential fatty acids results in scaling, erythema and poor wound healing. This can be corrected by topical or oral linoleic acid (found in oil of evening primrose, safflower or sunflower seed). Severe zinc deficiency arises in the rare inherited disorder acrodermatitis enteropathica and in patients on total parenteral nutrition without zinc supplementation. Less severe zinc deficiency is associated with diets consisting mainly of grains and refined foods, old age, pregnancy, lactation and alcoholism. It may also arise in sickle cell anaemia or if there is hyperzincuria due to liver or kidney disease. In these disorders, zinc supplementation may help wound healing. Obesity is associated with poor wound healing because of infection, oedema and increased prevalence of diabetes. Diabetes mellitus. Diabetes gives rise to high risk of major complications in wounds, including infection and amputation. Vascular, neuropathic, immune function, and biochemical abnormalities each contribute to delayed healing. Even careful wound care in a patient with excellent glucose control may fail. Chronicinfection itself contributes to raised blood glucose levels. Immune deficiencies. These may be due to aging, disease or drugs and may result in delayed wound healing because of intrinsic defects and secondary infection. Coagulation and haematological defects. Excessive bleeding and abnormal clot formation prevent normal healing. Abnormal collagen. There are at least six subtypes of Ehler Danlos syndrome, which involve genetic defects in collagen and connective tissue synthesis and structure. They are characterised by varying degrees of fragile and atrophic or . About 2- 3% surgical wounds are complicated by infection; the risk of infection is greatest during the first 4. It is more likely in patients with impaired haemostasis or inflammation such as those with advancing age, diabetes, steroid therapy and other immunosuppressants, obesity, severe malnutrition, compromised circulation, and infection in other sites. Tissue levels of greater than 1. Systemic signs of infection include fever, tachycardia, hypotension, delirium, and alterations in mental status in older patients. Histological features of infection include invasion of viable tissue by pathogens and polymorphonuclear (PMN) leukocyte response, although PMNs are also a feature of wound healing per se. Surgical or acute wound infection is most frequently due to Staphylococcus aureus and sometimes Streptococcus pyogenes and aerobic gram- negative bacilli. Enteric Gram- negative rods, Group D enterococcus and Bacteroides fragilis group affect wounds relating to the gut flora, while Streptococcus spp., pigmented Prevotella and Porphyromonas spp. Colonisation may be of benefit to granulation and epithelization but it may also impair wound healing. Aerobic bacteria are isolated from most chronic wounds, particularly coagulase- negative Staphylococcus, S aureus, . Propionibacterium acnes and Bacteroides genus are the most prevalent anaerobic isolates. Infection may sometimes result in a proliferative response i. For most procedures prophylactic antibiotics are unnecessary and risk adverse drug reactions. However they should be considered in those at high risk of wound infection especially if there are multiple predisposing factors. Where possible, correct for intrinsic patient risk factors: Control diabetes. Stop smoking. Minimise steroid use. Optimise nutrition. Avoid prolonged preoperative hospitalisation. Identify and eradicate nasal colonisation by S aureus. Preoperative transfusion if anaemic. Treatment of wound infection. An infected wound must be cleansed and debrided to remove necrotic tissue and foreign bodies. Techniques include: Surgical debridement. Topical enzymes. Moisture- retentive dressings. Biosurgical therapy (maggots etc)Negative- pressure wound therapy (also called vacuum assisted closure or VAC). Treatment with topical antibiotics is popular but undesirable because of increasing rates of bacterial resistance. Current interest is focused on antimicrobial moisture- retentive dressings, honey, essential oils and cationic peptides.
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