Introduction to wound management

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Introduction to wound management

• Wound Healing HLTEN406A

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Topics

• The healing process
• Chronic acute wounds
• Recognition management of infection
• Planning wound care
• Wound management products
• Aseptic technique - clinical laboratory
• Protocols, practice documentation

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Anatomy of skin

• Wounds1.com

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Causes of wounds

• Trauma, including burns
• Surgery
• Vascular insufficiency
• Venous insufficiency e.g. venous ulcer
• Ischaemia e.g. arterial leg ulcer
• Pressure e.g. pressure sore
• Radiation therapy

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Wound healing process

• Primary intention
• Wounds which are surgically closed
• Skin edges are approximated
• May have sutures, clips, adhesive tape
• Secondary intention
• Wounds which have delayed healing
• Where there is tissue loss, e.g. ulcers,
  macerated or dirty wounds

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Wound healing process

• Four important phases
• Inflammation
• Reconstruction
• Epithelialisation
• Maturation

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Inflammation

• Non-specific local reaction
• Part of bodys defence mechanisms
• Necessary part of healing process

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S S of inflammation

• Redness - caused by vasodilatation
• Heat - due to ? circulation
• Swelling due to ? extra cellular fluid
• Pain due to nerve damage, activation of kinin
  system, pressure of fluid in tissues or presence
  of enzymes (prostaglandin).

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Responses to injury

• Capillaries dilate and become more permeable
• Fluid flows into the injured tissues
• Platelets
• create a plug in injured vessels
• release growth factors and fibronectin

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Responses to injury cont/

• Fibronectin attracts neutrophils to the site and
  enhances their ability to squeeze through
  capillaries into tissue fluid
• Neutrophils phagocytise bacteria
• Growth factors attract monocytes which become
  macrophages in the tissue fluid

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Inflammation cont/

• Lasts about 4 5 days
• Requires energy nutritional resources
• In large wounds this may be considerable
• Prolonged irritation of the wound e.g. infection,
  F/B or dressings, is debilitating and delays
  healing.

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Reconstruction

• Macrophages produce growth factors which attract
  fibroblasts
• Fibroblasts multiply and produce collagen
• Fibronectin also enhances fibroblasts
• Activity of fibroblasts is dependent on oxygen
  supply (poor O2 poor healing)

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Reconstruction cont/

• Process of angiogenesis formation of new blood
  vessels
• May last about 24 days for wounds healing by
  primary intention
• This process is most obvious in granulating
  wounds
• wounds which heal by secondary intention

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Granulation
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Epithelialisation

• Epithelial cells migrate to cover the defect
• Relatively rapid in wounds healing by primary
  intention
• In chronic wounds, this is very slow
• Choice of dressing is very important so as not to
  disrupt this process

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Epithelialisation
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Maturation

• The wound becomes less vascularised
• Collagen fibres are reorganised
• Scar tissue is gradually remodeled and more like
  normal tissue over time
• Scar flattens to a thin white line
• Rate and appearance varies between individuals
  up to 1 yr in closed wounds, much longer in open
  wounds

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Maturation cont/

• Tensile strength of the wound increases over time
• At 10 days (when sutures are removed) wound has
  relatively little strength
• At 3/12, tensile strength is at 50 of normal
• Dehiscence is term used for ruptured wounds

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Factors affecting wound healing

• Hypoxia
• Dehydration
• Nutrition
• Temperature
• Excess exudate
• Recurrent trauma
• Diabetes

• Necrotic tissue debris
• Infection
• Chemicals
• Drugs
• Alcohol smoking

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Intrinsic factors affecting healing

• General health status
• Chronic disease (diabetes, COAD)
• Age
• metabolism slows with ageing
• Body build
• obesity is a deterrent (poor blood supply)
• Nutritional status, including fluids

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Suture removal

• Abdominal wounds usually ten days (see diagram)
• Hands, feet take much longer up to 3 weeks
• Scalp, face heal very quickly
• Facial sutures may be removed at 3 5 days
• Laparoscopic wounds heal in a few days - very
  small, little tension on area

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References

• Body1 Inc. 2008 Wounds1.com accessed 19/5/08
  http//www.wounds1.com/pr_ulc/index.cfm
• Carville, K. 2005 Wound Care, 5th edition.
  Silver Chain Nursing Association, Osborne Park,
  WA (617.14 CAR)
• Herlihy, B. 2007 The Human Body in Health and
  Illness 3rd edn., St Louis
• Stockslager, J. (Ed.) 2003 Wound Care made
  Incredibly Easy!, Lippincott Williams Wilkins,
  Philadelphia (617.14 WOU)
• Templeton, S. (Ed.) 2005 Wound Care Nursing A
  Guide to Practice, Ausmed Publications, Melbourne
  (617.106 WOU)
• Victorian Government Health Information, Pressure
  Ulcers accessed 19/5/08 http//www.health.vic.go
  v.au/pressureulcers/education.htm