tissue integrity

• Wound healing


  Occurs in four stages: hemostasis, inflammation, proliferation and remodeling

  
• Hemostasis

  Blood vessels constrict to stop bleeding and form blood clots
• Inflammation

  Neutrophils and macrophages work to remove debris and prevent infection. Signs and symptoms include redness and swelling.
• Proliferation

  The wound is rebuilt with connective tissue to promote granulation and repair the wound
• Remodeling

  Epithelial tissue forms in a moist healing environment
• Goals of wound management

  • Stop bleeding
  • Clean debris and prevent infection
  • Promote tissue growth and protect the wound
  • Protect new epithelial tissue

  
• Acute wound


  A wound which occurs suddenly and progresses through the stages of healing as expected

  
• Chronic wound


  A wound which fails to progress or progresses slowly through the stages of healing. Healing can be greater than 4-6 weeks.

  
• Surgical wound

  A wound which is secondary to surgical intervention e.g. scalpel incision, surgical drain

  
• Non-surgical wound

  An acute or chronic wound which is not secondary to surgical intervention

  
• Wound tissue types


  • Epithelial
  • Granulating
  • Slough
  • Necrotic
  • Hyper-granulating
• Epithelial tissue


  Appears pink or pearly white and wrinkles when touched. Occurs in the final stage of healing when the wound is covered by healthy epithelium.
• Granulating tissue

  Appears red and moist. Occurs when healthy tissue is formed in the remodeling phase that is well vascularized and bleeds easily.
• Slough

  Appears yellow, brown or grey. Slough is devitalized tissue made of dead cells or debris.
• Necrotic tissue

  Appears hard, dry and black. Necrotic tissue is dead tissue that prevents wound healing.
• Hyper-granulating tissue

  Appears red, uneven or granular. Occurs in the proliferative phase when tissue is over grown.
• Measuring a wound

  1. Measure length "head-to-toe" at the longest point

  2. Measure width side-to-side at the widest point

  3. Measure depth at the deepest point

  
• Tunneling

  Caused by destruction of the fascial planes which results in a narrow passageway. Tunneling results in dead space that has the potential for abscess formation.
• Undermining

  Occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface.
• Wound infection stages


  • Contamination
  • Colonization
  • Local infection
  • Spreading and systemic infection
• Contamination

  The presence of microorganisms that are contained and do not multiply. It does not provoke a host response so healing is not impaired. Antimicrobials are not indicated.
• Colonization

  Microorganisms multiply but do not provoke a host response. The infection is contained but wound healing may be delayed. Antimicrobials are not indicated.
• Local infection

  Invasion by an agent that, under favorable conditions, multiplies and produces effects that are injurious to the patient. When microorganisms and bacteria move into the wound tissue and invokes a host response. Healing is impaired and can lead to wound breakdown. Topical antimicrobials are indicated.
• Spreading and systemic infection

  Microorganisms spread from the wound through the vascular and or lymphatic systems and involves either a part of the body (spreading) or the whole body (systemic). Healing is impaired. A systemic approach is needed e.g. topical antimicrobials and the use of antibiotics to prevent sepsis.
• Wound odor

  • No odor
  • Slight malodor: odor when the dressing is removed
  • Moderate malodor: odor upon entering the room when the dressing is removed
  • Strong malodor: odor upon entering the room when dressing is intact
• Wound exudate


  Moisture produced by all wounds to maintain a moist environment, cleanse the wound, provide nutrients and white blood cells, as well as promote epithelialization.
• Excess exudate leads to maceration and degradation of skin, while too little moisture can result in the wound bed drying out.
• The overall goal of exudate is to effectively donate moisture and contain it within the wound bed.
• Advancing wound edges


  Edges are pink. Healing is taking place.
• Non-advancing wound edges


  Edges are raised, rolled, red or dusky.
• Extrinsic/Local factors affecting wound healing

  • Wound dehydration
  • Infection
  • Wound location
  • Mechanical stress, pressure/friction

  
• Intrinsic/Systemic factors affecting wound healing

  • Nutrition
  • Underlying or chronic disease
  • Impaired perfusion
  • Medications (immunotherapy, chemotherapy, radiation or NSAIDs)
  • Mental health (including stress, anxiety or depression)
  • Patient knowledge, understanding or compliance
  • Age of patient
• Wound healing types

  • Primary
  • Secondary
  • Tertiary
  • Negative pressure wound therapy

  
• Primary wound healing

  The wound edges can be pulled together e.g. surgical incision (using sutures, staples, steri-strips or glue), small wounds, paper cuts.

  
• Secondary wound healing

  The wound edges don't come together and need dressing products to promote granulation.

  
• Tertiary wound healing

  The wound is cleaned before it can be closed due to a high-risk of infection e.g. contaminated wounds.

  
• Negative pressure wound therapy

  Topical negative pressure or vacuum assisted closure (VAC) is a foam dressing attached to a device to assist with wound closure, proliferation, moisture removal and stabilization of the wound environment. Typically used in open or dehisced wounds, grafts, flaps or pressure injuries.
• Wound debridement types


  • Surgical
  • Mechanical (wet-to-dry)
  • Enzymatic
  • Biological (maggots)
  • Irrigation
• Standard Precautions are a set of practices that apply to the care of patients in all healthcare settings at all times. Standard precautions remain the cornerstone of infection prevention.
• Optimal nutrition for wound healing

  • Protein: provides building material for muscle and skin repair
  • Carbohydrates: supplies the energy needed for healing
  • Foods with vitamin A: supports skin repair and the immune system
  • Foods with vitamin C: assists in collagen production and supports the immune system