Wound Care

Question 0

What are acute wounds?

Answer 0

Wounds that proceed normally through the repair process.

Question 1

How is the process of wound healing described?

Answer 1

Best thought of as a cascade of events, which under normal circumstances result in repair.
It is a dynamic process where the descriptive stages overlap and do not occur in isolation of each other.

Question 2

What are chronic wounds?

Answer 2

Those that are failing to heal as anticipated or that have become fixed at any one phase of wound healing.

Question 3

What are the phases of wound healing?

Answer 3

• Haemostasis
• inflammation
• proliferation
• maturation

Question 4

What is haemostasis?

Answer 4

A physiological response which starts immediately after injury.

Question 5

How is haemostasis achieved? (What physiological processes are involved?)

Answer 5

A combination of:

• vasoconstriction to conserve blood loss
• and the release of clotting factors where the clot serves to act as a bacterial barrier and framework for migrating cells.

Question 6

What happens before haemostasis is achieved?

Answer 6

1. Fibrin forms a mesh trapping blood cells.
2. The fibrin, together with platelets, provide limited structural strength but the strands within the clot contract and draw the mesh cells inward drawing the edges of the wound together.
3. The clot seals blood vessels and contracts, resulting in the edges pulling together.

Question 7

Do all wounds follow/go through the haemostasis stage? Explain.

Answer 7

No. Not all wounds. Will depend on the nature of the wound.
- Many chronic wounds such as pressure ulcers are caused by lack of blood supply to the tissues; therefore they would not go through the haemostasis phase.

Question 8

What is inflammation?

Answer 8

It is a normal vascular and cellular response to any injury and healing cannot progress if inflammation does not occur.

Question 9

What does inflammation look like locally?

Answer 9

The presence of: - heat
-swelling
-erythema 
-discomfort
Note: these should not be confused with the signs of infection.

Question 10

What physiological processes are involved in inflammation?

Answer 10

1. Neutrophils cleanse the areas of bacteria and devitalised tissue.
2. Monocytes are also attracted to these areas; these transform into macrophages and help with the cleansing process through phagocytosis.
3. Wound exudate is produced during this stage.
4. In healthy wounds it contains many substances that are vital to wound healing including neutrophils, macrophages, lymphocytes, pro teases and growth factors.
5. Slough often occurs in the inflammatory phase (this is a collection of dead cellular debris on the wound surface)

Question 11

What must be taken into consideration about wound exudate in terms of healing?

Answer 11

Though the presence of exudate is vital for normal wound healing,
It can also damage intact skin
- therefore it must be managed effectively in order to prevent further breakdown.

Question 12

When does the Proliferation phase begin? (In terms of days)

Answer 12

About day 3 to 14.

Question 13

What controls the beginning of the proliferation phase and how?

Answer 13

Macrophages.
- through the secretion of vascular endothelial growth factor (VEGF)

• VEGF stimulates the formation of new blood vessels (angiogenesis) which are important for the delivery of oxygen and nutrients to the healing tissues.

Question 14

What happens during proliferation?

Answer 14

• An extracellular matrix (ECM) is formed from substances including collagen.
• This provides scaffolding into which the new blood vessels grow (angiogenesis).
• The deposition of the ECM, together with angiogenesis, comprises the granulation tissue.
• (Healthy granulation tissue can appear as bright red or pinky red in colour and does not bleed easily)
• Note: dark discoloured granulation tissue with increased friability is an additional symptom of wound infection.
• wound contraction also occurs in this phase.
• The activity of fibroblasts, collagen and elastin are all involved in contracting and pulling the wound edges together.
• once contraction has taken place, the regrowth of epithelial cells across the wound surface can start to take place.
• New epithelial cells will begin to migrate from the wound edges and also from within hair follicles, sebaceous glands and sweat glands.
• the new epithelial cells are white/pink, and they stop migrating once they meet other epithelial cells in the wound.
• epithelial migration is accelerated in a moist environments as it enables the epithelial cells to migrate more easily.
• epithelial cells proliferate and crawl across the wound bed providing cover for the new tissue.

Question 15

When does the maturation phase begin and how long does it last?

Answer 15

The onset of this phase may very extensively, depending on the size of the wound and weather it was initially closed or left open. Furthermore, it can last for a year of longer depending in the type of wound.
In chronic wounds this stage may be more protracted. During this phase the wound is strengthened and the scar will change colour significantly.

Question 16

What happens during the maturation phase?

Answer 16

• The wound becomes stronger as macrophages stimulate collagen bundles to mature and form a stronger more organised layer.
• The tensile strength of scar tissue compared to normal skin is about 70%.
• As the vascular network in the wound decreases, the scar changes colour.
• it becomes less red and more silver or white in appearance. The mature scar tissue is relatively a vascular and contains no hair, sebaceous or sweat glands.

Question 17

What is involved in healing by primary intention?

Answer 17

Primary intention healing refers to a wound where the edges have been bought together by sutures, clips, staples or glue.

Question 18

When is healing by primary intention suitable?

Answer 18

• a deliberate incisional wound with no tissue loss, where the wound edges are held in opposition to each other. (E.g a surgical wound)

Question 19

Do the phases of wound healing progress as normal with primary intention healing?

Answer 19

Yes

Question 20

How do these wounds heal? What does it look like?

Answer 20

-Usually heal quickly with minimal scar formation.
(As long as infection and secondary break down Are prevented)
-most acute wounds will heal uneventfully in a predictable timeframe and will only result in a small scarred area for the patient.
-A thin white scare may be all that remains after six months as the tissues shrink, becoming paler and less vascular.

Question 21

When does healing by secondary intention occur?

Answer 21

When damage has resulted in loss of tissue and where the skin edges cannot be brought together for wound closure. (Where the injury extends to deep tissue involving the epidermis and underlying tissue.)

Question 22

What is the healing process like with secondary intention healing?

Answer 22

The healing process takes longer due to the volume of connective tissue required to fill the wound.
Wounds heal by secondary intention where the wound granulated from the base up and epithelialises to form a larger area of scar tissue.

Question 23

How are wounds that require secondary intention healing managed?

Answer 23

Often by conventional dressings.

Question 24

What kind of wounds are usually healed by secondary intention?

Answer 24

Dehisced (burst open) abdominal wounds, complicated by infection.

Question 25

What is involved in tertiary or delayed primary closure?

Answer 25

• the wound is managed by delayed closure (I.e it is left open to be closed at a later date).

Question 26

In what situation would someone choose to delay primary closure (I.e choose to heal a wound through tertiary healing)?

Answer 26

• if closure of a wound is unsuccessful at time of surgery. One may choose to leave it open to close at a later date.
• This closure method is often used where there is considerable bacterial contamination or the wound is complicated by oedema or excessive exudate production.
• Risk of infection and tissue loss are higher during the days that the wound is left open.

Question 27

What was the traditional method for encouraging wounds to heal and what has changed?

Answer 27

• The traditional method for encouraging wounds to heal was to allow them to dry out and form a scab.
• Due to a number of studies showing the benefit of moist wound healing, It is now widely accepted that a ‘moist’ environment is optimal for wound healing.
• This has led to the development of our modern wound care products which aim to provide this environment.

Question 28

What are the benefits of moist wound healing?

Answer 28

• It supports epithelial cell migration.
• there is reduced pain. (The healing process is supposedly less painful)
• the natural autolysis process and it’s breakdown is promoted in a moist wound healing environment.

Question 29

Why is it important to control the moisture levels in a wound carefully?

Answer 29

• if there is too little moisture, healing will be slower.
• if there is too much moisture and the wound it too wet, it will be more prone to over granulation, infection and maceration of the surrounding skin.

Question 30

Why do chronic wounds occur?

Answer 30

• It is thought that chronic wounds may lack the initial trigger that begins the cascade of healing.
• they are often caused by an underlying pathology such as vascular insufficiency which produces repeated insults to the tissues.
• these wounds then become stuck in a vicious cycle in which a prolonged inflammatory phase serves to cause further tissue damage.

Question 31

What is assessment and why is it carried out within health care?

Answer 31

• Can be defined as information obtained via observation, questioning, physical examination and clinical investigations.
• done in order to establish a baseline for planning intervention.