1 Normal wound healing, and the enemies! Esther White Tissue Viability Nurse
2 A wound - definition A wound may be defined as the interruption of continuity in a tissue, usually following trauma. Skin is predominantly affected although any tissue, whether nerve, bone or organ, may be wounded.
3 How do wounds heal? Normal healing process is a well orchestrated, complex and interlinked series of four well recognised overlapping phases
4 Understanding normal healing Four phases of wound healing: 1. Vascular response (or coagulation) 2. Inflammation 3. Proliferation 4. Maturation The normal process can be interrupted at any stage and is vulnerable to a variety of intrinsic and extrinsic factors
5 Vascular response Trauma Bleeding Fibrin mesh temporarily closes wound and dries to form a scab Blood and serous fluid help to cleanse the wound surface
6 Inflammatory phase Release of inflammatory modulators Vasodilation, heat and erythema Increase in exudate rich in MMPs Neutrophils are 1 st line defence against infection (but short life span) Macrophages & lymphocytes clean wound bed so that cells go to proliferation phase
7 Proliferation Granulation tissue produced through collagen production (scaffolding) Extra cellular matrix is also built Scar tissue starts to be restored to structure and function Epithelial cells & fibroblasts from uninjured tissue & stem cells circulate towards the wound The fibroblasts send out Spiderman like web and pull edges inwards
8 Maturation Collagen fibres are re-organised and constantly new collagen is being synthesised Scar tissue is gradually remodelled & eventually is comparable normal tissue Full repair can take months but only 80% tensile strength is ever regained
9 As a rule... Most wounds follow this 4 stage process BUT...unfortunately most of the wounds that we see are chronic and often hard to heal Put your Detective Hat and pipe on...we need to see what is causing the break in this clever process in order to know how to treat it! Some science...
10 MMP s Matrix metalloproteinases Important part in wound healing Produced by inflammatory and wound cells essential in the migration of cells Can remove denatured cells HOWEVER they can start to degrade healthy tissue and functional parts of the matrix Too much present = degrading proteins, leading to delayed healing
11 How do we as nurses know? Wounds are failing to progress Wounds appear inflammatory Cycles of local wound bed infection Less than 40% wound area reduction in 4 6 weeks is a significant indicator A protease testing kit has been developed (still awaiting more info so don t get excited!)
12 Vicious circle of delayed wound healing
13 Breaking out of the circle to encourage healing
14 But wound care can be challenging
15 What are the challenges?
16 Skin care or wound care?
17 Dealing with complex underlying causes
18 Toe bandaging? You ARE joking??
19 Improve peri - wound skin
20 Skin problems?
21 Treat the cause unmanaged exudate will increase bacterial burden and therefore the inflammatory response
22 Debride or not debride?
23 DVT, Cellulitis or oedema?
24 How realistic can you be?
25 What are the underlying problems?
26 Identify problems for healing
27 Villains of wound healing... Pain Compromised blood supply Increased or decreased moisture Devitalised tissue slough, necrosis Infection local or systemic Oedema Co-morbidites
28 Specific factors think outside the box! Intrinsic Extrinsic Wound specific
29 Patient related - Intrinsic Co morbidities (Diabetes, PVD, Rh Arthritis, Renal disease, COPD) Pain Ischaemia EoL status Immobility Mental health (including anxiety & depression) Malnutrition Anaemia Medication associated with co morbidities Underlying osteomyelitis
30 Patient related factors - Extrinsic Non concordance Social isolation Financial/ employment issues Environmental Nurse/ pt relationship Is a carer for others Cultural/ religious beliefs Previous experiences Lifestyle choices
31 Wound related factors Long wound duration Large wound (> 100cm²) Full thickness wound (Exposed tendon or bone) Underlying osteomyelitis Failure to progress by 40% at 6 weeks Presence of devitalised tissue Presence of local infection Presence of systemic infection High exudate levels Wounds over a moveable joint Wounds that are in close proximity to an orifice (ie anus, stoma) Inflammatory/ excoriated or macerated peri wound skin Presence of oedema History of previous damage to same site Malignancy
32 In summary: Understand normal healing so you can recognise the abnormal Assess holistically to enable you to identify the risks for healing Recognise why a wound is behaving in a certain way and be able to put a evidence based plan in place to manage the problem. Measure the effectiveness of your management plan taking appropriate action if outcomes aren't being met.
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