i. REACTION (inflammation) injury to 3 days: Vasoconstriction to control haemorrhage formation

RDN-027 Wound Healing 1. TYPES OF WOUNDS: i. Acute wounds: An acute wound occurs as a result of injury or surgical intervention eg. surgical incisions, crushing wounds, shearing wounds, burns etc (Davis et.al.,1993). ii. Chronic wounds: Chronic wounds are the result of a predisposing condition, which impairs the tissue's ability to maintain its integrity or to heal eg. venous and arterial ulcers, diabetic ulcers, pressure ulcers etc. 2. 3R'S OF WOUND HEALING: (Note: the stages of healing overlap) i. REACTION (inflammation) injury to 3 days: Vasoconstriction to control haemorrhage formation Clot In the next 24 hours there is an acute inflammatory response at the wound margins and the formation of exudate. Vasodilatation leads to: - the formation of serosanguinous exudate in the wound and - redness (erythema) - heat - swelling (oedema) - pain - loss of function. INFLAMMATION (this is a normal process of healing) Debridement - The neutrophils and macrophages in the exudate remove dead cells and debris. ii. REGENERATION (proliferation and contraction) 1-24 days: Capillaries bud to form new vessels and collagen forms new tissue granulation tissue forms John Bailey 2009 Page Sequence: Page 1 of 19

Granulation moves inward from the wound margin. The epithelial cells at the skin margin begin to grow and in the next 36 to 72 hours the epithelium begins to cover the wound below the eschar (scab). The regenerating epithelium uses the granulation tissue beneath the scab as a base upon which to grow. Eventually the wound heals, with scar tissue closing the defect and regeneration of the epithelium. Once the epithelium covers the wound the scab drops off. Skin appendages such as hair follicles and sweat glands are unable to regenerate, and this scarred area will not contain these specialised structures. iii. REMODELLING (maturation) 24 days to 1-2 years Activity within the wound decreases no new granulation tissue Collagen reorganises softens pink scar tissue flattens and scar colour changes from to white 3. TYPES OF WOUND EXUDATE (DISCHARGE): i. Serous: is comprised chiefly of serum is watery in appearance clear to slightly brown ii. Purulent: thicker than serous exudate due to pus varies in colour, sometimes acquiring tinges of green or yellow iii. Sanguineous/Haemorrhagic: consists of large amounts of red blood cells colour may be bright red to dark red iv. Haemoserous/serosanguineous: contains both watery serum and red blood cells Wound exudate has been demonstrated to contain anti microbial substances that offer protection, cleanses the wound and provides a moist environment that is conductive for healing. However, excessive exudate will macerate the surrounding skin as well as provide an environment for micro-organisms. John Bailey 2009 Page Sequence: Page 2 of 19

WOUND HEALING MAJOR COMPLICATIONS OF WOUND HEALING: i. Wound dehiscence: a bursting open of the wound ii. Wound infection: wound infection prolongs the inflammatory stage-of healing. Most wounds are colonised by some micro-organism, however acute infections require appropriate treatment. Clinical signs of infection: inflammation, localised pain, heat and erythema oedema around the wound margin increased exudate copious pus - green, yellow or grey offensive odour pyrexia tachycardia granulation tissue that bleeds easily iii. Haemorrhage: persistent bleeding due to dislodged clot, slipped ligature or erosion of a blood vessel FACTORS AFFECTING HEALING: infection - (bacteria, fungus, viruses) hypoxia - decreased blood flow reduces oxygen and nutrients etc necessary for wound healing eg. diabetes (also leads to an increased susceptibility to infection), vascular disease, anaemia, smoking haematoma - blood in the surrounding tissue releases free radicals which kill fibroblasts (this can lead to necrosis) foreign bodies (need to clean the wound thoroughly by irrigation) age - affects epithelialisation and maturation of scar, blood supply and susceptibility to infection poor nutritional state - decreased amounts of protein, vitamin C & A, copper, iron and zinc, which are essential for wound healing. Obesity also affects the healing process. degree of injury/location of wound stress - glucocorticoids are released and this results in protein being broken down steroid therapy - the process of healing is delayed wound care - the use of antiseptics, frequent dressing changes, dry dressings chemotherapy (immunosuppressant agents) general health. John Bailey 2009 Page Sequence: Page 3 of 19

NURSING MANAGEMENT OF A WOUND. i. Aims of wound care: ii. Wound Dressings: to promote healing by providing a warm, moist, non-toxic environment or if the wound is palliative - to manage the problems the wound presents eg. control exudate level to select appropriate wound treatments (under the supervision of an RN) to monitor and evaluate the wound care initiated A clean moist environment does not mean excessive exudate on the wound bed - white blood cells & macrophages necessary for wound healing need a moist environment in which to function (Ramstadius 1993) Wound care should normalise the natural healing process so that granulation and epithelisation may occur at their optimum rates. Wound care should do no harm and should remove the adverse influences preventing a wound from healing while providing minimal discomfort and the best possible cosmetic effect. a. The optimum dressing should: promote a moist environment remove excess exudate provide the optimum temperature for healing to occur (approximately body temperature) be impermeable to micro-organisms be free from particles and toxic wound contaminants allow atraumatic removal b. Types of dressings: 1. Film Membranes 2. Foams (Hydrophilic, polyurethane dressings) 3. Foam Cavity Dressings 4. Particles 5. Hydrogels 6. Hydrocolloids 7. Alginates 8. Combinations John Bailey 2009 Page Sequence: Page 4 of 19

9. Miscellaneous The ideal dressing should provide an environment at the wound surface in order to promote wound healing at the maximum rate. NOTE: Studies have shown that wounds that are kept moist and warm heal more rapidly than those exposed to the air (destroy macrophages, leukocytes) or covered with dry traditional dressings (on removal destroy granulation tissue and epithelium cells) - (Winter 1960 cited in Ellis & Beckman 1997; Buchan 1980; Williams 1984 cited in Flanagan 1994). Occlusive dressings increase the rate of epidermal growth up to 40% (Eaglestein 1984 cited in Flanagan 1994) New age dressings are NOT more expensive as they greatly reduce nursing time. 1. FILM DRESSINGS composed of polyurethane and polyethylene film are occlusive or have moisture retentive properties and are waterproof they are usually transparent film dressings allow more rapid re-epithelialisation and result in less scarring than do gauze dressings non absorbent permeable to water vapour also used to prevent wounding eg. pressure ulcers - minimises friction; and as a retention dressing eg. cannulas do not require a secondary dressing Suitable for: relatively shallow, non/light exuding wounds Examples: Opsite (Smith & Nephew) Tegaderm (3M Healthcare) Bioclusive (Johnson & Johnson) Application: cleanse wound and dry the skin around the wound select a suitable size to allow 3cm margin around the wound peel off backing paper and apply to wound Removal: gently lift the dressing from the wound stretch the dressing parallel to the skin while holding the dressing down repeat until the dressing is removed Contra-indications: John Bailey 2009 Page Sequence: Page 5 of 19

infected wounds individuals with very fragile skin 2. FOAMS: HYDROPHILIC, POLYURETHANE DRESSINGS made of polyurethane foam the layer in contact with the wound is non-adherent absorbent - the exudate moves through this layer and into the hydrophobic layer permeable to oxygen and water vapour create a moist wound-healing environment, frequency of change depends on the amount of exudate requires a secondary dressing Suitable for: relatively shallow, moderately to heavily exudating wounds Examples: Allevyn (Smith & Nephew) Lyofoam, Lyofoam A is foam covered by a water resistant self-adhesive layer, Lyofoam Extra for heavily exudating wounds, Lyofoam C activated charcoal layer for malodorous wounds (Boots) Cutinova foam (Beiersdorf) Curafoam (Kendall) Application: cleanse wound and dry skin around select a size of dressing which will allow a 2-3 cm margin round the wound check manufactures instructions re side of dressing to apply to the wound apply secondary dressing (not necessary with Lyofoam A) Removal: remove secondary dressing and gently lift dressing from the wound Contra-indications: wounds covered in dry eschar wounds with no exudate 3. FOAM CAVITY DRESSINGS absorbent foam chipping encased in a perforated film may be used in conjunction with hydrogels if excessively doughy (check instructions for use) requires a secondary dressing John Bailey 2009 Page Sequence: Page 6 of 19

Suitable for: Large deep cavity wounds e.g. pressure ulcers, surgical incisions, pilonidal sinuses Example: Allevyn Cavity Dressings (Smith & Nephew) Cutinova Cavity (Beiersdorf) Application: cleanse wound and dry surrounding skin insert appropriate size/shape dressing into the cavity Removal: remove secondary dressing and gently lift dressing from the wound Contra-indications 4. HYDROGELS hard eschar or necrotic tissue contain mainly water (usually 80%) and carboxymethylcellulose are available in amorphous (without shape) gels or sheets maintain a moist healing environment rehydrates tissue facilitating autolysis (body's ability to absorb dead tissue) and can absorb small quantities of exudate immediate cooling effects that ease pain and may reduce bum inflammation Suitable for: suitable for necrotic, sloughy, and granulating Examples: Amorphous Gels Intrasite gel (Smith & Nephew) DuoDERM Hydroactive Gel (ConvaTec) Hydrogel gel wafers - sheets: NuGel (Johnson & Johnson) Clear Site (Boots) Application: Gel: cleanse wound and dry surrounding skin gel may be squeezed directly into the wound, allied to a depth of 1cm on necrotic wounds and 0.5 cm on other wounds can be applied via a syringe and filling cannula into sinuses John Bailey 2009 Page Sequence: Page 7 of 19

Wafers: cleanse wound and dry surrounding skin select suitable size to cover the wound remove protective layer of film and position exposed side onto the wound Removal: remove secondary dressing and gently irrigate with warmed normal Contra-indications: providone iodine/iodine preparations cause product drug interactions 5. HYDROCOLLOIDS contain hydrophilic (able to absorb fluid) particles eg. gelatin, pectin, and carboxymethylcellulose; formulated together with a hydrophobic adhesive matrix covered by an outer film or foam layer when applied to a wound, exudate combines with the polymers and forms a gel to cover the wound bed and stimulates granulation (the gel may appear to the patient to be pus so they should be warned before removal of the dressing) requires no secondary dressing promotes formation of granulation tissue and provides pain relief by keeping nerve endings moist waterproof, patient can bath or shower can be left in place for up to 7 days or change when leakage occurs (change in wafer colour indicates need for dressing change) Comes in 2 sizes: thin for lightly-exudating wounds standard, for moderately-exudating wounds Suitable for: de-sloughing and for light to medium exudate Examples: Comfeel (Coloplast) DuoDERM (ConvaTec) Aquacel - for heavily exudating wounds (ConvaTec) Cutinova (Beiersdorf) Johnson & Johnson Ulcer Dressing Cutinova thin (Beiersdorf) Application: cleanse wound and dry surrounding skin select a dressing to allow a margin of 1.5-2 cm around the wound remove protective paper and apply dressing to the wound John Bailey 2009 Page Sequence: Page 8 of 19

Removal: peel dressings back from the wound irrigate wound to remove any residue Contraindications: 6. ALGINATES exposed muscle, tendon or bone allergy caution for use on infected wounds medical supervision on ischaemic diabetic ulcers are a polysaccharide with the same chemical make up as seaweed highly absorbent interactive dressings e.g. venous leg ulcers, pressure ulcers, fungating wounds, infected wounds haemostatic effect as the calcium alginate fibres initiate blood coagulation response- suitable for donor sites and freshly bleeding wounds available in a ribbon for sinuses, fistulas and large irregular cavities requires a secondary dressing such as film, hydrocolloid or foam creates a moist wound healing environment Suitable for: highly exudating wounds bleeding wounds Examples: Sorbsan flat and ribbon (Boots) Kaltostat flat and ribbon (Faulding Pharmaceutical) Algoderm (ConvaTec) Curasorb (Kendall) Application: cleanse wound and dry surrounding skin select suitable size dressing to cover wounds if using ribbon packing, fill cavity loosely Removal: loosen outer dressing and peel dressings back from the wound irrigate wound to remove any residue Contraindications: low exudating wounds wounds with dry necrotic eschar John Bailey 2009 Page Sequence: Page 9 of 19

7. COMBINATION DRESSINGS A new group which combines different types of dressings: combinations eg. hydrocolloid and alginate, foam and hydrocolloid; Kendall - Ventex Wound dressing system (vented dressing &_absorbent dressing; Curaderm (Alginate Hydrocolloid) highly absorbent suitable for heavily-exudating wounds creates a moist healing environment 8. MISCELLANEOUS silver sulphadiazine (SSD) cream - clinically infected wounds in patients with diabetes mellitus whose wounds do not respond to other products & second/third degree bums Jelonet, Melonin, Bactigras etc. - gauze impregnated with soft paraffin. For wounds where moist healing is inappropriate i.e. prognosis or specifically ordered by medical officer. Can adhere to the wounds causing trauma during removal, prevents exudate from draining from the wound and can lead to tissue maceration dressings impregnated with providone iodine. Used for infected wounds with a broad-spectrum antiseptic effect. Can cause allergies dressings containing carbon - used for malodorous wounds absorbent dressings - combine pads etc waterproof self-adhesive dressing eg. Beiersdorf Cutifim plus, Hanspor stern NOTE: Dressing products need to be in contact with the wound surface to be effective. John Bailey 2009 Page Sequence: Page 10 of 19

WOUND HEALING ANTISEPTICS Cleansing the wound with or without an antiseptic agent does no actually reduce the bacterial count contaminating the wound, it merely redistributes them over the wound surface. Harper and Simpson (1986), Brennan (1986), Thomas (1990) have extensively reviewed the role of antiseptics and topical agents in wound management. The conclusions drawn from this research is that any benefits derived from the use of antiseptic agents must be weighed against their detrimental effects on wound healing (Flanagan 1994, 5) In addition to their adverse effects upon healing process antiseptics have the following properties: they are unstable compounds they lose their effect when they come into contact with organic material such as wound exudate they need to be in contact with bacteria for 20 minutes (Flanagan 1994, 6) COMMONLY USED ANTISEPTICS - CONTRAINDICATIONS ANTISEPTIC Eusol, Milton Mercurochrome: Gentian Violet CONTRAINDICATION destroy granulation tissue toxic to fibroblasts rapidly lose anti-bacterial properties (Thomas 1990) may cause mercury intoxication (Slee 1979) toxicity to broken skin or mucous membrane Hydrogen Peroxide Providone Iodine when used to irrigate large wounds under pressure or closed cavities air emboli have been reported (Basson 1982; Sleigh 1985). Note: Limited use for excessively doughy wounds, wounds contaminated with gravel, oil or foreign material antibacterial properties greatly reduced in the presence of pus/exudate possibility of skin sensitivity toxic to fibroblasts (Lineweaver 1985) Note: Can be used to clean contaminated traumatic wounds in theatre and Accident & Emergency (Flanagan 1994, 7-8) John Bailey 2009 Page Sequence: Page 11 of 19

CLEANSING OF WOUNDS: The objective of wound cleansing is to remove slough and devitalised tissue, which is necessary if the risk of infection, is to be avoided: * ONLY EXUDATING WOUNDS NEED CLEANSING a. Colonised wounds (wound surface bacteria not causing clinical infection of surrounding tissue: gentle irrigation with warmed Sodium Chloride 0.9% or gentle irrigation under warm shower (there is no evidence to suggest that tap water is harmful to a wound, however it should be noted that the quality of tap water needs to be considered eg. bore water. When in doubt use warmed Sodium Chloride 0.9%) b. Clinically Infected Wounds or Wounds of High Risk of Clinical Infection: warm sodium chloride 0.9% delivered by a 35-m1 syringe and 18g blunt needle (this creates the pressure needed at the wound bed to dislodge harmful micro-organisms) or when a large surface area -an [V bag punctured to deliver a shower effect to the wound CLASSIFICATION OF WOUNDS - RYB CLASSIFICATION SYSTEM i. Red Wounds: clean granulation tissue - RED clean epithelial tissue - PINK Objective: protect from trauma & cold promote wound contraction cleanse around intact skin only (no need to cleanse wound surface) Example: Opsite, DuoDERM ii. Yellow Wounds: doughy - cream, ivory, green or yellow exudate Objective: cleanse and absorb excess exudate and micro-organisms promote moist wound healing John Bailey 2009 Page Sequence: Page 12 of 19

Example: Sorbsan, DuoDERM iii. Black Wounds: necrotic - black, brown, grey adherent tissue Objective: debride o o mechanically using scalpel at the bedside (by Clinical Nurse Consultant - Wound Care or Medical Practitioner ) or under GA autolysis using an occlusive dressing Example: Duoderm NOTE: When a wound has more than one colour present treat the most serious colour first John Bailey 2009 Page Sequence: Page 13 of 19

WOUND HEALING NURSING ACTIONS NOTE: EFFECTIVE ASSESSMENT IS ESSENTIAL FOR EFFECTIVE WOUND MANAGEMENT! ASSESSMENT: type of wound type of healing stage of Healing - 3R's colour of the wound - RYES exudate - type/amount area depth site (draw on diagram) infection (odour, purulence or cellulitis, signs of inflammation, pain) condition of surrounding skin - wet/dry/eczema pain factors that may affect healing need for referral to a health care professional eg. vascular surgeon, dietitian At this stage it is important to identify the nursing objective 1 a PLANNING remember to consider all facets when considering your management - the environment and social circumstances eg. compliance, cost of the dressings, time lost from work, carer support if required select type of management eg cleansing techniques/dressing DO NOT forget other factors such as pressure relief, bed cradles, dietitian etc DOCUMENT plan preferably on a wound assessment chart & appropriate documentation EVALUATION evaluate progress of healing and performance of the dressing. Reassess if necessary the dressing should be given at least 7 days before being evaluated and changed to another product (unless there is an adverse allergic reaction) dressings only need to be changed when there is leakage of exudate or if you suspect infection 1 1 IMPLEMENTATION perform dressing procedure NOTE: in the early stages of management of exudating wounds, daily dressing changes are usually necessary to absorb exudate. As healing progresses exudate lessens, and the frequency of dressing can be reduced inspect daily to ensure they arc secure and intact the wound may initially increase slightly in size as necrotic /sloughy tissue is removed document your management wound field concept John Bailey 2009 Page Sequence: Page 14 of 19

WOUND FIELD CONCEPT The Wound Field Concept is a flexible, problem-solving approach to practising the implementation of current wound management practice. The Wound Field Concept considers the wound, its immediate surroundings and the items-used, to treat/dress the wound as one unique environment. All points external to the outer margin of the dressing used to cover the wound, including the nurse, would be considered an entirely separate environment. When the two environments come into contact, then contamination has occurred (Ellis & Beckman 1997). This is a slightly different concept to 'Aseptic Technique' which does not regard the materials going into the wound and the wound as one field. However, aseptic technique is still utilised in certain procedures such as the care of a central line, in catheterisation, lumber puncture, bone marrow biopsy, in the operating theatre etc. Yet, in wound management 'Wound Field' is more applicable as most of the wounds cared for are chronic wounds such as leg ulcers and pressure ulcers, where most often the dressing is changed in the shower. In these instances, aseptic technique is not adaptable enough to ensure safe practice. However, in applying the 'Wound Field Concept' the need to prevent contamination is still paramount to the safety of the patient. REFERENCES: Davis, M.H., Harder, R.M., Laidlaw J.M. (1993). The Wound Handbook. University of Dundee, Centre for Medical Education, Dundee. Ellis, T., & Beckmann, A. (1997). The Wound Field Concept: A New Approach to Teaching and Conceptualising Wound Dressing. Primary Intention. May, pp. 28-34. Flanagan, M (1994). Development of a Wound Care Protocol, Boot Company. Ramstadius, B. (1993). Illawarra Area Health Services: Guidelines for Wound Management. Unpublished, Illawarra Area Health Service. John Bailey 2009 Page Sequence: Page 15 of 19

PROCESS OF TISSUE REPAIR The 3R s Of Wound Healing: 1. Reaction (Inflammation) - injury to 3 days. This is the phase of wound cleaning and stimulation of healing. Initial vasoconstriction helps platelets to form a clot. Injured cells release a substance (histamine) that causes capillary vasodilation. As a result of this dilation, blood flow is increased to the area of damage to increase redness (erythema) and heat. The capillaries become more permeable with fluid leaking into the tissue and causing swelling (oedema). This increased pressure in the tissues can lead to pain and loss of function. These 5 characteristics (i.e. those underlined) are features of inflammation which is a normal process of healing. Serosanguinous exudate (clear watery yellow pink fluid) forms. This is necessary for effective healing. Removal of dead cells (debridement) by white blood cells infiltrating the area occurs. 2. Regeneration (proliferation) - up to 3 weeks. Capillaries bud to form new vessels. New tissue forms (this needs oxygen, iron and vitamin C). Epithelial cells migrate to form new skin at wound margins (epithelialisation). 3. Remodelling (maturation) - from 3 weeks to 2 years. Wound closes Scar tissue flattens and softens. Scar fades (i.e. from pink to white in fair skinned people). John Bailey 2009 Page Sequence: Page 16 of 19

SUMMARY: A) PRIMARY INTENTION HEALING Primary Intention: Full thickness wound edges are approximated shortly after the primary wound has been created. Epithelisation and wound contraction have little to do with healing in primarily closed wounds. Within 24-48 hours the wound is sealed from bacterial contamination i.e. surgical wounds with nil tissue loss. Delayed Primary Closure: Closure of grossly contaminated incisions should be delayed allowing time for host inflammatory and immune responses to control contamination i.e. contaminated wound with nil tissue loss i.e. colorectal surgery. 3. Describe the mechanisms of healing. i) REACTION PHASE (INFLAMMATION) - INJURY TO 3 DAYS. ii) REGENERATION PHASE (PROLIFERATION) UP TO 3 WEEKS. iii) REMODELLING (MATURATION) - FROM 3 WEEKS TO 2 YEARS. 4. What is inflammation? A SERIES OF CHANGES IN THE TISSUES INDICATING THEIR REACTION TO INJURY - REDNESS, HEAT, SWELLING, PAIN, LOSS OF FUNCTION. 5. List and explain the factors which affect healing. INFECTION: HYPOXIA: HAEMATOMA: Systematic (results in a depletion of protein); locally (some bacteria can delay the healing process. Decreased blood supply reduces oxygen and nutrients etc, necessary for wound healing. Can occur with diabetes, mellitus, vascular disease, anaemia, smoking. This can lead to necrosis. FOREIGN BODIES: Need to clean the wound thoroughly eg. By irrigation. AGE: Affects epithelialisation and maturation of scar, blood supply and susceptibility to infection. POOR NUTRITIONAL STATE: Protein, vitamin C and A, copper, iron and zinc are essential for wound healing. DEGREE OF INJURY/LOCATION OF WOUND STRESS: John Bailey 2009 Page Sequence: Page 17 of 19

Glucocorticoids are released and this results in protein being broken down. STEROID THERAPY:The process of healing is delayed. WOUND CARE: The use of antiseptics, frequent dressing changes, dry dressings. CHEMOTHERAPY: E.g. immunosuppressant agents. GENERAL HEALTH. 6. What are 2 adverse effects of primary intention healing? i) HYPERTROPHIC SCARRING ii) KELOID SCARRING B) SECONDARY INTENTION HEALING Healing by natural biological processes without surgical intervention Contraction is the most important phenomenon in the spontaneous closure of large open wounds i.e. dehiscence of primary healing wounds, tissue loss due to trauma, chronic ulceration due to various causes i.e.. arterial, venous, pressure necrosis. 7. What is the nursing objective for the care of a secondary intention healing wound? TO PROVIDE THE OPTIMAL CONDITIONS FOR HEALING IE. PROVIDE A MOIST ENVIRONMENT, PROTECT THE WOUND FROM FLUID/HEAT LOSS, MICROORGANISMS AND TRAUMA. 8. What are the goals of wound care for secondary intention healing wounds? TO KEEP THE WOUND CLEAN AND GIVE PROTECTION. 9. How does a secondary intention wound heal? THE FORMATION OF GRANULATION TISSUE AND CONTRACTION. 10. What type of wound usually heals by secondary intention? CHRONIC WOUNDS EG. ULCERS, THIRD DEGREE BURNS. 11. Why is the packing of a wound with gauze not appropriate? PACKING WITH GAUZE INCREASES THE PRESSURE IN THE WOUND WHICH IN TURN WILL REDUCE THE BLOOD FLOW TO THE AREA IN ADDITION, GRANULATION TISSUE IS REMOVED WITH THE GAUZE WHEN THE DRESSING IS CHANGED. THIS CAN CAUSE GREAT PATIENT DISCOMFORT AND DELAYS IN HEALING. John Bailey 2009 Page Sequence: Page 18 of 19

12. What is the major complication of secondary intention healing? C) PARTIAL THICKNESS HEALING Partial thickness wounds. Injury to the epidermis/dermis Repair involves epithelialisation (approximately 12 days) i.e. abrasions, skin graft, I and 2 degree burns. 13. Give some examples of a partial thickness wound. FIRST / SECOND DEGREE BURNS, ABRASIONS, DONOR SKIN GRAFT SITES. 14. How does a partial thickness wound heal? EPITHELIALISION - PROLIFERATION AND MIGRATION OF EPITHELIAL CELLS John Bailey 2009 Page Sequence: Page 19 of 19