Wound Healing-A Process Almost All RNs Encounter
June 5th, 2012
By Jennifer Olin, BSN, RN
Summer fun and all that comes with it can mean ice cream and fireworks or it can mean scraped knees and bandages. With all the baseball games, hanging out, and swimming in the lakes or at the beach, and riding bikes down mountain trails, injuries happen.
When those abrasions, lacerations, punctures, and incisions are taken care of there is a very definite healing process. In fact, there are three types of healing, distinguished by just how much skin and tissue has been lost:
- Primary Intention Healing – This occurs where the tissue surfaces have been approximated (closed). This can be with stitches, or staples, or skin glue (like Derma bond), or even with tapes (like steri-strips). This kind of closure is used when there has been very little tissue loss. It is also called “primary union” or “first intention healing.” An example of wound healing by primary intention is a surgical incision.
- Second Intention Healing – A wound that is extensive and involves considerable tissue loss, and in which the edges cannot be brought together heals in this manner. This is how pressure ulcers heal. Secondary intention healing differs from primary intention healing in three ways:
- The repair time is longer.
- The scarring is greater.
- The chances of infection are far greater.
- Tertiary Intention Healing – This type of wound healing is also known as “delayed” or “secondary closure” and is indicated where there is a reason to delay suturing or closing a wound some other way, for example when there is poor circulation to the injured area. These wounds are closed later.
Wounds that heal by tertiary intention require more connective tissue (scar tissue) than wounds that heal by secondary intention. An example of a wound healing by tertiary intention is an abdominal wound that is initially left open to allow for drainage but is later closed.
Promoting Wound Healing
Any type of wound undergoes considerable stress while in the healing process. For example, there may be physical stressors such as strain on sutures from coughing or sneezing; simple movement of the offended body part can cause undue trouble at the site and disrupt the wound layers.
One nursing responsibility is protecting the wound and promoting healing. It takes from 24 to 72 hours for a closed wound to really establish a seal. If a wound is going to become infected, it usually occurs three-to-six days after the incident but can take up to 30 days to appear as defined by the Centers for Disease Control and Prevention in their Criteria For Defining A Surgical Site Infection (SSI).
A clean surgical wound usually doesn’t regain strength against normal stress for 15-20 days after surgery. For other types of wounds, depending on the severity, those numbers can be greater or lesser. Ongoing observation for the wound identifies early signs and symptoms of stress such as infections.
Factors Affecting Wound Healing
There are a number of factors to take into consideration when waiting for a wound to heal. Any one or a combination of these can multiply how long it will take for a patient to fully recover from a wound of any type, superficial or deep.
- Developmental Considerations – Healthy children and adults heal more quickly than the elderly. Older adults are more likely to have chronic diseases, such as peripheral vascular disease, which impairs blood flow. Reduced liver function or diabetes are can also impair healing times. Also, with aging, skin loses its flexibility and scar tissue is less elastic.
- Nutrition – Wound healing places a lot of demands on the body. Clients need a diet rich in protein, carbohydrates, lipids, vitamins A & C, and minerals, such as iron, zinc, and copper. Obese patients are at an increased risk of wound infection and slower healing because adipose tissue usually has an inadequate blood supply.
- Lifestyle – People who exercise regularly tend to have better circulation and are more likely to heal quickly because blood brings oxygen and nourishment to the wound. Smoking reduces the amount of functional hemoglobin (the iron-containing oxygen-transport protein) in the blood which limits the oxygen-carrying capacity of the blood. Smoking also has been linked to clot formation in the circulatory system.
- Medications – Patients who are on anti-inflammatory drugs, (such as steroids or aspirin), heparin or antineoplastic agents (such as medications used in chemotherapy) often suffer delayed healing. Also prolonged use of antibiotics can make a person more likely to develop a wound infection.
- Infection – Wound infections slow healing. There may be infectious agents involved at the time of injury, they may be acquired during surgery or come from exposure later in the healing process.
If any of the aforementioned factors occur while someone is trying to heal from a wound there are a number of complications which can arise:
- Hemorrhage – Some escape of blood from a wound site is normal. However, if there is persistent bleeding it may be caused by a dislodged clot or erosion of a blood vessel or a even a slipped ligature. Internal hemorrhage is often detected by swelling or distention in the area around the wound or even by symptoms more serious such as a rapid, thread pulse, increased respirations, sweating, restlessness, and/or clod, clammy skin.
- Hematoma – Sometimes patients will develop a collection of blood right underneath the skin. A hematoma may appear as a swelling that is reddish-blue in color. A large hematoma may be dangerous because it can place pressure on blood vessels and obstruct blood flow.
- Dehiscence with Possible Evisceration – Dehiscence is the partial or total rupturing of a wound. Evisceration is the protrusion of internal viscera through an incision. These complications are most often involve the layers of the abdomen. A number of factors, including obesity, poor nutrition, multiple trauma, failure of sutures, excessive coughing, vomiting, and dehydration, heighten a patient’s risk of dehiscence. This is most likely to occur four to five days after the wound has been repaired, before the body has had time to deposit sufficient collagen in the wound site.
As nurses we see wounds at all stages of repair. It is important to recognize the different types of wound healing that are occurring, where in the process the patient has progressed to, and if they are not healing well we must assess why and take the appropriate measures to help the process along.