wound healing, a process to restore to a state of soundness any injury that results in an interruption in the continuity of external surfaces

of the body. Also called wound repair. See also healing, intention. Mosby's Medical Dictionary, 8th edition. 2009, Elsevier. healing [h ling] 1. the process of returning to health; the restoration of structure and function of injured or diseased tissues. The healing processes include blood clotting, tissue mending, scarring, and bone healing. See also WOUND HEALING. 2. the process of helping someone return to health; COMPASSION by a health care provider is part of this. Authentic perception of the experience of illness in the particular person is the essential basis. healing by first intention (healing by primary intention) WOUND HEALING in which restoration of continuity occurs directly by fibrous adhesion, without formation of granulation tissue; it results in a thin scar.

Healing by primary, or first intention. In primary wound healing there is no tissue loss. A, Incised wound is held together by a blood clot and possibly by sutures or surgical clamps. An inflammatory process begins in adjacent tissue at the moment of injury. B, After several days, granulation tissue forms as a result of migration of fibroblasts to the area of injury and formation of new capillaries. Epithelial cells at wound margin migrate to clot and seal the wound. Regenerating epithelium covers the wound. C, Scarring occurs as granulation tissue matures and injured tissue is replaced with connective tissue. healing by second intention WOUND HEALING by union by adhesion of granulating surfaces, when the edges of the wound are far apart and cannot be brought together. Granulations form from the base and sides of the wound toward the surface.

Healing by second intention occurs when there is tissue loss, as in extensive burns and deep ulcers. The healing process is more prolonged than in healing by primary intention because large amounts of dead tissue must be removed and replaced with viable cells. A, Open area is more extensive; inflammatory reaction is more widespread and tends to become chronic. B, Healing may occur under a scab formed of dried exudate, or dried plasma proteins and dead cells (eschar). C, Fibroblasts and capillary buds migrate toward center of would to form granulation tissue, which becomes a translucent red color as capillary network develops. Granulation tissue is fragile and bleeds easily. D, As granulation tissue matures, marginal epithelial cells migrate and proliferate over connective tissue base to form a scar. Contraction of skin around scar is the result of movement of epithelial cells toward center of wound in an attempt to close the defect. Surrounding skin moves toward center of wound in an effort to close the defect. healing by third intention 1. WOUND HEALING by the gradual filling of a wound cavity by granulations and a cicatrix. 2. delayed primary CLOSURE. wound healing see WOUND HEALING. wound [wo nd] an injury or damage, usually restricted to those caused by physical means with disruption of normal continuity of structures. Called also injury and trauma. blowing wound open PNEUMOTHORAX. contused wound one in which the skin is unbroken. wound drain any device by which a channel or open area may be established for the exit of material from a wound or cavity. See also WOUND HEALING. wound healing restoration of integrity to injured tissues by replacement of dead tissue with viable tissue; this starts immediately after an injury, may continue for months or years, and is essentially the same for all types of wounds. Variations are the result of differences in location, severity of the wound, extent of injury to the tissues, the age, nutritional status, and general state of health of the patient, and available body reserves and resources for tissue regeneration.

The repair of damaged cells and tissue takes place by REGENERATION, in which structures are replaced by proliferation of similar cells, such as happens with skin and bone; and by formation of a SCAR, consisting of fibrous structures with some degree of contraction. Since most wounds extend to more than one type of tissue, complete regeneration is impossible; therefore, scar formation is an expected outcome of wound healing. In HEALING BY FIRST INTENTION (primary union), restoration of tissue continuity occurs directly, without granulation; in HEALING BY SECOND INTENTION (secondary union), wound repair following tissue loss (as in ULCERATION) is accomplished by closure of the wound with granulation tissue. This tissue is formed by proliferation of FIBROBLASTS and extensive capillary budding at the outer edges and base of the wound cavity, with slow extension from the base and sides of the wound toward its center. If, however, the wound is very deep and extensive, granulation tissue cannot fill the defect and GRAFTING may be needed to cover the space and avoid severe contracture and loss of function. HEALING BY THIRD INTENTION (delayed primary closure) occurs when a wound is initially too contaminated to close and is closed surgically 4 or 5 days after the injury. (See also illustrations at HEALING.) The insertion of DRAINS can facilitate healing by providing an outlet for removing accumulations of serosanguineous fluid and purulent material, and obliterating dead space such as that created by surgical removal of an organ. If the area of injury is not very large, the products of inflammation, small blood CLOTS, and other debris from the wound can be absorbed into the blood stream and disposed of. Wounds that are filled with large amounts of dead cells, blood clots, and other debris must be cleansed in order for healing to take place. This can be accomplished by surgical or chemical DBRIDEMENT or by IRRIGATIONS. Enzymes are sometimes used to remove the debris by enzymatic action. Since foreign bodies, such as sutures, slivers of glass, splinters, and the like, can delay healing, they too must be removed from the wound to facilitate healing. PATIENT CARE. Assessment of the progress of wound healing begins with frequent inspection of the site for signs of bleeding in or around the wound. Discoloration of the skin adjacent to a surgical or traumatic wound that has been sutured may indicate a pooling of blood in the tissue spaces and the beginning stages of a HEMATOMA. Bleeding in a wound and clot formation can delay healing. Accumulations of serosanguineous fluid and purulent drainage also must be watched for, because they retard the healing process and pose a problem of SUPERINFECTION. If a drain has been inserted to remove excess fluid, the color, amount, odor, and other characteristics of the drainage must be noted and recorded. If there is more than one drain, the drainage from each should be noted separately.

Dressings also must be observed frequently, especially a pressure DRESSING, which can become dangerously restrictive if there is swelling. Any change in sensation, such as tingling or numbness, signs of impaired circulation, or complaint of discomfort, should be reported to the physician.

Other data important to the ongoing assessment of wound healing are the leukocyte COUNT, COAGULATION tests, and ELECTROLYTE levels. An elevated body temperature can signal local or systemic infection. Another sign of infection is the presence of purulent drainage. The color of the drainage is often indicative of the particular infecting organism. For example, a yellow color may indicate presence of Staphylococcus aureus, and a blue-green color may indicate Pseudomonas aeruginosa infection. In a surgical wound, a discharge of serosanguineous fluid on the fourth or fifth postoperative day may signal wound DEHISCENCE and, therefore, should be reported immediately to the surgeon. During the scarring phase of healing, the wound is inspected for changes in size, color, and shape, which can continue for months even in superficial wounds. New scar tissue is usually purplish, raised, and irregular. With time, the color fades, the scar grows smaller, and its surface and edges become less irregular. Sometimes the scar tissue grows to excess and extends beyond the normal limits of the wound. This hypertrophic scar or KELOID may require steroid injections or surgical removal. In order to achieve adequate and uneventful healing of a wound the patient must be in a good state of nutrition. Virtually every nutrient plays some role in the healing process; hence, a wide range of dietary nutrients must be supplied, either through oral feedings, supplemental vitamins and protein, or PARENTERAL NUTRITION. Oxygen is also essential to the healing process. This means that measures must be taken to ensure adequate circulation of blood to the wound, employing measures such as exercise, ambulation when possible, and applications of warmth when prescribed. Positioning also is important to avoid prolonged pressure against blood vessels serving the wounded area. Adequate rest is needed to facilitate healing. The patient should understand the need for rest and the purpose of splints, casts, and other devices employed for immobilization of a wounded part. Mechanical injury to a wound can greatly impede healing by damaging the tissues involved in the healing process. The wound should be protected from friction and direct blows. The affected part must be handled gently, and great care must be used in applying and removing dressings and bandages. Protective bandages and shields made from rubber, plastic cups, tongue blades, and other supportive materials may be needed to protect the wound from additional trauma. Other factors that work against optimal healing are stress, old age, smoking, obesity, and diabetes mellitus. It is thought that in the poorly controlled diabetic patient there is an increased affinity of hemoglobin for oxygen, which hampers the release of oxygen to the healing tissues. Additionally, poorly controlled diabetic patients have an abnormal function of the phagocytes, which predisposes wounds to infection. Although cancer does not itself interfere with the healing process or make the patient more susceptible to infection, RADIATION THERAPY, STEROIDS, and antineoplastic AGENTS, as well as the general debility of the patient, do compromise healing in cancer patients.

Wound dressing construction and design. From Cohen et al., 1992. Factors Affecting Wound Healing Age The physiological changes that occur with aging place the older patient at higher risk of poor wound healing. Reduced skin elasticity and collagen replacement influence healing. The immune system also declines with age, making older patients more susceptible to infection. Older people can also present with other chronic diseases, which affect their circulation and oxygenation to the wound bed. Dehydration This leads to an electrolyte imbalance and impaired cellular function. It is a particular problem in patients with burns and fistulae.

Hand Washing Effective hand washing greatly reduces the risk of transferring pathogenic organisms from one patient to another by direct contact or by contamination of inanimate objects that are shared. Infection Infection has been defined as the deposition and multiplication of organisms in tissue with an associated host reaction. If the host reaction is small or negligible then the organism is described as colonizing the wound rather than infecting it. It is important to distinguish between colonization and infection since colonized wounds will heal without the need for antibiotics (Cutting 1994). Contamination is the deposition and survival, but not the multiplication, of the organism (Ayton 1985). Wound infection is a problem because, at the most fundamental level, infection stops a wound from healing by:
y y y

Prolonging the inflammatory phase Disrupting the normal clotting mechanisms Promoting disordered leukocyte function and ultimately preventing the development of new blood vessels and formation of granulation tissue.

Assessment of a wound in order to identify wound infection should not be limited to swabbing the wound for bacteriological analysis. Infection occurs when virulence factors expressed by one or more microorganisms in a wound out-compete the person's immune system. Subsequent invasions and spread of microorganisms in good tissue provokes a series of local and systemic responses such as: i) Surgical (acute wounds)
y y y y y y

local pain / tenderness local swelling / edema increased exudates, either serous or purulent or haemoserous separation of wound edges / wound breakdown pyrexia delayed healing

ii) Chronic wounds

y y y y y y y

delayed healing increased fragility or change in appearance of granulation tissue unexpected pain / tenderness pocketing or bridging of epithelial tissue an abnormal smell presence of exudate either serous or purulent haemoserous local swelling / edema

y y y

extending margin or erythema pyrexia wound breakdown

Medication Anti-inflammatory, cytotoxic, immunosuppressive, and anticoagulant drugs all reduce healing rates by interrupting cell division or the clotting process. Oxygenation and tissue perfusion
y y

Good wound oxygenation is essential for wound healing. Oxygen influences angiogenesis, epithelialization, and resistance to infection Discourage smoking

Personal and oral hygiene

y

The need for good personal and oral hygiene should be discussed with the patient.

Nutrition
y y y y y y

Protein is required for all the phases of wound healing, particularly important for collagen synthesis. Glucose balance is essential for wound healing. Iron, required to transport oxygen. Minerals, zinc, copper, are important for enzyme systems and immune systems. Zinc deficiency contributes to disruption in granulation tissue formation. Vitamins A, B complex and C are responsible for supporting epithelialization and collagen formation. It is also important for the inflammatory phase of wound healing. Carbohydrates and fats. These provide the energy required for cell function. When the patient does not have enough, the body breaks down protein to meet the energy needs. Fatty acids and essential for wound healing. Refer to dietitian if patient is malnourished

PATIENT EDUCATION - suggest to patient that:

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Food is here to be enjoyed Variety in what we eat is healthy They should eat the right amount to be a healthy weight. This will vary for age, gender, and level of activity. They should try not to eat too much fat, sugar, or salt. The diet should provide plenty of vitamins and minerals Keep levels of alcohol within recommended limits

Physiology of Wound Healing Inflammatory Phase

y y y y y y

Wound Healing cycle starts Lasts from injury to 4-6 days Edema, erythema, inflammation, pain Vessels form clots to prevent excessive loss of blood and fluids Platelets release growth factors to trigger healing process White cells go to area to "clean up"

Proleferative Phase
y y y y y

Lasts 4-24 days Granulation tissue fills in wound Fibroblasts lay network of collagen in wound bed which gives strength to tissue Wound begins to contract - edges pull together Epithelial cells from wound margins migrate inward to cover wound

Maturation Phase
y y y y

Lasts 21 days to 2 years Begins when wound has filled in and re-surfaced Collagen fibers reorganize, remodel, and mature to give wound tensile strength forming scar tissue Scar tissue is only 80% as strong as original tissue.

The key cells in the healing process are the macrophages and the fibroblasts. Macrophages engulf and destroy bacteria and clean the wound site of debris. Fibroblasts synthesize collagen, the principle component of connective tissue. Acute wounds in the non-compromised host progress through the 3 phases of healing without delays. However, chronic wounds stagnant between the inflammatory and proliferative phases. Chronic wounds may be present from weeks to years and require a comprehensive approach to therapy in order to accomplish healing. Chronic wounds are oftentimes compromised due to vascular insufficieny. This causes tissue ischemia and hypoxia, which lead to loss of vascular membrane integrity, which results in edema. Tissue edema can then cause further vascular insufficiency and the start of a vicious downward spiral for the patient. During the early phases of wound healing (inflammatory & proliferative) the metabolic and oxygen demands of the wound can increase by a factor of 20 or more. Macrophages, fibroblasts and all 3 wound-healing phases are oxygen dependent and tissue oxygen tensions above 30mmHg are needed for collagen synthesis. Hyperbaric Oxygen can assist in increasing tissue oxygenation when patients are compromised due to end-stage vascular disease. Principles of wound healing Principles of wound healing include supporting the fluid and nutritional intake of the patient in addition to gaining control of systemic factors affecting wound healing. The wound care team must address vascular compromise and maximize blood flow; reduce the mechanical problems of

pressure, shear, and friction, and control moisture and infection. A healed wound will eliminate pain, improve the quality of life, and is cost effective. Wound Care Protocols - Once the type and etiology of the wound has been identified, and the factors compromising wound healing have been addressed, management and care of the patient's wound is based on its classification. The protocol utilized depends on this classification. The type of advanced wound care product or technology used depends on the judgment of the wound care physician. Providing the optimal wound environment consists of aggressive debridement of necrotic tissue, identification and eradication of infection, obliteration of dead space, absorption excess drainage, providing protection and thermal insulation, and finally maintaining a moist wound environment. Wound Classification - Based on the appearance of the wound it may be classified. Management is then determined by this classification.