Wound and Healing process

Wound and Healing process 150 150 Tony Guo

Wound and Healing process

 

  • A wound is a break or opening into the skin
    • Often occur because of accidents or injury
    • Range from minor scrapes to deep wounds involving bones, blood vessels, and nerves
  • Regeneration
    • Replacement of lost cells and tissues with cells of same type
  • Repair
    • Healing as a result of lost cells being replaced with connective tissue
    • More common than regeneration
    • More complex than regeneration
    • Occurs by primary, secondary, or tertiary intention

 

Repair

Primary intention

  • Includes 3 phases
    • Initial phase
      • Lasts 3 to 5 days
      • Edges of incision are aligned
      • Blood fills the incision area, which forms matrix for WBC migration
      • Acute inflammatory reaction occurs
    • Granulation phase
      • Fibroblasts migrate into site and secrete collagen
      • Wound is pink and vascular
      • Surface epithelium begins to regenerate
    • Maturation phase and scar contraction
      • Begins 7 days after injury and continues for several months/years
      • Fibroblasts disappear as wound becomes stronger
      • Mature scar forms

Secondary intention

  • Wounds that occur from trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss
  • Edges cannot be approximated
  • Results in more debris, cells, and exudate

Tertiary intention

  • Delayed primary intention due to delayed suturing of the wound
  • Occurs when a contaminated wound is left open and sutured closed after the infection is controlled

 

Wound Classification

  • Wounds are classified according to 
    • Cause
      • Surgical or nonsurgical
      • Acute or chronic
    • Depth of tissue affected
      • Superficial, partial thickness, full thickness

 

Nursing Assessment

  • Assess on admission and on a regular basis
  • Identify factors that may delay healing

Nursing Implementation

  • Purposes of wound management
    • Protecting a clean wound
    • Cleaning a wound
    • Treating infection
  • Clean wound
    • Clean wounds that are granulating and re-epithelializing should be kept slightly moist and protected
    • Dryness is an enemy of wound healing
    • Topical antimicrobials and antibactericidals used with caution
    • Transparent film may be used
  • Contaminated wound 
    • Debridement may be necessary
    • Absorption or hydrocolloid dressing may be used
  • Negative-pressure wound therapy (NPWT)
    • Suction removes drainage and speeds healing
    • Monitor serum protein levels, fluid and electrolyte balance, and coagulation studies
  • Hyperbaric O2 therapy (HBOT)
    • Delivery of O2 at increased atmospheric pressure
    • Allows O2 to diffuse into serum
    • Last 90 to 120 minutes, with 10 to 60 treatments
  • Drug  Therapy
    • Becaplermin (Regranex)
  • Nutritional Therapy
    • Diet high in protein, carbohydrates, and vitamins with moderate fat
  • Infection prevention
    • Do not touch recently injured area
    • Culture may be ordered
    • Keep environment free from possibly contaminated items
    • Antibiotics may be given prophylactically
  • Psychologic implications
    • Fear of scar or disfigurement
    • Drainage or odor concerns
    • Be aware of your facial expressions while changing dressing

 

Patient teaching

  • Teach signs and symptoms of infection
  • Note changes in wound color or amount of drainage
  • Provide medication teaching

 

Human Immunodeficiency Virus Infection

 

  • Retrovirus that causes immunosuppression making persons more susceptible to infections
    • More than 1 million currently living with HIV
    • About 50,000 new infections occur in United States each year
    • Effective treatment has led to a significant drop in death rates

 

Transmission of HIV

  • HIV can be transmitted through contact with certain body fluids
    • Blood, semen, vaginal secretions, and breast milk
    • HIV is not spread through casual contact
  • Sexual Transmission
    • Unprotected sex with an HIV-infected partner is most common mode of transmission
    • Greatest risk is for partner who receives semen
      • Prolonged contact with infected fluids
      • Women at higher risk
      • Trauma increases likelihood of transmission
  • Contact with blood
    • Sharing drug-using paraphernalia is highly risky
    • Screening measures have improved blood supply safety
    • Puncture wounds are most common means of work-related HIV transmission
  • Perinatal transmission
    • Can occur during pregnancy, delivery, or breastfeeding
    • An average of 25% of infants born to women with untreated HIV will contract the infection
    • Treatment can reduce rate of transmission to less than 2%

 

Pathophysiology of HIV

  • HIV is a ribonucleic acid virus
    • Called retroviruses because they replicate in a “backward” manner going from RNA to DNA
    • CD4+T cell is the target cell for HIV
      • Type of lymphocyte
      • HIV binds to the cell through fusion
  • Immune problems start when CD4+ T cell counts drop to < 500 cells/μL
    • Severe problems develop when < 200 CD4+ T cells/μL
    • Normal range is 800 to 1200 cells/μL
  • Insufficient immune response allows for opportunistic diseases

Clinical Manifestations and complications

  • Acute Infection
    • Flulike symptoms
    • Fever, swollen lymph nodes, sore throat, headache, malaise, nausea, muscle and joint pain, diarrhea, or a diffuse rash 
    • Occurs about 2 to 4 weeks after infection
    • Highly infectious
  • Asymptomatic Infection
    • Left untreated, a diagnosis of AIDS is made about 10 years after initial HIV infection
    • Symptoms are generally absent or vague
    • High risk behaviors may continue
  • Symptomatic Infection
    • CD4+ T cells decline closer to 200 cells/μL
    • Symptoms become worse
    • HIV advances to a more active stage
    • Oral thrush
      • One of the more common infections associated with symptomatic infection is oropharyngeal candidiasis (thrush). 
      • Candida organisms rarely cause problems in healthy adults, but are more common in HIV-infected people.
    • Shingles
    • Persistent vaginal candidal infections
    • Herpes
    • Bacterial infections
    • Kaposi Sarcoma
      • Malignant vascular lesions such as Kaposi sarcoma lesions can appear anywhere on the skin surface or on internal organs. 
      • Kaposi sarcoma is caused by human herpes virus VIII.
      • Lesions vary in size from pinpoint to very large and may appear in a variety of shades.
    • Oral hairy leukoplakia
      • Epstein-Barr virus infection that causes painless, white, raised lesions on the lateral aspect of the tongue, can occur at this phase of the infection and is another indicator of disease progression

 

AIDS

  • Immune system severely compromised
    • Infections
    • Malignancies
    • Wasting
    • HIV-related cognitive changes
  • Most useful screening tests detect HIV-specific antibodies and/or antigens
    • May take several weeks to detect antibodies (window period)
    • Performed using blood or saliva
    • Combination (4th generation) tests can detect HIV earlier
  • Laboratory studies
  • HIV progression is monitored by
    • CD4+ T-cell counts 
      • CD4+ T-cell count provides a marker of immune function 
    • Viral load
      • The lower the viral load the less active the disease
  • Abnormal blood tests are common 
    • Caused by HIV, opportunistic diseases, or complications of therapy
      • Decreased WBC counts
      • Low platelet counts
      • Anemia is associated with ART
      • Altered liver function

Interprofessional Care

  • Initial patient visit
    • Gather baseline data
    • Begin to establish rapport and use patient input to develop a plan of care
    • Initiate teaching about spectrum of HIV, treatment, preventing transmission, improving health, and family planning

Drug therapy

  • Main goals
    • Decrease viral load
    • Maintain/increase CD4+T counts
    • Prevent HIV-related symptoms and opportunistic diseases
    • Delay disease progression
    • Prevent HIV transmission
  • Opportunistic diseases complicate management of HIV infection
    • Prevention is key
    • Onset can be delayed with adequate measures
    • Effective management has significantly increased life expectancy

 

Nursing Assessment

  • Do not make assumptions about who may be at risk
  • Candid conversation is important for effective management of HIV
  • Ask at-risk patients
    • Received blood transfusion or clotting factors before 1985?
    • Shared needles with another person?
    • Had a sexual experience with your penis, vagina, rectum, or mouth in contact with these areas of another person?
    • Had a sexually transmitted infection?

Planning

  • Goals for care are aimed at
    • Compliance with drug regimens
    • Adopting a healthy lifestyle
    • Beneficial relationships
    • Spiritual well-being in regard to life and death
    • Coping with the disease and its treatment

Implementation

  • Primary prevention and health promotion are the most effective strategies for diseases of a chronic nature including HIV
    • When prevention fails
      • Disease results
      • Early intervention is facilitated by health promotion practices
  • Health promotions
    • HIV infection is preventable
      • Avoid risky behaviors
      • Modify risky behaviors
      • Candid, culturally sensitive, language- appropriate, age-specific information and behavior change counseling
  • Prevention of HIV
    • Decreasing risks: Sexual intercourse
      • Abstinence
      • Noncontact safe sex
      • Use of barriers
    • Decreasing risks: Drug use
      • Do not use drugs
      • Do not share equipment
      • Do not have sexual intercourse under the influence of any impairing substance
      • Refer for help with substance use
    • Decreasing risks: Perinatal transmission
      • Family planning
      • Prevent HIV in women
      • Appropriately medicate HIV-infected pregnant women
    • Decreasing risk:  Work
      • Adhere to precautions and safety measures to avoid exposure
      • Report all exposures for timely treatment and counseling
      • Post-exposure prophylaxis with combination ART can significantly decrease risk of infection
  • HIV Testing and counseling
    • Testing is the only sure method of determining HIV infection
      • CDC recommends universal, voluntary testing as part of routine medical care
      • An estimated 14% of people living with HIV are not aware they are infected
    • Acute intervention
      • Early intervention promotes health and delays disability
      • Reactions to positive HIV test
  • Similar to any life-threatening, chronic illness
  • Panic, anxiety, fear, guilt, depression, denial, anger, hopelessness
  • Antiretroviral therapy
    • ART can significantly slow HIV progression, but it 
      • Is complex
      • Has side effects
      • Does not work for everyone
      • Is expensive
    • Adherence to drug regimens is critical to prevent
      • Disease progression
      • Opportunistic disease
      • Viral drug resistance
    • An individualized approach is best
  • Delaying disease progression
    • Supporting a healthy immune system
      • Adequate nutrition
      • Current vaccinations
      • Health habits
      • Avoiding risky behaviors
      • Supportive relationships
    • Acute exacerbations of recurring problems. Infections, cancers, debility, and psychosocial or economic issues may interact to overwhelm the patient’s ability to cope. They need to understand that:-
      • Has no cure
      • Continues for life
      • Causes physical disability
      • Impairs social, emotional, economic, and spiritual wellbeing
      • Ultimately leads to death
  • Ambulatory care
    • Stigma can lead to discrimination and result in social isolation, dependence, frustration, low self-image, loss of control, and economic pressures
      • This, in turn, could lead to further involvement in risky behaviors
    • Disease and Drug side effects
      • Common physical problems
  • Anxiety, fear, depression
  • Diarrhea
  • Peripheral neuropathy
  • Pain
  • Nausea/vomiting
  • Fatigue

Evaluation

  • The patient at risk will 
    • Analyze personal risk factors
    • Develop and implement a personal plan to decrease risks
    • Get tested for HIV
  • The patient with HIV will
    • Describe basic aspects of the effects of HIV on the immune system
    • Compare and contrast various treatment options for HIV disease
    • Work with a team of HCPs to achieve optimal health
    • Prevent transmission of HIV to others

 

Gerontologic considerations

  • Increasing rates of HIV disease among older adults
    • Death rate from opportunistic infections reduced
    • People 60 and older are increasingly being infected

 

Leave a Reply

Your email address will not be published.