Wound Healing
Wound Healing
And Microorganisms
Types of Wound Healing
1st Intention
2nd Intention
3rd Intention
First Intention
Has no postoperative swelling
No serous discharge or local infection
No separation of wound edges
Minimal scar formation (hairline scar)
Heals by primary union
Second Intention
Infection, excessive trauma, loss of tissue or poorly approximated tissue is present
Healing is by process of granulation from the bottom up
Wound is not closed (sutured)
Granulation tissue forms in the gap of the wound and closes it by contraction
Healing takes longer than first intension because more area must be filled in.
Scar formation is excessive
Healing may produce a weak union, which may be conducive to incisional herniation (rupture) later
Risk of a secondary infection is proportional to amount of necrotic tissue present.
Third Intention
Similar to second intention except wound is sutured, either delayed or secondary
When wound is infected at time of surgery, suturing is delayed until infection subsides
When sutured wound becomes very infected after surgery, the primary sutures are removed and secondary sutures are put in later
During the period of waiting for infection to subside, wound has begun to heal by granulation
Healing takes longer than second intention
A deeper and wider scar usually results
Healing may produce a weak union, which may result in incisional herniation later.
Phases of 1st Intention Wound Healing
Lag (substrate) phase (days 1-6)
Exudates containing blood, lymph, and fibrin begins clotting and loosely binds the cut edges together.
Fibrin, clotting blood, and serum protein dry out, forming a scab which seals the wound
Leukocytes remove bacteria and damaged tissue debris
Healing (proliferative) Phase (days 6-14)
Fibroblasts multiply rapidly bridging wound edges, and secrete collagen which forms fibers
Tensile strength grows rapidly because of collagen.
New cells are formed.
Maturation (remodeling) Phase (days 14-21)
Scar forms
Collagen reforms into cross-links which increase tensile strength.
As collagen density increases, vascularity decreases and scar grows pale
Types of Wounds
Chronic wounds
Wounds that will not heal by 2nd intention
Examples: ulcerations, pressure sores, sinus tracts
Traumatic wounds
When a chemical, thermal, or other extrinsic agent has injured living body tissue
Surgical incisions
When a surgeon cuts through intact tissue using aseptic technique
Classes of Traumatic Wounds
Closed Wounds
Open Wounds
Closed wounds
The skin is intact, but the underlying tissue is injured
Example: simple fractures, torn ligaments, blister
Open Wounds
The skin is broken – 4 classifications
Simple – the skin is interrupted but the without loss or destruction of underlying tissue
Complicated – the skin and underlying tissues are injured or destroyed by crushing, burning, or implantation of a foreign object
Clean – the object or conditions surrounding the injury were relatively clean. Wound is cared for within 6 hours. Heals with 1st intention
Contaminated – the conditions and/or object surrounding the injury are obviously not clean; or the wound is over 6 hours old. Heals by 2nd intention
Types of Traumatic Wounds
Abrasion, Avulsion
Contusion, Crush
Incised, Laceration
Puncture, Perforation
Abrasion
Wound caused by mechanical irritation such as boot rubbing, scraping or being injured with sand paper.
Avulsion
A portion of the skin and soft tissue is partially or completely torn away.
Partial Complete
Contusion
A bruise that may be caused by a blunt instrument in which skin is not broken, the tissues below the surface are damaged, and the blood vessels have ruptured causing discoloration.
Crush Injury
A wound that has been squeezed or forced by pressure so as to alter or destroy the tissue structure.
Incised
A wound with smooth edges that is made by a cutting instrument; may be contaminated (glass) or clean (scalpel)
Laceration
A torn wound with irregular edges
Puncture
A wound made by a sharp, pointed instrument.
Perforation
A wound in which the vulnerating body (such as a bullet, knife or pipe) both enters and emerges from the tissue.
Classifications of Surgical Wounds
Class I - Clean
Class II - Clean-contaminated
Class III - Contaminated
Class IV - Dirty/Infected
Class I - Clean
Expected infection rate: 1% to 5%
Elective procedures – wound made under ideal conditions
Primary closure, no drain
No breaks in aseptic technique
No inflammation present
Alimentary, genitourinary, respiratory tracts or oropharyngeal cavity not entered
Class II - Clean-contaminated
Expected infection rate: 8% to 11%
Primary closure, wound drained
Minor breaks in aseptic technique occurred
No inflammation present
Alimentary, genitourinary, or respiratory tract or oropharyngeal cavity entered under controlled conditions – without unusual contamination or spillage.
Includes hysterectomies, appendectomy, cholecystectomy, and face lift.
Class III - Contaminated
Expected infection rate: 15% to 20%
Open fresh traumatic wound less than 4 hours old
Major break in aseptic technique
Acute, non-purulent inflammation present
Gross spillage/contamination from gastrointestinal tract
Entry into biliary or genitourinary tracts with infected bile or urine present
Class IV - Dirty/Infected
Expected infection rate: 27% to 40%
Old traumatic wound over 4 hours old from a dirty source or the presence of necrotic tissue, foreign body, or fecal material
Microbial contamination is present in the operative field before the procedure
Acute bacterial inflammation is present, may be purulent or there is a known clinical infection
Factors Influencing Healing
Type of wound
Operative technique
Physical condition of Patient
Physical Condition of Patient
and Wound Healing
Age, Weight, and general health
Nutrition
Immune response
Drug therapy
Radiation Therapy
Postoperative complications
Age, weight ,and general health
Skin tone and muscle tone decrease with age
Excess fat causes difficulty in confining and securing good closure, and is most vulnerable of all tissues to trauma and infection
Associated diseases such as diabetes, anemia, cirrhosis delay wound healing
Malignancies, debilitating injuries, and systemic or localized infections can also adversely affect wound healing
Adequate nutrition
Wound healing is impaired by deficiencies in zinc, protein, carbohydrates, and vitamins A, B, C and E
Protein provides essential amino acids for new tissue construction
C permits collagen formation and also aids in the production of connective tissue and a strong scar
B is necessary for carbohydrate metabolism
E is necessary for softening tissue to produce less scarring
Immune Response
Normal immune response speeds tissue healing
Abnormalities in immune responses such as allergic reactions can contribute to delayed wound healing
A person with an immunosuppressed or compromised immune system condition can be life threatening
Drug Therapy
Since wound healing is basically collagen synthesis, any agent that interfere with cellular metabolism such as steroids have a potentially negative effect on the healing process
Radiation Therapy
Healing is delayed if the patient has had radiation in large doses preoperatively
The blood supply in irradiated tissue is decreased
However little change from the normal healing pattern occurs if radiation has been given in low doses
Postoperative complications
Edema, vomiting, or coughing can place stress on the healing wound before fibroblasia takes place
Complications in other parts of the body, far from the site of operation, such as pneumonia or embolus formation, can inhibit oxygen supply to the wound site.
Physical Activity
Very Important!
Early ambulation speeds up circulation and decreases post operative complication
Operative Technique and Healing
Aseptic Technique
Hemostasis
Tissue handling
Tissue Approximation
Wound Closure
Aseptic Technique
Must be followed by every member of the surgical team
It is less expensive to change out a whole set up than it is to treat an infection
A little embarrassment on your part is not as important as the well being of the patient
Hemostasis
Must be achieved to prevent loss of the patient’s blood and to provide as bloodless a field as possible for accurate dissection and to prevent hematoma formation.
Tissue Handling
All tissues should be handled as gently as possible
Incisions should be just long enough to be able to perform the procedure
Laparoscopies are used more often because they cause minimal trauma and heal quickly
Retractors are placed for exposure and should not be pulled so hard that they cause tissue damage
Tissue Approximation
Tissue edges should be brought together precisely, avoiding strangulation and eliminating dead space
Too tight a closure under tension causes ischemia
Serum or blood collect in dead spaces
Drains and pressure dressings are placed to help decrease dead spaces
Wound Closure
The suture material provides all of the strength of the wound immediately after closure
Closely spaced sutures give a stronger suture line
The strength of the suture should not be stronger than the tissue that it is used on
Complication in Wound Healing
Dehiscence, Evisceration
Adhesions, Herniation
Fistula, Sinus tract
Keloid Scarring, Infection
Dehiscence
Partial or total separation of the layers of a surgical wound
Evisceration
Extrusion of internal organs or viscera resulting from a wound dehiscence. The wound totally separates.
Adhesions
Abnormal attachment of two surfaces or structures that are normally separate
Herniation
The result of wound dehiscence and could cause incarceration of the bowel
Fistula
A tract between two epithelial surfaces, open at both ends
Sinus tract
A tract between two epithelial surfaces, open at one end
Keloid scarring
A hypertrophic scar formation that mainly occurs in dark-skinned individuals
Characteristics of Wound Disruption
May occur in a small percentage of clean, surgical, abdominal wounds
Usually happens between 4th and 6th postoperative days
Symptoms
Patient feels something give way
There may be a lot of drainage on dressing
The contour of the abdomen may change or spillage of abdominal contents
Causes of Wound Disruption
Infection
Abdominal distention
Type and direction of incision
Nutritional status of the patient
Coughing, straining, unusual activity
Obesity
Diseases
Infectious Process
Sepsis
The invasion of the body of a microorganism or their toxins
Involves three phases
Invasion
Localization
Recovery
Infectious Process
(continued)
Most wound infections present in the first postoperative week
Factors in recovery
Identification of organism
Administration of antibiotic
Virulence and drug resistance of the microbe
Health of the patient
Infectious Process
(continued)
If the body cannot contain a localized infection it becomes a regional infection.
The lymph nodes become responsible for trying to contain it.
If the lymph nodes cannot contain the infection it becomes a systemic infection.
Infectious Process
(continued)
Septicemia (systemic infections)
Are very dangerous
Symptoms include
Fever, chills
Elevated metabolic rate placing stress on vital organs
Toxicity
Elevated cardiac output (approx 60% above normal resting value)
If there are multiple infection sites and shock is present, the prognosis is poor
Septicemia
Nosocomial Infections
An infection that develops while a patient is in the hospital
Two types
Exogenous
Acquired from source outside the patient’s body
Endogenous
Acquired from source within patient’s body
Approximately 35% of nosocomial infections occur in surgical patients.
Postoperative Wound Infections
Two types
Incisional infection
Penetrates the skin, subcutaneous tissue and muscle
May require I&D
Deep-tissue
Involves layers under fascia or peritoneum
Requires I&D
Increased risk of dehiscence
If it occurs around implants, such as plates or screws, they may have to be removed
Postoperative Wound Infections (continued)
Burn and trauma patients are at high risk of developing viral, bacterial and fungal infections
Common bacterial infections in burn patients:
Streptococcus pyogenes
Staphylococcus aureus
Pseudomonas aeruginosa
Common fungal infections:
Candida
Postoperative Wound Infections (continued)
Common pathogens acquired from the OR
Aerobic
Staphylococcus aureus
Most common
Pseudomonas aeruginosa
Found in water, soil, and GI tract
Has a smelly odor and a blue-green color
Postoperative Wound Infections (continued)
Anaerobic
Clostridium perfringens
Causes gas gangrene
High mortality rate
Clostridium tetani
Introduced by penetrating wound with soil or fecal matter
Causes tetanus
Postoperative Wound Infections (continued)
Infections will appear within a week of surgery
If infection occurs after a week it indicates that the contamination did not happen int the operating room.
The skin is the most likely source of contamination
If the patient is not the source, it is likely contamination from the hair or nares of the surgical personnel
Peri-operative Precautions
Careful shaving of the patient’s skin
No nicks or cuts
Skin prep
Meticulous draping procedures
Proper aseptic technique
Use of PPE’s
Hair covering, protective eyewear, mask, sterile gown and gloves
Homework
Questions for further study
Page 382
#3, 5, and 8
And Microorganisms
Types of Wound Healing
1st Intention
2nd Intention
3rd Intention
First Intention
Has no postoperative swelling
No serous discharge or local infection
No separation of wound edges
Minimal scar formation (hairline scar)
Heals by primary union
Second Intention
Infection, excessive trauma, loss of tissue or poorly approximated tissue is present
Healing is by process of granulation from the bottom up
Wound is not closed (sutured)
Granulation tissue forms in the gap of the wound and closes it by contraction
Healing takes longer than first intension because more area must be filled in.
Scar formation is excessive
Healing may produce a weak union, which may be conducive to incisional herniation (rupture) later
Risk of a secondary infection is proportional to amount of necrotic tissue present.
Third Intention
Similar to second intention except wound is sutured, either delayed or secondary
When wound is infected at time of surgery, suturing is delayed until infection subsides
When sutured wound becomes very infected after surgery, the primary sutures are removed and secondary sutures are put in later
During the period of waiting for infection to subside, wound has begun to heal by granulation
Healing takes longer than second intention
A deeper and wider scar usually results
Healing may produce a weak union, which may result in incisional herniation later.
Phases of 1st Intention Wound Healing
Lag (substrate) phase (days 1-6)
Exudates containing blood, lymph, and fibrin begins clotting and loosely binds the cut edges together.
Fibrin, clotting blood, and serum protein dry out, forming a scab which seals the wound
Leukocytes remove bacteria and damaged tissue debris
Healing (proliferative) Phase (days 6-14)
Fibroblasts multiply rapidly bridging wound edges, and secrete collagen which forms fibers
Tensile strength grows rapidly because of collagen.
New cells are formed.
Maturation (remodeling) Phase (days 14-21)
Scar forms
Collagen reforms into cross-links which increase tensile strength.
As collagen density increases, vascularity decreases and scar grows pale
Types of Wounds
Chronic wounds
Wounds that will not heal by 2nd intention
Examples: ulcerations, pressure sores, sinus tracts
Traumatic wounds
When a chemical, thermal, or other extrinsic agent has injured living body tissue
Surgical incisions
When a surgeon cuts through intact tissue using aseptic technique
Classes of Traumatic Wounds
Closed Wounds
Open Wounds
Closed wounds
The skin is intact, but the underlying tissue is injured
Example: simple fractures, torn ligaments, blister
Open Wounds
The skin is broken – 4 classifications
Simple – the skin is interrupted but the without loss or destruction of underlying tissue
Complicated – the skin and underlying tissues are injured or destroyed by crushing, burning, or implantation of a foreign object
Clean – the object or conditions surrounding the injury were relatively clean. Wound is cared for within 6 hours. Heals with 1st intention
Contaminated – the conditions and/or object surrounding the injury are obviously not clean; or the wound is over 6 hours old. Heals by 2nd intention
Types of Traumatic Wounds
Abrasion, Avulsion
Contusion, Crush
Incised, Laceration
Puncture, Perforation
Abrasion
Wound caused by mechanical irritation such as boot rubbing, scraping or being injured with sand paper.
Avulsion
A portion of the skin and soft tissue is partially or completely torn away.
Partial Complete
Contusion
A bruise that may be caused by a blunt instrument in which skin is not broken, the tissues below the surface are damaged, and the blood vessels have ruptured causing discoloration.
Crush Injury
A wound that has been squeezed or forced by pressure so as to alter or destroy the tissue structure.
Incised
A wound with smooth edges that is made by a cutting instrument; may be contaminated (glass) or clean (scalpel)
Laceration
A torn wound with irregular edges
Puncture
A wound made by a sharp, pointed instrument.
Perforation
A wound in which the vulnerating body (such as a bullet, knife or pipe) both enters and emerges from the tissue.
Classifications of Surgical Wounds
Class I - Clean
Class II - Clean-contaminated
Class III - Contaminated
Class IV - Dirty/Infected
Class I - Clean
Expected infection rate: 1% to 5%
Elective procedures – wound made under ideal conditions
Primary closure, no drain
No breaks in aseptic technique
No inflammation present
Alimentary, genitourinary, respiratory tracts or oropharyngeal cavity not entered
Class II - Clean-contaminated
Expected infection rate: 8% to 11%
Primary closure, wound drained
Minor breaks in aseptic technique occurred
No inflammation present
Alimentary, genitourinary, or respiratory tract or oropharyngeal cavity entered under controlled conditions – without unusual contamination or spillage.
Includes hysterectomies, appendectomy, cholecystectomy, and face lift.
Class III - Contaminated
Expected infection rate: 15% to 20%
Open fresh traumatic wound less than 4 hours old
Major break in aseptic technique
Acute, non-purulent inflammation present
Gross spillage/contamination from gastrointestinal tract
Entry into biliary or genitourinary tracts with infected bile or urine present
Class IV - Dirty/Infected
Expected infection rate: 27% to 40%
Old traumatic wound over 4 hours old from a dirty source or the presence of necrotic tissue, foreign body, or fecal material
Microbial contamination is present in the operative field before the procedure
Acute bacterial inflammation is present, may be purulent or there is a known clinical infection
Factors Influencing Healing
Type of wound
Operative technique
Physical condition of Patient
Physical Condition of Patient
and Wound Healing
Age, Weight, and general health
Nutrition
Immune response
Drug therapy
Radiation Therapy
Postoperative complications
Age, weight ,and general health
Skin tone and muscle tone decrease with age
Excess fat causes difficulty in confining and securing good closure, and is most vulnerable of all tissues to trauma and infection
Associated diseases such as diabetes, anemia, cirrhosis delay wound healing
Malignancies, debilitating injuries, and systemic or localized infections can also adversely affect wound healing
Adequate nutrition
Wound healing is impaired by deficiencies in zinc, protein, carbohydrates, and vitamins A, B, C and E
Protein provides essential amino acids for new tissue construction
C permits collagen formation and also aids in the production of connective tissue and a strong scar
B is necessary for carbohydrate metabolism
E is necessary for softening tissue to produce less scarring
Immune Response
Normal immune response speeds tissue healing
Abnormalities in immune responses such as allergic reactions can contribute to delayed wound healing
A person with an immunosuppressed or compromised immune system condition can be life threatening
Drug Therapy
Since wound healing is basically collagen synthesis, any agent that interfere with cellular metabolism such as steroids have a potentially negative effect on the healing process
Radiation Therapy
Healing is delayed if the patient has had radiation in large doses preoperatively
The blood supply in irradiated tissue is decreased
However little change from the normal healing pattern occurs if radiation has been given in low doses
Postoperative complications
Edema, vomiting, or coughing can place stress on the healing wound before fibroblasia takes place
Complications in other parts of the body, far from the site of operation, such as pneumonia or embolus formation, can inhibit oxygen supply to the wound site.
Physical Activity
Very Important!
Early ambulation speeds up circulation and decreases post operative complication
Operative Technique and Healing
Aseptic Technique
Hemostasis
Tissue handling
Tissue Approximation
Wound Closure
Aseptic Technique
Must be followed by every member of the surgical team
It is less expensive to change out a whole set up than it is to treat an infection
A little embarrassment on your part is not as important as the well being of the patient
Hemostasis
Must be achieved to prevent loss of the patient’s blood and to provide as bloodless a field as possible for accurate dissection and to prevent hematoma formation.
Tissue Handling
All tissues should be handled as gently as possible
Incisions should be just long enough to be able to perform the procedure
Laparoscopies are used more often because they cause minimal trauma and heal quickly
Retractors are placed for exposure and should not be pulled so hard that they cause tissue damage
Tissue Approximation
Tissue edges should be brought together precisely, avoiding strangulation and eliminating dead space
Too tight a closure under tension causes ischemia
Serum or blood collect in dead spaces
Drains and pressure dressings are placed to help decrease dead spaces
Wound Closure
The suture material provides all of the strength of the wound immediately after closure
Closely spaced sutures give a stronger suture line
The strength of the suture should not be stronger than the tissue that it is used on
Complication in Wound Healing
Dehiscence, Evisceration
Adhesions, Herniation
Fistula, Sinus tract
Keloid Scarring, Infection
Dehiscence
Partial or total separation of the layers of a surgical wound
Evisceration
Extrusion of internal organs or viscera resulting from a wound dehiscence. The wound totally separates.
Adhesions
Abnormal attachment of two surfaces or structures that are normally separate
Herniation
The result of wound dehiscence and could cause incarceration of the bowel
Fistula
A tract between two epithelial surfaces, open at both ends
Sinus tract
A tract between two epithelial surfaces, open at one end
Keloid scarring
A hypertrophic scar formation that mainly occurs in dark-skinned individuals
Characteristics of Wound Disruption
May occur in a small percentage of clean, surgical, abdominal wounds
Usually happens between 4th and 6th postoperative days
Symptoms
Patient feels something give way
There may be a lot of drainage on dressing
The contour of the abdomen may change or spillage of abdominal contents
Causes of Wound Disruption
Infection
Abdominal distention
Type and direction of incision
Nutritional status of the patient
Coughing, straining, unusual activity
Obesity
Diseases
Infectious Process
Sepsis
The invasion of the body of a microorganism or their toxins
Involves three phases
Invasion
Localization
Recovery
Infectious Process
(continued)
Most wound infections present in the first postoperative week
Factors in recovery
Identification of organism
Administration of antibiotic
Virulence and drug resistance of the microbe
Health of the patient
Infectious Process
(continued)
If the body cannot contain a localized infection it becomes a regional infection.
The lymph nodes become responsible for trying to contain it.
If the lymph nodes cannot contain the infection it becomes a systemic infection.
Infectious Process
(continued)
Septicemia (systemic infections)
Are very dangerous
Symptoms include
Fever, chills
Elevated metabolic rate placing stress on vital organs
Toxicity
Elevated cardiac output (approx 60% above normal resting value)
If there are multiple infection sites and shock is present, the prognosis is poor
Septicemia
Nosocomial Infections
An infection that develops while a patient is in the hospital
Two types
Exogenous
Acquired from source outside the patient’s body
Endogenous
Acquired from source within patient’s body
Approximately 35% of nosocomial infections occur in surgical patients.
Postoperative Wound Infections
Two types
Incisional infection
Penetrates the skin, subcutaneous tissue and muscle
May require I&D
Deep-tissue
Involves layers under fascia or peritoneum
Requires I&D
Increased risk of dehiscence
If it occurs around implants, such as plates or screws, they may have to be removed
Postoperative Wound Infections (continued)
Burn and trauma patients are at high risk of developing viral, bacterial and fungal infections
Common bacterial infections in burn patients:
Streptococcus pyogenes
Staphylococcus aureus
Pseudomonas aeruginosa
Common fungal infections:
Candida
Postoperative Wound Infections (continued)
Common pathogens acquired from the OR
Aerobic
Staphylococcus aureus
Most common
Pseudomonas aeruginosa
Found in water, soil, and GI tract
Has a smelly odor and a blue-green color
Postoperative Wound Infections (continued)
Anaerobic
Clostridium perfringens
Causes gas gangrene
High mortality rate
Clostridium tetani
Introduced by penetrating wound with soil or fecal matter
Causes tetanus
Postoperative Wound Infections (continued)
Infections will appear within a week of surgery
If infection occurs after a week it indicates that the contamination did not happen int the operating room.
The skin is the most likely source of contamination
If the patient is not the source, it is likely contamination from the hair or nares of the surgical personnel
Peri-operative Precautions
Careful shaving of the patient’s skin
No nicks or cuts
Skin prep
Meticulous draping procedures
Proper aseptic technique
Use of PPE’s
Hair covering, protective eyewear, mask, sterile gown and gloves
Homework
Questions for further study
Page 382
#3, 5, and 8
posted by Ms. Carpenter | 11:34 AM
0 Comments:
Post a Comment
<< Home