Wound Care

Introduction

What should I know about Wound care?

By definition, a wound is a physical injury that results in an opening or break of the skin.

Types:
There are several types of wounds, including surgical, traumatic, and chronic wounds. Traumatic wounds may be caused by mechanical, traumatic or thermal injury, including contusions, abrasions, punctures, fractures, burns, and frostbite. The surgical wound is usually clean and easiest to heal. By definition, chronic wounds may be more difficult to heal, and include pressure sores and diabetic ulcers.

Generally, wounds can be further classified into 2 categories: partial and full thickness. Partial thickness wounds present with damage to the epidermal and dermal tissues, including flame burns, scalds, and blisters, usually being painful to the touch. Full thickness wounds present with damage to epidermal, dermal, or subcutaneous tissues, including flame burns, boiling liquids and chemical burns, usually without pain being evident.

The most common type of wound is a traumatic wound. Traumatic wounds are categorized into several types: (1) abrasion - exists when the surface of the skin or a mucous membrane is scraped away, (2) contusion - an injury where the surface of the skin is not broken, but underlying or internal tissues are damaged, usually resulting from a sharp blow to the body and frequently producing a discoloration or bruising of the skin surface, (3) incision - a traumatic wound made with a sharp instrument that produces a clean cut, such as a scalpel, (4) tunneled wound - presents with a passageway under the surface of the skin that is generally open at the skin level, with most of the tunneling not seen, (5) laceration - the skin is irregularly torn and a penetration wound results from events like a stab or gunshot, (6) bites - abrasions and/or contusions caused by the entrance and crushing of teeth, usually in animals, humans, or insects, (7) cuts - classified as traumatic wounds where there is only a minor break in the integrity of the skin, and (8) thermal wounds - include heat injuries such as burns, sunburns, and electric injuries.

Surgical wounds result from the trauma induced by surgery. Surgical wounds include: (1) post-surgical incisions, including dental extraction, (2) suture site wounds, (3) donor site wounds such as in blood donation, (4) IV site wounds, (5) skin graft wounds, (6) periostomy skin wounds, and (7) peritracheotomy wounds.

The most difficult wounds to treat are the chronic, non-healing wounds. These include: diabetic wounds, arterial ulcers, venous ulcers, and pressure ulcers.

Repair of the Wound:
The process of repair and regeneration following injury represents one of the most fundamental defense mechanisms of an organism against the environment. Wound healing in individuals generally occurs over a reasonable length of time. However, there are reasons that wounds may not heal appropriately, such as in impaired immunity, diseases such as diabetes and CVD, immobility, poor nutrition, and the like. Intervention is necessary in these individuals. Even with minor injuries such as cuts, wounds in impaired individuals may readily develop into very traumatic injuries requiring medication, hospitalization, and even surgery. In general, if a wound does not heal within a month, medical intervention is necessary.

Immediately after injury, the wound fills with blood and a clot forms. The clot contains a threadlike protein called fibrin, which binds the edges of the wound together and stops any bleeding. If tissues are damaged, a cascade of cellular events is initiated to prepare the injured area for the deposition of collagen, which ultimately will replace damaged mesenchymal tissues. Wound healing occurs in several stages.

    Inflammation: A wound initiates a natural inflammatory response with heat, redness, pain, swelling, and impaired function of the involved body tissues. Vasoconstriction occurs within seconds and lasts only a few minutes. This response is followed by vasodilation with an increase in vascular permeability. Next, pronounced leakage of serum proteins occurs in the wound for approximately 10-20 minutes. The final stage of inflammation spans a period of several hours and is characterized by vascular stasis, local hemorrhage, and infiltration of tissues with leukocytes. Vasoactive substances are released from cells in the local environment, most notably histamine. Histamine-induced vasodilation is brief, and seldom lasts more than one hour. Other unknown factors may be involved, including kinins and serotonin.

    During the inflammatory phase the patient will develop leukocytosis, a mildly elevated temperature, and general malaise. Wound management during this phase of healing should include monitoring the wound for erythema or swelling and redness outside the edges of the wound, possibly indicating infection.

    Proliferative Phase: The second stage of wound healing begins three to four days after wounding, and lasts approximately 21 days. During this stage, the wound starts to get smaller and new tissue begins to grow.

    Remodeling Phase: This final stage of healing begins around day 21 and can continue for as long as one to two years post-injury. Collagen that has been deposited in the wound is remodeled, making the healed wound stronger and more like the adjacent tissue. New collagen continues to be deposited, and this compresses the blood vessels in the healing wound, so that the scar eventually becomes a thin, flat, white line. The scar is a vascular collagen tissue that does not sweat, grow hair, or tan in the sunlight. Maximum scar strength is achieved in about three months.

Some factors that may negatively influence wound healing include:

    Age– aging may alter many phases of wound healing including: vascular changes, reduced liver function and synthesis of clotting factors, slowed inflammatory response, reduced immune function, changes in collagen. Obesity- adipose tissue lacks adequate blood supply to resist bacterial infection or deliver nutrients and cellular elements for healing. Malnutrition– may impair all phases of wound healing due to vitamin and mineral deficiencies. (1) Decreased oxygenation of wound site Smoking Diabetes Radiation Wound stress Pharmaceutical medications

Statistic

Nurse Practitioner,The 24(10):66,69-70,73,74.

    Simple traumatic lacerations are one of the most common reasons for visits to the emergency department.

Geriatrics 53(5):88-90,92-94.

    Common causes of wounds in older persons are pressure and friction.

Signs and Symptoms

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Serious complications may occur to neglected wounds and, at times, even the best cared for wounds.

If you notice any of these signs when examining your wounds, you should see a doctor immediately:
  • Redness, excessive swelling, or tenderness in the wound area
  • Throbbing pain or tenderness in the wound area
  • Red streaks in the skin around the wound or progressing away from the wound
  • Pus or watery discharge collected beneath the skin or draining from the wound
  • Tender lumps or swelling in your armpit, groin, or neck
  • Foul odor from the wound
  • Generalized chills or fever

Treatment Options

Conventional

Some non-pharmacological interventions that may encourage the healing of a wound include:

    Limiting wound size – the smaller the wound, the faster the rate of healing. Encourage blood supple – proper blood supply is critical for the wound to receive nutrients and oxygen. Micro-organism containment – make sure the wound is properly cleaned. Adequate nutrition – proper nutritional status is a major factor in rate and extent of wound healing. Reduce physical and mental stresses - both physical and mental stress can depress immunity, thereby decreasing the ability of a wound to heal appropriately.

The pharmacological approach to wound healing may include:

    Topical antibacterial agents, including cleansers, creams, ointments. Growth factors. Analgesics. Collagen. Hyperbaric oxygen.

Nutritional Suplementation

Protein: In the United States, the Recommended Daily Allowance (USRDA) for protein intake for healthy individuals is 0.8 grams per kilogram of body weight per day. To support wound healing, the USRDA protein requirement is substantially higher at 2 to 4 gm/kg/day. (2) Furthermore, approximately 25% of hospitalized patients exhibit signs of malnutrition while 50% of general surgery patients reportedly have moderate-to-severe protein malnutrition. (3)

In protein-deficient patients, the inflammatory stage of wound healing is significantly prolonged. (4) Protein supplementation before a surgical procedure is more effective than supplementation after surgery. As little as one week of preoperative protein supplementation has been shown to improve wound healing. (5)


Zinc

Zinc has a long history as an agent used to promote wound healing. It was used topically as calamine lotion as far back as 1500 BC by the Egyptians. There are over 200 zinc requiring enzymes in the body. Zinc is important in wound healing because it is a required constituent of many proteins and plays a central role in regulating cellular division and differentiation. (6) In cases of zinc deficiency, it is known that zinc supplementation accelerates the healing process. (7) Conversely, zinc deficiency is known to delay the wound healing process. (8)

In general, topical zinc is widely recognized as an effective treatment for wound healing whereas oral zinc supplementation only seems to be beneficial in patients who are zinc deficient. (9)


L-Glutamine

L-glutamine is a conditionally essential amino acid whose requirements increase dramatically during critical illness. Catabolic states causes glutamine metabolism to increase dramatically, causing its tissue and plasma pools to become depleted. In fact, glutamine’s uptake during stress exceeds that of any other amino acid. It is involved in nitrogen exchange, the regulation of nucleotide and protein synthesis, and it is an important substrate for rapidly dividing cells, including those of the gastrointestinal tract, pancreas, pulmonary alveoli, and white blood cells. Because it is an effective nitrogen donor and a precursor for nucleotide and protein synthesis, glutamine is extremely important when wounded tissues are rebuilding. (10)


Vitamin C

Vitamin C plays several critical roles in wound healing. It is necessary for the synthesis of collagen and elastin, which is essential in the repair of injured tissue and, wound healing is impaired when vitamin C levels are not adequate. For example, in a dental study, the healing rate of gingival tissue was compared in patients receiving 250 mg of vitamin C twice daily, 500 mg of vitamin C twice daily, and placebo controls. Wound healing was 40% faster in patients taking 250 mg of vitamin C twice daily, and healing was 50% faster in patients who took 500 mg of vitamin C twice daily. (11)

A summary of vitamin C’s effects include increasing the strength of new collagen formation and the rate of healing, enhancing the immune system and fighting infections, in addition to its well known anti-oxidant, free radical scavenging effects.


Vitamin A

Vitamin A is an important immune system nutrient. Studies report that vitamin A deficiency is common in hospitalized patients, and individuals who are severely wounded or burned can become vitamin A deficient, which impedes wound healing. (12)

Vitamin A plays a significant role in each stage of wound healing. It enhances the early inflammatory phase.


Iron

Iron is an essential nutrient for new cellular growth and wound healing. The enzyme ribonucleotide reductase, which requires iron as a cofactor, is necessary for DNA synthesis. Since cells cannot divide without prior DNA synthesis, iron deficiency can retard the proliferation of cells involved in wound healing. (13)


Vitamin E

Vitamin E supplementation has been shown to enhance immune function and increase resistance to infection. It also helps prevent excessive free radical destruction to wounded tissue, thus reducing secondary damage and improving the healing process. (14)

When vitamin E is applied topically to wounds it may inhibit collagen synthesis. For example, in a study with laboratory animals, back incisions had a significantly lower tensile strength after 7 days of treatment. However, topical administration of vitamin E did produce a marked reduction in scar formation and in the apparent size of the area of injury. This suggests that topical vitamin E may provide some cosmetic benefits, but if the strength of a wound closure is important, topical vitamin E should be avoided. (15)


Arginine

Arginine is an amino acid that promotes healing. After a surgical procedure, rats receiving diets supplemented with arginine do better than control rats on arginine-free diets. Rats administered arginine are more capable of surviving a bacterial challenge, exhibit improved immune function, higher protein levels, and a faster rate of healing. (16)

Arginine also increases T-cell mediated activity, which enhances immune function. Finally, arginine is an important constituent of wound proteins, and supplementation with arginine has been shown to significantly increase the amount of collagen deposited into a wound site during the healing process. (17)

Herbal Suplementation


Calendula

Calendula extracts have been used topically to promote wound healing, with several studies reporting a measurable effect. In a laboratory study, an ointment containing a 5% fractionated extract of calendula flowers markedly stimulated the physiological regeneration of wound tissue, reported to be due to more intensive metabolism of glycoproteins, nucleoproteins, and collagen proteins during the regenerative period in the tissues. Various case reports of calendula preparations used in healing wounds, including traumatic wounds and chronic wounds (including pressure sores and diabetic ulcers). (18)


Tea Tree Oil

An oil from the leaves has been used medicinally for centuries and was first reported to the western world by the crew of Captain James Cook's expeditions in the 1700's. The plant gained widespread notoriety because of claims of its ability to treat various problems including skin ailments, cuts, and burns.

Tea tree oil has historically been used in many conditions including the treatment of acne, aphthous stomatitis, tinea pedis, boils, burns, carbuncles, corns, gingivitis, herpes, empyema, impetigo, infections of the nail bed, insect bites, lice, mouth ulcers, pharyngitis, psoriasis, root canal treatment, ringworm, sinus infections, skin and vaginal infections, thrush, and tonsillitis - a literal panacea for topical infectious conditions. Also, as early as 1930, the antiseptic properties of the plant were recognized by the Australian dental profession. (19)

The therapeutic use of tea tree oil is largely based on its antiseptic and antifungal properties.


Aloe Vera

Aloe vera leaf gel has been heralded for centuries as a topical wound healing agent, including traumatic wounds (from mechanical, traumatic, or thermal injury, including contusions, abrasions, punctures, fractures, sunburn, burns, and frost bite), and chronic wounds (including pressure sores and diabetic ulcers). (20)


Gotu Kola

Gotu kola is reported to have a positive effect on tissues, specifically skin, connective tissue, lymph and mucous membranes. (21) , (22) , (23) It does not contain any caffeine and is not related in any way to kola nut. Gotu kola has been used primarily for venous insufficiency, soft tissue inflammation and infection, and for post surgical wound healing. (24) , (25)

References

  1. View Abstract: Young ME. Malnutriton and wound healing. Heart Lung. 1988;17:60-67.
  2. View Abstract: Doweiko JP, Nompleggi D. The role of albumin in human physiology and pathophysiology: part III, albumin and disease states. J Parenter Enteral Nutr. 1991;15:476.
  3. View Abstract: Mazzotta MY. Nutrition and Wound Healing. J Am Podiatric Med Ass. Sep1994;84(9): 456-462.
  4. View Abstract: Gallucci RM, Simeonova PP, Matheson JM, et al. Impaired cutaneous wound healing in interleukin-6-deficient and immunosuppressed mice. FASEB J. Dec2000;14(15):2525-31.
  5. View Abstract: Windsor J, et al. Wound healing response in surgical patients: recent food intake is more important than nutritional status. Br J Surg. 1988;75:135.
  6. View Abstract: Fabris N, Mocchegiani E. Zinc, human diseases and aging. Milano. Aging. Apr1995;7(2):77-93.
  7. View Abstract: Okada A, et al. Zinc in clinical surgery: a research review. Japanese Journal of Surgery. 1990;20:635.
  8. View Abstract: Andrews M, Gallagher-Allred C. The role of zinc in wound healing. Adv Wound Care. Apr1999;12(3):137-8.
  9. View Abstract: Agren MS. Studies on zinc in wound healing. Stockh. Acta Derm Venereol Suppl. 1990;154:1-36.
  10. View Abstract: Balzola FA, Boggio-Bertinet D. The metabolic role of glutamine. Minerva Gastroenterol Dietol. Mar1996;42(1):17-26.
  11. View Abstract: Ringsdorf WM Jr, Cheraskin E. Vitamin C and human wound healing. Oral Surgery. 1982;53(3):231-236.
  12. View Abstract: Hunt TK. Vitamin A and wound healing. J Am Acad Dermatol. 1986;15:517.
  13. Ward CG. Influence of iron on infection. Am J Surg. 1986;42:166.
  14. Goldstein R, et al. Effect of vitamin E and allopurinol on lipid peroxide and glutathione level in acute skin grafts. J Inves Dermatol. 1990;95:470.
  15. View Abstract: Greenwald DP. Zone II flexor tendon repair: Effects of vitamins A, E and B-carotene. J Surg Res. 1990;49:98.
  16. View Abstract: Nirgiotis JG, et al. The Effects of an Arginine-Free Enteral Diet on Wound Healing and Immune Function in the Postsurgical Rat. Journal of Pediatric Surgery. Aug1991;26(8):936-941.
  17. View Abstract: Barbul A, et al. Arginine enhances wound healing and lymphocyte immune responses in humans. Surgery. Aug1990;108(2):331-336.
  18. View Abstract: US Patent # US5266330. Method for treating pressure ulcers using calendula. Nov1993.
  19. Penfold AR, Morrison FR. Some notes on the Essential oil of M. alternifolia. Aust J Dent. Mar1930;417-4181930.
  20. Salcido R. Complementary and alternative medicine in wound healing. Adv Wound Care. Nov1999;12(9):438.
  21. View Abstract: Suguna L, et al. Effects of Centella asiatica Extract on Dermal Wound Healing in Rats. Indian J Exp Biol. 1996;34(12):1208-11.
  22. View Abstract: Hausen BM. Centella asiatica (Indian Pennywort), an Effective Therapeutic But a Weak Sensitizer. Contact Dermatitis. 1993;29(4):175-79.
  23. View Abstract: Tenni R, et al. Effect of the Triterpenoid Fraction of Centella asiatica on Macromolecules of the Connective Matrix in Human Skin Fibroblast Cultures. Ital J Biochem. 1988;37(2):69-77.
  24. View Abstract: Maquart FX, et al. Stimulation of Collagen Synthesis in Fibroblast Cultures by a Triterpene Extracted from Centella asiatica. Connect Tissue Res. 1990;24(2):107-20.
  25. View Abstract: Cesarone MR, et al. The Microcirculatory Activity of Centella asiatica in Venous Insufficiency. A Double-blind Study. Minerva Cardioangiol. 1994;42(6):299-304.