28.1 Cellular Response and Adaptation in Wound Healing

The skin consists of three main layers: epidermis, dermis, and subcutaneous tissue. Each layer and its sublayers play an integral part in the external and internal roles of the skin.
Regardless of wound etiology, all wounds undergo the same biological repair process, which consists of four phases.
Understanding the four phases—hemostasis, inflammation, maturation, and remodeling—is important to understanding how to approach the wound and develop a comprehensive care plan.

28.2 Wound Healing Process

The wound-healing cascade involves complex biochemical and physiological pathways. It includes the secretion of inflammatory cells and cytokines to facilitate healing.
Various types of wounds require specific treatments based on their characteristics and etiology. Open wounds, such as abrasions, lacerations, punctures, avulsions, and incisions, involve breaks in tissue integrity. Chronic wounds fail to progress through healing phases in a timely manner.
Wounds can heal through primary, secondary, or tertiary intention. Primary intention involves rapid closure with closely approximated edges, while secondary intention occurs when edges cannot be closed. Tertiary intention involves delayed closure, often to resolve infection or prepare for further intervention like grafting.
Barriers to wound healing include physical, physiological, local, and systemic factors. Factors like age, immune status, perfusion, smoking, and comorbidities impede healing. The wound bed must be prepared using the TIME principles: tissue, infection/inflammation, moisture, and edges.

Pressure injuries are preventable occurrences. It is the responsibility of every clinician and health-care provider to prevent them.
Understanding the risk factors and pathophysiology of pressure injury development is critical for prevention.
Pressure injuries should be staged.
Pressure injury treatment follows the same method as other wounds and is accomplished through assessment and maximizing the principles of wound bed preparation.

Debridement, a cornerstone therapy in wound progression, has five current modalities: autolytic, biological (MT), enzymatic, mechanical, and surgical/sharp.
Choosing the mode of debridement requires considering the presentation of the wound and the whole patient.
Contraindications to debridement therapy rely on the specific modality. Regardless of the technique used, the removal of devitalized tissue is critical to facilitating wound progression.

There are more than a dozen topical therapy options and hundreds of wound care products on the market today. As a nurse, it is important to have a basic working knowledge of the categories of topical therapy and of the basic principles that govern patient care.
Common lower leg ulcers encountered in wound care practice include venous leg ulcers, arterial ulcers, and diabetic foot ulcers.
Any patient with a history of compromised circulation must have an ABI performed. If compression occurs and perfusion is compromised, the patient may risk losing or severely damaging the limb.

Wound care is a collaborative effort among the interdisciplinary team. Often wounds are complex and require extensive or innovative measures to help heal.
Specialized therapies include HOBT, NPWT, and drain management.
As a nurse, it is important to understand what different treatment modalities are available to a patient and how to monitor the therapy.
If a nurse is interested in specializing in wound care, there are options to continue education and obtain a board certification.
Wound care is constantly evolving and needs specialists to help educate other clinicians, patients, and caregivers on wound care best practices.

A comprehensive wound assessment documents the status and progress of a wound. It includes a record of the observation, data collection, and evaluation and serves as the baseline for future comparisons.
The comprehensive wound assessment includes patient history, wound measurement, observation of the wound base, and periwound assessment.
Wound documentation should occur upon patient admission and transfer or discharge. Additional documentation should occur weekly, with each dressing change, and with any changes in the wound or periwound.
Documentation should include type of wound, measurements, description of the wound base and periwound, drainage, odor, pain, and patient response to treatment in simple, objective terms.
Documentation that is not thorough can be considered low quality and can lead to medico-legal issues. Consistency is important and prevents gaps in charting.
Incomplete documentation can be interpreted as evidence of negligence and may also lead to issues with reimbursements for medical services rendered.