Skin and Wound Care

Determining Healability

To individualize the goals of care, wounds first need to be identified as Healing, Non-healing or Non-healable.

  • Healing - Clients have the physical capability to heal and the system can support optimal wound healing:
    • The wound’s underlying cause, such as pressure, can be treated.
    • There is adequate arterial blood flow to perfuse the wound area.
    • The client’s risk factors for healability can be optimized or managed.
    • The client and/or client’s caregivers are willing and able to participate in the care plan.
  • Non-healing - Client has the physical capabilities to heal but cannot due to client, wound and/or system factors that cannot be eliminated resulting in wound healing that is slow or stalled. Wound healing does not occur when:
    • Resources, equipment or supplies to support wound healing are not used or not available.
    • The client and/or client’s caregivers are unwilling or unable to participate in the care plan.
    • The risk factors or underlying causes of the wound cannot be eliminated to promote healing in a timely fashion.
  • Non-healable - Client is unable to heal wound due to:
    • The underlying causes, such as malignancy, impending death or gangrene, cannot be treated.
    • There is an insufficient level of arterial blood flow to the wound to support healing.
    • The client’s risk factors for healability such as systemic disease, medications or poor nutrition cannot be modified.

Healing Phases

Phases of Healing Time Post Injury Cells Involved in Phase Function or Activity Analogy to House Repair
1. Hemostasis Immediate
  • Platelets
  • Clotting
  • Release of growth factors
  • Cap off broken utilities
2. Inflammation Days 1-4
  • Neutrophils
  • Macrophages
  • Monocytes
  • Phagocytosis
  • Unskilled labourers clean up site
3. Proliferation (Granulation and Contraction) Days 4-21
  • Macrophages
  • Pericytes
  • Lymphocytes
  • Angiocytes
  • Fibroblasts
  • Keratinocytes
  • Epithelial
  • Fill defect
  • Re-establish skin function
  • Closure
  • Contractor or supervisor
  • Specific labourers
  • Plumbers
  • Electricians
  • Framers
  • Roofers and siders
4. Remodelling (Maturation) Day 21-2 years
  • Fibrocytes
  • Fibroblasts
  • Develop tensile strength
  • Remodellers

Reused with permission from Wound Canada, 2017.

Barriers to Healing

Age

  • Healing responses slow down
  • Thinning of epidermis -- increases risk of tearing and shearing
  • Decrease in elastin
  • Dermis atrophies -- slows contractility and increases risk of dehiscence
  • pH becomes more neutral -- skin more susceptible to bacterial growth and infections

Co-morbidities

  • Cardiopulmonary2-7: oxygen-transport pathways are affected
    • O2 necessary for wound healing
    • Conditions that impair oxygen delivery, or carbon monoxide removal affects wound healing
  • Diabetes Mellitus2-7: poor glycemic control can increase the risk for ulceration and delayed healing
    • High glycemic levels predisposes to infection8-10
    • Microvasculature and neuropathic components of DM increase risk for impaired healing
  • Immune suppression2-4,7: DM, cancer, HIV, immunosuppressive therapy, immunosuppression syndrome
    • Body lacks ability to produce inflammatory phase that will initiate cascade of wound healing
    • Susceptible to infection8,10

Perfusion and Oxygenation

  • Peripheral Vascular Impairment2-9
    • Healing depends on a well-vascularized area to sustain the growth of new tissue and immunological responses of the tissue to counter infection
    • Arterial insufficiency (blood flow to extremities) leads to tissue death, increased risk of infection
    • Venous insufficiency (blood returning to heart) leads to fluid accumulation in tissues that initiates changes to skin and increases risk for ulceration (edema)11,12
    • Stress hormones released due to stress response cause vasoconstriction and lead to impaired tissue perfusion2-4

Neurologically impaired skin3,4,6,7,9

  • Peripheral neuropathy: complication related to DM, alcoholism, chemotherapy
    • Loss of neuronal signaling and transmission
    • Sensory: loss of the ability to recognize and react to sensations of touch, pressure, temperature, pain. Gait changes, burning sensation
    • Autonomic: affects function of the sweat and sebaceous glands. Dry, flaky, cracked skin
    • Motor: loss of motor control of muscles that result in atrophy and imbalance that contributes to structural changes and deformity
  • Spinal cord injury
    • Results in alterations of three nervous system components: sensory, autonomic and motor

Medications

  • Anticoagulants and anti-inflammatory agents2-4:
    • Decreased collagen production
    • Interfere with platelet activation
  • Steroids2-4:
    • Delay all phases of wound healing
    • Inhibit macrophages, reduce lymphocytes, decrease antibody production, and diminish antigen processing

Nutrition2-7,13

  • Insufficient proteins and calories lead to impaired healing
  • Protein necessary for cell multiplication, synthesis of collagen and connective tissue
  • Protein also had role in antibody production and thus affect the immune system
  • Vitamins and minerals are important to the wound healing phases

Bioburden and Infection

  • Impair cell migration for healing in wound bed 

Stress

  • Releases cortisol which impacts immune function and wound healing

Local ischemia3

  • Local ischemia from sustained pressure
    • Internal: bone and structures causing outward pressure (deformity)
    • External: external environment causing inward pressure (positioning)
  • Smoking = vasoconstrictive to blood vessels

Inappropriate wound care3

  • Misuse of topical agents
  • Poor technique in application

Additional trauma to wound bed

  • Lack of pressure redistribution3,5,7,14,15
  • Improper packing to wound bed -- tight packing3

Best Practices & Additional Resources

1. Orsted HL, Keast DH, Forest- Lelande L, Kuhnke JL, O’Sullivan-Drombolis D, Jin S, Haley J, Evans R. (2017). Skin: anatomy, physiology and wound healing. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017 [cited 2018 Nov 07]. 26p. Available from: https://www.woundscanada.ca/docman/public/health-care-professional/bpr-workshop/166-wc-bpr-skin-physiology/file

2. Orsted HL, Keast DH, Forest-Lelande L, Kuhnke JL, O’Sullivan-Drombolis D, Jin S, et al. Best practice recommendations for the prevention and management of wounds. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017 [cited 2018 Jan 23]. 73p. Available from:https://www.woundscanada.ca/health-care-professional/education-health-care-professional/advanced-education/12-healthcare-professional/110-supplements.

3. Ennis WJ & Menses P. (2010). Complications in repair. In McCulloch JM & Kloth LC (Ed.), Wound Healing Evidence-Based Management (4th ed.). pp 51-64. Philadelphia PA: F.A Davis Company.

4. British Columbia Provincial Nursing Skin and Wound Committee. (2018). Guideline: Wound Management for Adults & Children. [cited 2018 Nov 7]. Available from https://www.clwk.ca/buddydrive/file/guideline-wound-management-2018-august/

5. Registered Nurses’ Association of Ontario (2013). Assessment and Management of Foot Ulcers for People with Diabetes (2nd ed.). Toronto, ON: Registered Nurses’ Association of Ontario.

6. Botros M, Kuhnke J, Embil J, Goettl K, Morin C, Parsons L, Scharfstein B, Somayaji R, Evans R. (2017) Best practice recommendations for the prevention and management of diabetic foot ulcers. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017 [cited 2018 Nov 07]. 67p. Available from:https://www.woundscanada.ca/health-care-professional/education-health-care-professional/advanced-education/12-healthcare-professional/110-supplements.

7. Sibbald, G., et al. (2011). Special considerations in wound bed preparation 2011: An update. Advances in Skin and Wound Care, 24(9), 415-436.

8. Sibbald, G., et al. (2006). Increased bacterial burden and infection: The story of NERDS and STONES. Advances in Skin and Wound Care, 19(8), 447-461.

9. Brogle A. (2010). Conservative management of arterial ulceration. In: J.M McCulloch and L.C Kloth (Ed.), Wound Healing Evidence Based Management (4th ed.). pp. 256-278. Philadelphia. PA: F.A. Davis Company.

10. International Wound Infection Institute (IWII) Wound infection in clinical practice. Wounds International 2016. Retrieved from http://www.woundinfection-institute.com/2016/11/wound-infection-in-clinical-practice-update2016/

11. Registered Nurses Association of Ontario (2004). Assessment and Management of Venous Leg Ulcers. Toronto, Canada: Registered Nurses Association of Ontario.

12. Franks, P., Barker, J., Collier, M. et al. Management of patients with venous leg ulcer: challenges and current best practice, J Wound Care, 25; 6, Suppl, 1–67.

13. Posthauer ME, Banks M, Dorner B, Schols JM. The role of nutrition for pressure ulcer management: national pressure ulcer advisory panel, European pressure ulcer advisory panel, and pan pacific pressure injury alliance white paper. Advances in skin & wound care. 2015 Apr 1;28(4):175-88.

14. National Pressure Advisory Panel, European Pressure Ulcer Advisor Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emilt Haesler (ED.). Cambridge Media: Perth, Australia; 2014.

15. Norton L, Parslow N, Johnston D, Ho C, Afalavi A, Mark M, O’Sullivan-Drombolis D, Moffat S. Best practice recommendations for the prevention and management of pressure injuries. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017 [cited 2018 July 11]. Available from: https://www.woundscanada.ca/health-care-professional/education-health-care-professional/advanced-education/12-healthcare-professional/110-supplements.

16. British Columbia Provincial Nursing Skin and Wound Committee. Guideline: wound bed preparation for healable and non-healable wounds in adults and children. June 2015. [cited 2018 Jan 23]. Available from: https://www.clwk.ca/communities-of-practice/skin-wound-community-of-practice/buddydrive/.

17. Van Rijswijk L, & Eisenberg M. (2010). Wound assessment and documentation. In: Krasner D.L, Rodeheaver G.T, Sibbald G, Woo K (Ed.), Chronic Wound Care A Clinical Source Book for Health Care Professionals (5th ed.). pp. 99-116. Malvern PA: HMP Communications.

18. Sibbald RG, Elliott JA, Ayello EA, Somayaji R. Optimizing the moisture management tightrope with wound bed preparation 2015. Adv Skin Wound Care. 2015; (10):466-76.