wound

Patient Care. Assessment of the progress of wound healing begins with frequent inspection of the site for signs of bleeding in or around the wound. Discoloration of the skin adjacent to a surgical or traumatic wound that has been sutured may indicate a pooling of blood in the tissue spaces and the beginning stages of a hematoma. Bleeding in a wound and clot formation can delay healing. Accumulations of serosanguineous fluid and purulent drainage also must be watched for, because they retard the healing process and pose a problem of superinfection. If a drain has been inserted to remove excess fluid, the color, amount, odor, and other characteristics of the drainage must be noted and recorded. If there is more than one drain, the drainage from each should be noted separately.



Dressings also must be observed frequently, especially a pressure dressing, which can become dangerously restrictive if there is swelling. Any change in sensation, such as tingling or numbness, signs of impaired circulation, or complaint of discomfort, should be reported to the physician.

Other data important to the ongoing assessment of wound healing are the leukocyte count, coagulation tests, and electrolyte levels. An elevated body temperature can signal local or systemic infection. Another sign of infection is the presence of purulent drainage. The color of the drainage is often indicative of the particular infecting organism. For example, a yellow color may indicate presence of Staphylococcus aureus, and a blue-green color may indicate Pseudomonas aeruginosa infection.

In a surgical wound, a discharge of serosanguineous fluid on the fourth or fifth postoperative day may signal wound dehiscence and, therefore, should be reported immediately to the surgeon.

During the scarring phase of healing, the wound is inspected for changes in size, color, and shape, which can continue for months even in superficial wounds. New scar tissue is usually purplish, raised, and irregular. With time, the color fades, the scar grows smaller, and its surface and edges become less irregular. Sometimes the scar tissue grows to excess and extends beyond the normal limits of the wound. This hypertrophic scar or keloid may require steroid injections or surgical removal.

In order to achieve adequate and uneventful healing of a wound the patient must be in a good state of nutrition. Virtually every nutrient plays some role in the healing process; hence, a wide range of dietary nutrients must be supplied, either through oral feedings, supplemental vitamins and protein, or parenteral nutrition. Oxygen is also essential to the healing process. This means that measures must be taken to ensure adequate circulation of blood to the wound, employing measures such as exercise, ambulation when possible, and applications of warmth when prescribed. Positioning also is important to avoid prolonged pressure against blood vessels serving the wounded area. Adequate rest is needed to facilitate healing. The patient should understand the need for rest and the purpose of splints, casts, and other devices employed for immobilization of a wounded part.

Mechanical injury to a wound can greatly impede healing by damaging the tissues involved in the healing process. The wound should be protected from friction and direct blows. The affected part must be handled gently, and great care must be used in applying and removing dressings and bandages. Protective bandages and shields made from rubber, plastic cups, tongue blades, and other supportive materials may be needed to protect the wound from additional trauma.

Other factors that work against optimal healing are stress, old age, smoking, obesity, and diabetes mellitus. It is thought that in the poorly controlled diabetic patient there is an increased affinity of hemoglobin for oxygen, which hampers the release of oxygen to the healing tissues. Additionally, poorly controlled diabetic patients have an abnormal function of the phagocytes, which predisposes wounds to infection. Although cancer does not itself interfere with the healing process or make the patient more susceptible to infection, radiation therapy, steroids, and antineoplastic agents, as well as the general debility of the patient, do compromise healing in cancer patients.