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Before treatment takes place it is essential to make a full assessment of:
The assessment must be completed in accordance with your employing organisations policies, procedures and guidelines.
All documentation must be completed in accordance with national and professional guidelines on record keeping.
There is an increased need to manage more complex wounds both within and without the secondary / acute setting.
Registered practitioners need to understand the numerous cellular processes which take place in the wound repair process to enable them to make informed decisions regarding dressing selection.
Correct usage of modern dressings will facilitate the function of the wound healing process rather than just cover a wound.
Correct use of debridement and surrounding skin care plus correction of underlying pathology along with the correct usage of modern dressings will result in improved patient comfort, correct wear time, effective use of nurse time and a reduction in cost.
Managing complex wounds may require specialised nurse input which you may want to consider if difficulties are experienced.
A local reaction to tissue damage. It is an important part of the body's defence mechanism and also an essential part of the healing process.
Signs of inflammation are redness, heat, pain and swelling.
The coagulation cascade is activated initially following an injury. Vasoconstriction occurs preventing excessive blood loss. A clot is formed over the wound.
Tissue injury and clotting activation stimulates the release of vasoactive substances such as prostaglandins and histamine, causing vasodilation and increased capillary permeability to serum and blood cells. Fluid flows into the injured tissue, the fluid contains plasma proteins, white blood cells and platelets, and is known as exudate.
Platelets in the exudate release growth factors, prostaglandins, adhesive glycoproteins and fibronectin, which initiate the promotion of cell migration and wound site access via vasodilation and increased capillary permeability, and production of the extracellular matrix.
The signature cells of this phase are leucocytes. The first to arrive are neutrophils, which engulf and destroy any bacteria found at the wound site. Macrophages arrive later and destroy bacteria and damaged tissue around the wound.
The macrophages move from the first stage into this stage. They produce growth factors, which attract fibroblasts, which divide and produce collagen fibres. These collagen fibres gradually become organised to give the wound elasticity. Fibroblasts also contract the wound.
It has been suggested that this process of contraction could be responsible for as much as 40-80% of the closure of the wound.
Macrophages also produce angiogenesis factor, which instigates the process of angiogenesis (growth of new blood vessels). Capillaries beneath the wound sprout buds, which grow towards the surface and then loop back over again to the capillary. These loops supply oxygen and nutrients to the wound. The wound fills up with new tissue and a new capillary network is formed. The number of macrophages and fibroblasts gradually decreases.
Epithelial cells begin to move across the wound bed. These epithelial cells respond to the chemotactic stimuli from within the wound bed. When epithelial cells meet they stop dividing and moving, a process known as contact inhibition. Epithelial cells move best in a moist environment.
Wound becomes less vascular. Epithelialisation is now complete. After a period of time the scar tissue gradually remodels and begins to look like normal tissue. The scar flattens. It should be remembered that although great strides have been made in understanding the healing process, it is still incompletely understood.