Inflammation and Wound Healing

KEY POINTS

INFLAMMATORY RESPONSE
The inflammatory response is a sequential reaction to cell injury. It neutralizes
and dilutes the inflammatory agent, removes necrotic materials, and establishes an
environment suitable for healing and repair.
The mechanism of inflammation is basically the same regardless of the injuring
agent. The intensity of the response depends on the extent and severity of injury and on
the reactive capacity of the injured person.
The inflammatory response can be divided into a vascular response, a cellular
response, formation of exudate, and healing.
The vascular response results in vasodilation causing hyperemia
(increased blood flow in the area) and increased capillary permeability. These
actions result in redness, heat, and swelling at the site.
During the cellular response, neutrophils and monocytes move to the inner
surface of the capillaries (margination) and then through the capillary wall
(diapedesis) to the site of injury.
Exudate consists of fluid and leukocytes that move from the circulation to
the site of injury. The nature and quantity of exudate depend on the type and
severity of the injury and the tissues involved.
A number of chemical mediators assist in the inflammatory process.
The complement system is an enzyme cascade consisting of pathways to
mediate inflammation and destroy invading pathogens. Major functions of the
complement system are enhanced phagocytosis, increased vascular permeability,
chemotaxis, and cellular lysis.
PGs are generally considered proinflammatory and are potent vasodilators
contributing to increased blood flow and edema formation. PGs also perform a
role in sensitizing pain receptors to stimuli that would normally be painless.
The local response to inflammation includes the manifestations of redness, heat,
pain, swelling, and loss of function.
Systemic manifestations of inflammation include an increased WBC count with a
shift to the left, malaise, nausea and anorexia, increased pulse and respiratory rate, and
fever.
The basic types of inflammation are acute, subacute, and chronic.
In acute inflammation, the healing occurs in 2 to 3 weeks and usually
leaves no residual damage.
A subacute inflammation has the features of the acute process but lasts
longer.
Chronic inflammation lasts for weeks, months, or even years.

NURSING AND INTERPROFESSIONAL MANAGEMENT: INFLAMMATION

 The best management of inflammation is the prevention of infection, trauma,
surgery, and contact with potentially harmful agents.
The ability to recognize the clinical manifestations of inflammation is important
so that appropriate treatment can begin. Treatment may include fever management, rest,
drug therapy, or specific treatment of the injured site. Immediate treatment may prevent
the extension and complications of inflammation.
Drug therapy to decrease the inflammatory response and lower the body
temperature involves the use of aspirin, acetaminophen, some nonsteroidal
antiinflammatory drugs (NSAIDs), antihistamines, and corticosteroids.

HEALING PROCESS
Healing includes the two major components of regeneration and repair.
Regeneration is the replacement of lost cells and tissues with cells of the same type.
Repair is the more common type of healing and usually results in scar formation. Repair
occurs by primary, secondary, and tertiary intention.
Primary intention takes place when wound margins are neatly
approximated, such as in a surgical incision or a paper cut. There are three phases
of the continuum for this process: initial, granulation, and maturation.
Secondary intention wounds occur from trauma, ulceration, and infection
and have large amounts of exudate and wide, irregular wound margins with
extensive tissue loss. These wounds may have edges that cannot be brought
together.
Tertiary intention occurs with delayed suturing of a wound in which two
layers of granulation tissue are sutured together.
Wounds can be classified by their cause (surgical or nonsurgical; acute or chronic)
and depth of tissue affected (superficial, partial thickness, or full thickness).

NURSING AND INTERPROFESSIONAL MANAGEMENT: WOUND HEALING

The purposes of wound management include (1) cleaning a wound to remove any
dirt and debris from the wound bed, (2) treating infection to prepare the wound for
healing, and (3) protecting a clean wound from trauma so that it can heal normally.
A thorough assessment of wounds should be performed on admission and on a
regular basis, with observation and recording of wound characteristics being an essential
task.
Nursing and interprofessional care for the patient with a tissue injury is highly
variable. It depends on the causative agent, the degree of injury, and the patients
condition.
The type of wound management and dressings required depend on the type,
extent, and characteristics of the wound and the phase of healing.
A variety of adjunctive therapies may be used to assist in wound healing:
Negative-pressure wound therapy (vacuum-assisted wound closure) uses
suction to remove drainage and speed wound healing.
Hyperbaric O2 therapy accelerates granulation tissue formation and wound
healing.
 Platelet-derived growth factor stimulates wound healing by promoting cell
proliferation and migration.
Special nutritional measures facilitate wound healing. A high fluid intake
is needed to replace fluid loss from perspiration and exudate formation. A diet
high in protein, carbohydrate, and vitamins with moderate fat intake is necessary
to promote healing.
It is important that the patient, the family, or both know how to care for the wound
and perform dressing changes.

PRESSURE ULCERS
A pressure ulcer is a localized area (usually over a bony prominence) of tissue
necrosis caused by unrelieved pressure that occludes blood flow to the tissues. Pressure
ulcers generally fall under the category of healing by secondary intention.
The clinical manifestations of pressure ulcers depend on the extent of the tissue
that is involved.
Assess patients for pressure ulcer risk initially on admission and at periodic
intervals based on the patients condition and care setting.
Care of a patient with a pressure ulcer requires local care of the wound and
support measures of the whole person such as adequate nutrition, pain management,
control of other medical conditions, and pressure relief.
Local care of the pressure ulcer may involve debridement, wound
cleaning, application of a dressing, and relief of pressure.
The maintenance of adequate nutrition is an important nursing
responsibility and involves the identification and correction of malnutrition states.
Pressure ulcers affect the quality of life of patients and their caregivers. It is
important that the nurse support the caregiver through the added responsibility of
pressure ulcer treatment.