Chapter 21: Wound Healing

Question 1

What are the skin layers?

Answer 1

• Pink and Purple, Top Layer = Epidermis
• Light Pink, Middle Layer = Dermis
• Yellow, Bottom Layer = SubcuQ fat

Question 2

Which skin layer provides critical components of the immune response for theh complex processes of wound healing?

Answer 2

DERMIS

Question 3

Define partial thickness versus full thickness wounds.

Answer 3

• Partial = shallow wounds involving full or partial epidermal loss and partial loss of the dermal layer
• Full = Total loss of the both epidermal and dermal layers, extending to at least the subcutaneous tissue layer and possibly as deep as the fascia, muscle layer, and the bone.

Question 4

Define chronic wounds

Answer 4

Wounds that have not healed within 12 weeks of the initial injury

Question 5

What are the 3 phases of healing?

Answer 5

1. Inflammatory Phase
2. Proliferative Phase
3. Maturation Phase

Question 6

Explain the inflammatory phase.

How long does it last?

Answer 6

• Beings immediately following an acute injury to the tissue and is accompanied by the classic signs of tissue damage, including rubor (redness), heat, swelling, and pain.
• Fibrin clot forms and forms protective barrier
• Inflammatory mediators are released that attract neutrophils and monocytes to the wound.
  
  • Neutrophils arrive w/in 6 to 12 hours after initial injury
  • Leukocytes and monocytes arrive, over the next 24 hours and over the next 3 to 7 days
• During this phase, the foundation is set with granulation tissue, and the removal of cellular debris and other foreign materials prepares the site of healing.
• The need for energy, protein and micronutrients (vitamins C, E, and K, iron, selenium, and copper) increases

Question 7

The prescence of which vitamin in the extracellular environment protects the neutrophils, fibroblasts, and collagen, thereby allowing the wound healing process to transition from the inflammatory to the proliferative phase.

Answer 7

Vitamin C

• It also helps maintain homeostasis at the wound site by promoting the inflammatory phase whil participating in the regulation of ROS production and oxidative damage.

Question 8

Explain the proliferative phase.

Answer 8

AKA Construction phase

• Begins within 3 to 4 days after the initial injury, and continues for up to 2 weeks.
• 3 key changes occur
  
  • Epithelization
  • Granulation
  • Angiogensis

Question 9

What nutrient are thought to be ‘conditionally essential’ during the proliferative phase of healing?

Answer 9

AA: Arginine and glutamine

Question 10

Why does iron have an important role in the proliferative phase?

Answer 10

• Plays a vital role in the formation of collagen requires the participation of iron as a cofactor
• Important for hemoglobin synthese
• Delivery of adequate oxygen via hemoglobin
• Collagen synthesis
• Fibroblastic proliferation
• Angiogensis
• Epithelization

Question 11

Explain the maturation phase.

Answer 11

AKA Remodeling phase

• Collagen synthesis
• Tissue regeneration
• Wound contraction all continue and persist for many years.
• Scar tissue is remodeled, capillaries dissolve and the scar tissue gains strength (only up to 80% of original tensile strength)

Question 12

What is ‘dysfunctional’ wound healing?

Answer 12

Occurs when healing steps are adversely affected or inhibited.

• Prolonged inflammatory state
• Reduced availablity of growth factors
• Increased burden (all contribute to wound chronicity)
• Underlying disease (DM)
• Prolonged bleeding
• Inadequate availability of nutrients and blood supply, prescribed drugs, hypoxemia, and inadequate energy intake.

Question 13

What does a wound VAC do?

Answer 13

• Used to remove inflammatory substrates, excess interstitial fluid, and edema to promote improvements in tissue oxygenation.
• Associated with reduced infection and promotion for wound granulation.

Question 14

Explain the difference between prevalence and incidence.

Answer 14

• Prevalence: a measure of the number of cases of pressure ulcers/injuries at a specific time
• Incidence: measures the number of NEW pressure ulcers/injuries in individuals without an ulcer/injury at baseline and is a better indication of quality of care.

Question 15

What is a “never event?”

Answer 15

It is a term used by the CMS (Centers for Medicard and Medicaid Services) to deny payment for costs associated with select complications of patient care that could be prevented

• For example: Preexisting malnutrition was a positive predictive variable for pressure ulcer after a major surgery.

Question 16

(TRUE/FALSE)

In 2008, CMS stopped reimbursing inpatient medical facilities for care for stage 3 and 4 pressure injuries that develop during inpatient stay.

Answer 16

TRUE

aka “never events”

Question 17

Define bioburden.

Answer 17

Refers to the number of microorganisms present on a contaminated object or, in this case, a wound.

Question 18

Explain how excess adipose tissue affects wound healing?

Answer 18

• Exerts additional burden on dependent tissues and causes vascular obstruction, which can impair blood flow and delivery of essential nutrients to the wound.
• Obese individuals are at risk for immune incompetence, wound infections and delayed wound healing.

Question 19

How do uncontrolled BGs, specifically, impact wound healing?

Answer 19

Uncontrolled BGs are associated with impairment of the production of leukocytes

• This problem has implications for the healing process, risk of infection, and impaired wound healing.

Question 20

**What is the recommended energy guideline for adults with pressure injuries who are assessed as being at risk for malnutrition?

Answer 20

**30 to 35 kcal/kg/day

NOTE: It is also recommended that energy intake is adjusted based on weight change or level of obesity.

Question 21

**What is the energy recommendation for patients with pressure injuries but not at risk for malnutrition?

Answer 21

** 30 kcal/kg/day

NOTE: Harris-Benedict equation underestimates by ~10%.

Question 22

**What is the protein recommendation for adults with pressure injuries?

Answer 22

**1.25 to 1.5 g/kg/day.

Question 23

**What are the recommendations regarding arginine, glutamine, etc. for wound healing?

Answer 23

**NPUAP, EPUAP, PPPIA recommend supplements associated with protein, arginine and micronutrients for adults with stage 3 or 4 or multiple pressure injuries/ulcers when traditional high-calorie, high-protein supplements do not meet nutritional requirements and facilitate wound healing.

• **No research examining the use of arginine ALONE as a supplement to promote wound healing demonstrated efficacy.

Question 24

**What are the recommendations in regards to MVIs?

Answer 24

**Recommend a MVI with minerals be considered when an individual with a pressure injury is NOT consuming a balanced diet OR a deficiency is suspected or confirmed.

Question 25

What is the RDA for vitamin C in men, women, smokers?

Answer 25

* Men: 90 mg/day * Women: 75 mg/day * Smokers: Additional 35 mg/day for all tobacco product usage

Question 26

Which vitamin is an antioxidant that is responsible for normal fat metabolism and collagen synthesis. Studies noted a synergistic effect on pressure injury healing when this vitamin is combined with other antioxidants in an energy-dense, oral supplemtn enriched with arginine and zinc.

Answer 26

Vitamin E

Question 27

(TRUE/FALSE) Serum zinc levels accurately related zinc status.

Answer 27

FALSE. * There is no accurate, practical and cost-effective mtethod for assessing zinc status. * Plasma and serum zinc are the most common methods of zinc assessment, but they do NOT necessarily reflect zinc status because zinc is widely distributed throughout the body as a component of proteins. * Zinc is an essential trace mineral necessary for cell profileration and growth; a cofactor for collagen and protein synthesis and profileration of inflammatory cells and epithelial cells.

Question 28

What are the RDAs for zinc in men and women?

Answer 28

* Men: 11 mg/day * Women: 8 mg/day

Question 29

What conditions/diseases do zinc deficiencies occur?

Answer 29

Zinc deficiencies occur secondary to GI surgery and diseases that impair intestinal absorption and/or increase zinc losses (such as, Celiac disease, cystic fibrosis, IBS and Crohn's disease). Chronic diarrhea and exudate from large wounds also can lead to zinc losses.

Question 30

What are the zinc recommendations for patients receiving PN?

Answer 30

* 2.5 to 4 mg/day for patients in non-catabolic states. * 4.5 to 6 mg/d for severely injured patient * An additional 12.2 mg zinc per L of fluid loss (small intestinal fluid loss) * 17.1 mg zinc per kg of stool output or ileostomy drainage

Question 31

\*\*What are the overall energy and protein needs for patients with wounds?

Answer 31

* \*\* 30 to 35 kcal/kg/d energy * 1.2 to 1.5 g/kg/d protein * Plus DRIs for micronutrients

Question 32

(TRUE/FALSE) \*\*SCCM and ASPEN recommend the use of immune-modulating formulations for surgical and trauma patients.

Answer 32

TRUE.

Question 33

\*\*According to SCCM/ASPEN guidelines, when should nutrition support be initiated?

Answer 33

\*\*In patients who are unable to achieve 60% of their energy and protein requirements with EN alone AFTER 7 to 10 days, the SCCM/ASPEN guidelines recommend using supplemental PN. PN should also be considered when patients who are high nutrition rik or malnourished and nutrition support is indicated but EN is not feasible.

Question 34

Explain the TIME acronym.

Answer 34

* T: issue characteristics * I: nfection * M: oisture * E: dges It is a recommended approach for wound bed assessment.