The nurse determines that a patients abdominal surgical wound is healing by primary intention

Cutaneous wound healing is the process by which the skin repairs itself after damage. It is important in restoring normal function to the tissue.

Inhaltsverzeichnis Show

Primary Intention
Surgical Wound Healing
Secondary Intention
Factors Affecting Wound Healing
Contamination and Infection
Phases of Wound Healing
Wound Healing
Wound Assessment
Attribution
Is surgical wound healing by primary intention?
What stage of healing is primary intention?
What determines primary or secondary intention healing?
What does primary intention mean quizlet?

Table of Contents

Primary Intention
Surgical Wound Healing
Secondary Intention
Factors Affecting Wound Healing
Contamination and Infection
Phases of Wound Healing
Wound Healing
Wound Assessment
Attribution

There are two main types of healing, primary intention and secondary intention. In both types, there are four stages which occur; haemostasis, inflammation, proliferation, and remodelling.

In this article, we shall look the mechanisms of wound healing, factors affecting healing, and wound infection.

Primary Intention

Healing by primary intention occurs in wounds with dermal edges that are close together (e.g a scalpel incision). It is usually faster than by secondary intention, and occurs in four stages:

Haemostasis - the action of platelets and cytokines forms a haematoma and causes vasoconstriction, limiting blood loss at the affected area
- The close proximity of the wound edges allows for ease of clot formation and prevents infection by forming a scab
Inflammation - a cellular inflammatory response acts to remove any cell debris and pathogens present
Proliferation - cytokines released by inflammatory cells drive the proliferation of the fibroblasts and the formation of granulation tissue
- Angiogenesis is promoted by the presence of growth mediators (e.g VEGF), allowing for further maturation of the granulation tissue; the production of collagen by fibroblasts allows for closure of the wound after around a week
Remodelling - collagen fibres are deposited within the wound to provide strength in the region, with the fibroblasts subsequently undergoing apoptosis

The end result of healing by primary intention is (in most cases) a complete return to function, with minimal scarring and loss of skin appendages.

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Figure 1 - A surgical wound, closed by sutures. This is an example of healing by primary intention.[/caption]

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Surgical Wound Healing

Any wound made by a scalpel will heal by primary intention. Surgeons can aid healing by ensuring adequate opposition of the wound edges, through use of surgical glue, sutures, or staples.

When sutures are used to close a wound, ensuring the correct tension of the sutures is essential:

Too loose and the wound edges will not be properly opposed, limiting the primary intention healing and reducing wound strength
Too tight and the blood supply to the region may become compromised and lead to tissue necrosis and wound breakdown

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Secondary Intention

Healing by secondary intention occurs when the sides of the wound are not opposed, therefore healing must occur from the bottom of the wound upwards.

It occurs in the same four stages as primary intention:

Haemostasis - a large fibrin mesh forms, which fills the wound
Inflammation - an inflammatory response acts to remove any cell debris and pathogens present
- There is a larger amount of cell debris present, and the inflammatory reaction tends to be more intense than in primary intention
Proliferation - granulation tissue forms at the bottom of the wound
- This is an important step, as the epithelia can only proliferate and regenerate once granulation tissue fills the wound to the level of the original epithelium; once the granulation tissue reaches this level, the epithelia can completely cover the wound
Remodelling - the inflammatory response begins to resolve, and wound contraction can occur

Myofibroblasts are vital cells in secondary intention. They are modified smooth muscle cells that contain actin and myosin, and act to contract the wound; decreasing the space between the dermal edges. They also can deposit collagen for scar healing.

An uncommon complication from wound healing (particularly in people with darker skin), are keloid scars, whereby there is excessive collagen production, leading to extensive scarring. This can occur in both primary and secondary intention healing.

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Figure 2 - Healing by Primary versus Secondary Intention[/caption]

Factors Affecting Wound Healing

There are several factors that affect the success of any wound healing. They can be divided into local factors and systemic factors:

Local Factors	Systemic Factors
Type, size, location of wound	Increasing age
Local blood supply	Co-morbidities, especially CV disease or DM
Infection	Nutritional deficiencies (especially Vitamin C)
Foreign material or contamination	Obesity
Radiation damage

Table 1 - Risk Factors for Reduced Wound Healing

Contamination and Infection

Surgical site infections (SSI) occur when any infection gains entry to the body via a surgical environment. They represent around 15% of all healthcare-associated infections.

Wound contamination increases the risk of infection. It can be classified as per the US National Research Council guidance, which defines four classes of contamination, ranging from clean to dirty.

Classification	Criteria description	Infection Rate
Clean	Elective, non-emergency, non-traumatic, and primarily closed, with GI, biliary, and GU tracts remaining intact	2.1%
Clean-Contaminated	Urgent or emergency case that is otherwise clean Elective opening of respiratory, GI, biliary, or GU tract with minimal spillage and not encountering infected urine or bile	3.3%
Contaminated	Gross spillage from GI tract or entry into biliary or GU tract (in the presence of infected bile or urine) Penetrating trauma <4 hours old or a chronic open wound to be grafted or covered	6.4%
Dirty	Purulent inflammation (e.g. abscess) Preoperative perforation of respiratory, gastrointestinal, biliary, or genitourinary tract, or a penetrating trauma >4 hours old	7.1%

Table 2 – Classification of Wound Contamination, adapted from Berard et al

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Key Points

Cutaneous wound healing is the process by which the skin repairs itself after damage
Healing by primary intention occurs in wounds with dermal edges that are close together
Primary intention typically occurs in four stages: haemostasis, inflammation, proliferation, and remodelling
Wound contamination increases the risk of surgical site infection, which can influence wound healing

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Wound healing is a dynamic process of restoring the anatomic function of living tissue. Since damage to the body’s tissue is common, the body is well adapted to utilizing mechanisms of repair and defence to elicit the healing process. Normal wound healing is profoundly influenced by the type of injury and by factors about the wound (intrinsic) and within the patient (extrinsic) (Perry, Potter, & Ostendorf, 2014).

Phases of Wound Healing

There are four distinct phases of wound healing. These four phases must occur in correct sequence and in a correct time frame to allow the layers of the skin to heal (see Figure 4.1). Table 4.1 describes how a wound heals.

Table 4.1 Phases of Wound Healing for Full Thickness Wounds

Phase	Additional Information
Hemostasis phase	Blood vessels constrict and clotting factors are activated. Clot formation blocks the bleeding and acts as a barrier to prevent bacterial contamination. Platelets release growth factors, which alert various cells to start the repair process at the wound location.
Inflammatory phase	Vasodilation occurs, allowing plasma and leukocytes (white blood cells) into the wound to start cleaning the wound bed. This process is seen as edema, erythema, and exudate. Macrophages (another type of white blood cell) work to regulate the cleanup.
Proliferative phase	Four important processes occur in this phase: Epithelialization: new epidermis and granulation tissue are developed New capillaries: angiogenesis occurs to bring oxygen and nutrients to the wound Collagen formation: this provides strength and integrity to the wound Contraction: the wound begins to reduce in size
Maturation (remodelling) phase	Collagen continues to strengthen the wound, and the wound becomes a scar.
Data source: British Columbia Provincial Nursing Skin and Wound Committee, 2011; Perry et al., 2014

Figure 4.1 Phases of wound healing

To determine how to treat a wound, consider the etiology, amount of exudate, and available products to plan appropriate treatment. Wounds are classified as acute (healing occurs in a short time frame without complications) or chronic (healing occurs over weeks to years, and treatment is usually complex). Examples of acute wounds include a surgical incision or a traumatic wound (e.g., a gunshot wound). Examples of chronic wounds include venous and arterial ulcers, diabetic ulcers, and pressure ulcers. Table 4.2 lists the six main types of wounds.

Table 4.2 Types of Wounds

Type	Additional Information
Surgical	Healing occurs by primary, secondary, or tertiary intention. Primary intention is where the edges are sutured or stapled closed, and the wound heals quickly with minimal tissue loss. The healing time for a surgical wound is usually short, depending on the surgery. A surgical wound left open to heal by scar formation is a wound healed by secondary intention. In this type of wound, there is a loss of skin, and granulation tissue fills the area left open. Healing is slow, which places the patient at risk for infection. Examples of wounds healing by secondary intention include severe lacerations or massive surgical interventions. Healing by tertiary intention is the intentional delay in closing a wound. On occasion, wounds are left open (covered by a sterile dressing) to allow an infection or inflammation to subside. Once the wound is closed with staples or sutures, the scarring in minimal.
Traumatic	Examples are gunshot wounds, stab wounds, or abrasions. These wounds may be acute or chronic.
Diabetic/neuropathic ulcer	This is a nerve disorder that results in the loss or impaired function of the tissues affecting nerve fibres. These wounds generally occur as a result of damage to the autonomic, sensory, or motor nerves and have an arterial perfusion deficit. They are usually located in the lower extremity on the foot. Diabetic/neuropathic ulcers are often small with a calloused edge. Pain may be absent or severe depending on the neuropathy.
Arterial ulcer	Arterial ulcers occur when tissue ischemia occurs due to arterial insufficiency from the narrowing of an artery by an obstruction (atherosclerosis). They are located on the distal aspects of the arterial circulation, and can be anywhere on the legs, including feet or toes. Wound margins are well defined with a pale wound bed with little or no granulation. Necrotic tissue is often present. There is minimal to no exudate present. Pedal pulses are usually absent or diminished. Pain occurs in limb at rest, at night, or when limb is elevated. Arterial ulcers account for 5% to 20% of all leg ulcers. Perfusion must be assessed prior to initiating treatment.
Venous ulcer	A venous ulcer is a lower extremity wound. Tissue ischemia occurs due to the failure of the venous valve function to return blood from the lower extremities to the heart. It is usually located in the ankle to mid-calf region, usually medial or lateral, and can be circumferential. Drainage can be moderate to heavy. A venous ulcer can be irregularly shaped, large, and shallow with generalized edema to lower limbs. Pulse may be difficult to palpate. Venous ulcers account for 70% to 90% of all leg ulcers. Perfusion must be assessed prior to initiating treatment.
Pressure ulcer	Also known as a pressure sore or decubiti wound, the pressure ulcer is a localized area of tissue damage that results from compression of soft tissue between a hard surface and a bony prominence (coccyx, ankle, shoulder blade, or hip). As blood supply decreases to the area of compression, tissue anoxia occurs, which can lead to eventual tissue death. Wounds are usually circular and may have viable or necrotic tissue, and exudate can vary from none to heavy. Pressure ulcers are classified depending on the level of tissue damage (stages 1 to 4). Treatment is based on stage, exudate, type of available dressing, and frequency of dressing changes.
Data source: British Columbia Provincial Nursing Skin and Wound Committee, 2011, 2014; Perry et al., 2014

Wound Healing

Wounds require different treatment throughout the phases of healing. There are multiple factors that affect how a wound heals as it moves through the phases of healing. It is important to look at the “whole patient” rather than the “hole in the patient” to identify the correct treatment and work efficiently and effectively from the beginning of the healing process.

Table 4.3 lists a number of factors that inhibit the ability of tissues and cells to regenerate, which can delay healing and contribute to wound infections.

Table 4.3: Patient Considerations for Wound Healing

Influencing Factors	Additional Information
Patient’s age	Vascular changes occur with increasing age, skin is less pliable, and scar tissue is tighter. For example, an older adult’s skin tears more easily from mechanical trauma such as tape removal.
Patient’s nutritional status	Tissue repair and infection resistance are directly related to adequate nutrition. Patients who are malnourished are at increased risk for wound infections and wound infection-related sepsis.
Patient’s size	Inadequate vascularization due to obesity will decrease the delivery of nutrients and cellular elements required for healing. An obese person is at greater risk for wound infection and dehiscence or evisceration.
Oxygenation	Factors such as decreased hemoglobin level, smoking, and underlying cardiopulmonary conditions will decrease oxygenation. Adequate oxygenation at the tissue level is essential for adequate tissue repair. Hemoglobin level and oxygen release to tissues is reduced in smokers.
Patient’s medications	Steroids reduce the inflammatory response and slow collagen synthesis. Cortisone depresses fibroblast activity and capillary growth. Chemotherapy depresses bone marrow production of white blood cells and impairs immune function.
Chronic diseases or trauma	Chronic diseases and traumas such as diabetes mellitus or radiation decrease tissue perfusion and oxygen release to tissues.
Data source: Gallagher-Camden, 2012; Perry et al., 2014; Stotts, 2012

Watch this 30-minute video about how wounds heal from Connecting Learners with Knowledge (CLWK), a provincial resource.

Wound Assessment

Frequent wound assessment based on the type, cause, and characteristics of the wound is necessary to help determine the type of treatment required to manage the wound effectively and to promote maximal healing. The health care professional should always compare the wound to the previous assessment to determine progress toward healing. If there has been no improvement in the healing of the wound, alternative options or consulting a wound care specialist should be considered.

Checklist 32 outlines the steps to take when assessing a wound.

Checklist 32: Wound Assessment



1. Location	Note the anatomic position of the wound on the body.
2. Type of wound	Note the etiology (cause) of the wound (i.e., surgical, pressure, trauma). Common types are pressure, venous, arterial, or neuropathic/diabetic foot ulcers, or surgical or trauma wounds.
3. Extent of tissue involvement	A full-thickness wound involves both the dermis and epidermis. A partial-thickness wound involves only the epidermal layer. If the wound is a pressure ulcer, use the Braden Scale Interventions Algorithm.
4. Type and percentage of tissue in wound base	Describe the type of tissue (i.e., granulation, slough, eschar) and the approximate amount.
5. Wound size	Follow agency policy to measure wound dimensions, including width, depth, and length. Assess for a sinus tract, tunnelling, or induration.
6. Wound exudate	Describe the amount, colour, and consistency: Serous drainage (plasma): clear or light yellowish Sanguineous drainage (fresh bleeding): bright red Serosanguineous drainage (a mix of blood and serous fluid): pink Purulent drainage (infected): thick and yellow, pale green, or white
7. Presence of odour	Note the presence or absence of odour. The presence of odour may indicate infection.
8. Peri-wound area	Assess the temperature, colour, and integrity of the skin surrounding the wound.
9. Pain	Assess pain using LOTTAARP.
Data source: British Columbia Provincial Nursing Skin and Wound Committee, 2014; Perry et al., 2014

Watch this 30-minute Wound Assessment video, a provincial resource from CLWK, to learn how to improve wound-assessment skills.

Your patient is 75 years old, smokes cigarettes, has renal disease, and is overweight. What additional factors should you consider prior to assessing the patient’s wound?
What phase of wound healing is indicated by the presence of epithelialization and wound contraction?

Attribution

Figure 4.1
Phases of wound healing by Mikael Häggström is in the public domain.

Is surgical wound healing by primary intention?

Surgical Wound Healing. Any wound made by a scalpel will heal by primary intention. Surgeons can aid healing by ensuring adequate opposition of the wound edges, through use of surgical glue, sutures, or staples.

What stage of healing is primary intention?

Healing by first (primary) intention, or primary closure, refers to the healing of a wound in which the edges are closely re-approximated. In this type of wound healing, union or restoration of continuity occurs directly with minimal granulation tissue and scar formation.

What determines primary or secondary intention healing?

Healing by first intention or Primary intention healing happens when the wound edges are approximated e.g. by sutures, staples or glue. Healing by second intention or Secondary intention healing takes place when the wound edges cannot be approximated and the wound needs to heal from the bottom.

What does primary intention mean quizlet?

Primary intention healing. Occurs where the tissue surfaces has been approximated (closed) and there is minimal or no tissue loss; it is categorized by the formation of minimal or no tissue loss; it is characterized by the formation of minimal granulation tissue and scarring.