Chapter 4: Wound Care
4.2 Wound Healing and Assessment
Critical Thinking Exercises: Questions, Answers, and Sources / References
Critical thinking questions are in bold type, and the answers are italicized. Additional resources or references are provided below.
- A 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? Provide your rationale.
- Type of wound: This helps the nurse to anticipate findings.
- Medications: Corticosteroids delay wound healing. Chemo = potential bone marrow suppression = ↓WBC = impaired immunity
- Other chronic disease: Diabetes is characterized by delayed wound healing due to circulatory changes associated with fat, and carbohydrate and protein metabolism. Anemia lowers oxygen availability to tissues. Impaired autoimmunie respnse = impaired healing
- Age: Associated with vascular changes = potential ↓ oxygen to the tissues = ↓ potential for healing
- Smoking: Results in vasoconstriction and arterial damage = potential ↓ oxygen to the tissues = ↓ potential for healing
- Obesity: Obese tissue is poorly vascularized = potential ↓ oxygen to the tissues = ↓ potential for healing
- Diet: does the patient have a well balance diet to provide the necessary fats, carbohydrates and protein needed for healing? What is the patient’s hydration status?
Source:
Potter, P., Perry, A., et al (2019). Canadian fundamentals of nursing (6th ed.). Elsevier; Mosby.
2. What indications might lead the nurse to suspect that a patient is malnourished and, therefore, at risk for delayed wound healing?
- Recent unexplained weight loss, lethargy, loose skin, low prealbumin / albumin, poor dietary (food & fluids) intake, poorly healing wounds
- Note: A diagnosis of malnutrition is based on a multitude of factors. Often through observations, the RN suspects malnutrition is present. The RN can implement dietary strategies / dietary consults as initial strategies to address this important health issue.
Source:
Potter, P., Perry, A., et al (2019). Canadian fundamentals of nursing (6th ed.). Elsevier; Mosby.
3. What phase of wound healing is indicated by the presence of epithelialization and wound contraction?
- Proliferation phase
4. Name three extrinsic factors that can contribute to the risk of pressure injury.
- Shear force: e.g., when being pulled up in the bed
- Friction: e.g., repetitive rubbing on the surface
- Immobility: If blood supply to areas of compression is diminished anoxia occurs, which can lead to tissue damage or death. This includes immobilization procedures such as restraints, or medication induced.
- Humidity: e.g., wet incontinence products
Source:
Magalhães, M., Gragnani, A., Veiga, D., Blanes, L., Galhardo, V., Kállas, H., Juliano, Y., Ferreira, J. (2007). Risk factors for pressure ulcers in hospitalized elderly without significant cognitive impairment. Wounds, 19(1), 20-24. https://www.woundsresearch.com/article/6708
Sample Learning Activity
- Find an assessment tool for pressure injury risk (e.g., Braden scale). For each of the risk categories in the table below, identify strategies that the nurse might choose to implement to help mitigate the risk.
Risk Category |
Potential Nursing Strategies |
| Friction & shear |
|
| Nutrition |
|
| Mobility / activity |
|
| Moisture |
|
| Sensory perception |
|
Source:
Interior Health. (2016, September 20). Braden Q scale [Infographic]. https://www.clwk.ca/buddydrive/file/cc-16-01-b-braden-q-scale/
Potter, P., Perry, A., et al (2019). Canadian fundamentals of nursing (6th ed.). Elsevier; Mosby.
Sample Quiz Questions
1. Name four different types of wounds
Wound dehiscence, surgical, arterial, venous, diabetic neuropathic, traumatic, pressure injury
Source:
Vancouver Coastal Health Authority. (2009). Wound assessment [online course]. http://ccrs.vch.ca/onlinecourses/wound_management/woundassessment_v4/index.html
2. Order the phases of non-complicated wound healing in the correct sequence: hemostasis, maturation, inflammatory, proliferation.
- Hemostasis
- Inflammatory
- Proliferation
- Maturation
Source:
British Columbia Provincial Nursing Skin and Wound Committee. (2011). Guideline: Assessment and treatment of surgical wounds healing by primary and secondary intention in adults and children. https://www.clwk.ca/buddydrive/file/guideline-surgical-wounds-primary-secondary-intention/
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed.). Elsevier; Mosby.
3. True or false? Wet to dry dressings are effective in promoting wound healing.
False. Wet to dry dressings are not considered best practice. When removed they disrupt the wound bed including healing healthy cells. Moist wound environments are considered best practice and can be achieved through moist compresses and manufactured products such as hydrogel.
Source:
Harris, C., Kuhnke, J., Haley, J., Cross, K., Somayaji, R., Dubois, J., Bishop, R., & Lewis, K. (2018). Best practice recommendations for the prevention and management of surgical wound complications. Canadian Association of Wound Care. https://www.woundscanada.ca/docman/public/health-care-professional/bpr-workshop/555-bpr-prevention-and-management-of-surgical-wound-complications-v2/file
4. Which of the following do NOT promote wound healing? (Select all that apply)
- Soaking wounds in a warm bath Incorrect: Warm baths—unless sterile—promote growth of microorganisms and can cause wound infection
- Eating a balanced diet Correct: fats, carbohydrates, protein, hydration
- Exerting prolonged pressure on the site Incorrect: Exerting prolonged pressure can occlude capillary beds, thereby preventing delivery of oxygen and nutrients to the site.
- Elevated blood glucose Incorrect: Hyperglycemia encourages bacterial growth and contributes to arterial changes, which lead to impaired circulation.
- Smoking Incorrect: Smoking results in vasoconstriction and contributes to arterial changes, which lead to impaired circulation.
Source:
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed.). Elsevier; Mosby.
5. Which elements are important to consider when assessing a closed (surgical) wound?
- Location
- Peri skin condition (colour edema)
- Are the wound edges approximated or dehisced
- Presence of staples or sutures
- Pain
Source:
British Columbia Provincial Nursing Skin and Wound Committee. (2011). Guideline: Assessment and treatment of surgical wounds healing by primary and secondary intention in adults and children. https://www.clwk.ca/buddydrive/file/guideline-surgical-wounds-primary-secondary-intention/
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed.). Elsevier; Mosby.
6. Which elements are important to consider when assessing an open wound (e.g., dehisced abdominal wound). Select all that apply.
- Location (Answer: yes)
- Wound bed (slough, granulation, foreign bodies) (Answer: yes)
- Periskin (intact, erythema, macerated, excoriated, callused, etc.) (Answer: yes)
- Pain (Answer: yes)
- Size (length, width, depth) (Answer: yes)
- Presence of undermining / tunnels (location, size) (Answer: yes)
- Exudate (colour, amount, odour) (Answer: yes)
Source:
British Columbia Provincial Nursing Skin and Wound Committee. (2011). Guideline: Assessment and treatment of surgical wounds healing by primary and secondary intention in adults and children. https://www.clwk.ca/buddydrive/file/guideline-surgical-wounds-primary-secondary-intention/
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed.). Elsevier; Mosby.