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TISSUE VIABILITY
SKILLS MODULE
WOUND HEALING
SECTION ONE:
THE HEALING PROCESS
Lead Educator:
Julie Trudgian
PDD Logo
WOUND MANAGMENT COMPETENCY MODULE
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May 2003

CONTENTS PAGE NUMBER
Aim
Objectives
Tissue Viability Competency Modules
Tissue Viability Self Directed Learning Packs
Learning Outcomes
Competency Levels
Wound Healing Competency Descriptor
Responsibilities of an Assessor
Summary Sheet One
Summary Sheet Two
Summary Sheet Three
Section One Level One
Section One Level Two
Section One Level Three
Reflective Statement / Account on Skills Acquisition
Reflective Statement
References and Suggested Reading
All rights reserved. Should you need to copy, record, store in a retrieval system or
transmit electronically or otherwise any element of this pack permission must be
obtained from the Tissue Viability Service, Practice Development Department, Royal
Cornwall Hospitals NHS Trust.
WOUND MANAGMENT COMPETENCY MODULE
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AIM
To provide an educational module pack that can easily be accessed and used by link
practitioners, educators and health care workers, to develop skills in the management of
wounds and care of patients receiving treatment. Practitioners will therefore be able to
demonstrate underpinning theoretical and practical knowledge to the required level of
competence.
OBJECTIVES
 That all health care workers deliver care in accordance with Trust Protocols,
Policies, Guidelines and Standards which relate to the care of patients with wounds.
 That patients receive the highest quality care as demonstrated by analysis of
research / clinical evidence.
 That staff continue to maintain their own competence upon completion of this
module through questioning their own practice, the practice of others and the Trust
guidelines to ensure practice changes with the dynamic processes of new
information.
TISSUE VIABILITY COMPETENCY MODULES
(To be available from August 2003)
 Wound Management
 Pressure Ulcer Prevention
 Leg Ulcer Management
 Larval Therapy
 Diabetic Foot Care
TISSUE VIABILITY SELF DIRECTED LEARNING PACKS
 Hand held Doppler Assessment
 Compression Bandaging
 Pressure Ulcer Prevention
 Sharp Debridement
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WOUND MANAGMENT COMPETENCY MODULE
LEARNING OUTCOMES
LEVEL ONE
 To demonstrate knowledge of the condition of a healthy wound bed.
 To be aware of factors which may influence healing.
 To demonstrate an understanding of the experience of the patient with a wound.
 To demonstrate knowledge of the importance of support and information for the
patient receiving wound care.
 To prepare the patient and environment prior to application of a wound dressing.
 To perform dressings to non-problematic wounds following instruction from a
qualified practitioner.
 To identify when dressing changes are required.
LEVEL TWO
 To demonstrate awareness of the stages of healing and the appearance of a wound
bed at each stage of the process.
 To be aware of barriers to achieving successful healing.
 To understand the impact of a wound upon an individual’s lifestyle.
 To confidently perform holistic patient assessment and identify local and systemic
variables which influence healing.
 To select wound care products based upon holistic assessment and the best availab
le
evidence.
 To evaluate the efficacy of intervention.
 To understand the role of the multi-disciplinary team in achieving clinical
effectiveness.
 To demonstrate an ability to prepare and inform the patient and support him / her
throughout the treatment.
WOUND MANAGMENT COMPETENCY MODULE
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LEARNING OUTCOMES
LEVEL THREE
 To demonstrate knowledge of the pathophysiology of wound healing.
 To perform wound classification.
 To demonstrate skills in determining the impact of physiological, psychological and
social variables upon healing.
 To manage complex wounds influenced by multi-factorial variables.
 To liase with members of the multi-disciplinary team to achieve positive patient
outcomes.
 To demonstrate an ability to assess psychological preparation of the patient and his /
her understanding of the treatment when obtaining consent.
 To demonstrate awareness of the role of interactive wound care products and their
impact upon wound biochemistry.
 To demonstrate an understanding of the indications and contra-indications of wound
care products and apply knowledge to determine its suitability for use.
 To competently evaluate the efficacyof intervention.
LEVEL FOUR
 To demonstrate advanced skills and knowledge in assessment and management of
patients with complex, multi-factorial wounds.
 Expands knowledge of wound care through evaluation of wound care products,
audit and research.
This module supports the development of competency to level three, required for
practitioners instigating this treatment in clinical practice. Practitioners can then
continue to build upon their level of knowledge and skill in this area independently.
Advanced modules encompassing competency development to level four will be
available early in 2004.
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WOUND MANAGMENT COMPETENCY MODULE
COMPETENCY LEVELS
LEVEL ZERO
Not in possession of specific knowledge related to the skill
LEVEL ONE
Expected of a health care support worker, technician or other support staff who have
undertaken training in this skill.
LEVEL TWO
Expected from any registered practitioner caring for patients with wounds following
completion of preceptorship.
LEVEL THREE
Expected from a registered practitioner who has acquired competence through
experience, or completion of specific education / training. He / she can provide
guidance for colleagues who are developing knowledge and skills within this area of
practice.
LEVEL FOUR
Expected of a nurse who is experienced in caring for patients with tissue viability needs
and who has undertaken advanced educational programmes. He / she is able to provide
education and assess colleagues who are developing knowledge within this area of
practice.
All levels are expected to maintain equipment safety, mimimalise patient risk and
adhere to national / local policies, procedures, guidelines and standards (for
example infection control).
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ADD COMPETENCY DESCRITOR
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WOUND MANAGMENT COMPETENCY MODULE
RESPONSIBILITIES OF AN ASSESSOR
 Always act in a manner to promote and safeguard the interests and well being of
patients and clients.
 Assist professional colleagues in the context of your own knowledge, expertise and
sphere of responsibility, to develop their professional competence.
 To honestly acknowledge any limitation within their personal knowledge and skill
and take steps to remedy any relevant deficits.
 Recognise and honour the personal accountability borne by all aspects of
professional practice.
 Enhance trust and confidence within a healthcare team and promote collaborative
work between all health professional.
 To assist health professionals in their role as clinical assessors it is expected that all
experienced clinically competent health professionals complete the theoretical self-
directed learning sections of the skills training packages
 By completing the theoretical training the clinically competent health professional
will maintain their knowledge base and ensure they are equipped to assess other
health care workers.
 Health professionals who decline to complete the theoretical section of the training
package, may not have sufficient expertise or knowledge to do this, and therefore,
would not make suitable assessors.
 Health professionals who do not follow this process may compromise trainees.
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WOUND MANAGEMENT COMPETENCY MODULE
SUMMARY SHEET ONE
TRAINING ENTRY CRITERIA
Any health care worker who is involved in the care of patients with wounds following
agreement with his / her unit manager.
CRITERIA FOR ASSESSORS /SUPERVISORS
 Healthcare professionals who are competent to level three or level four.
 The supervisor will supervise practice on a one to one basis.
 A supervisor is not necessarily required to be an assessor.
POLICIES, PROCEDURES AND GUIDELINES ASSOCIATED
WITH WOUND HEALING
1. MP44 Procedure for the Application of Regranex 0.01% Becaplermin gel
2. MP45 Protocol for Overgranulation
3. MP46 Protocol for the Debridement of Devitalised Tissue
4. MP47 Procedure for the Application of Alginate Dressing
5. MP48 Procedure for the Application of Cadexomer Iodine (Iodoflex)
6. MP49 Procedure for the Application of Film Dressings
7. MP50 Procedure for the Application of Foam Dressings
8. MP51 Procedure for the Application of Hydrocolloids
9. MP52 Procedure for the Application of Hydrogel to a Wound
10. MP53 Procedure for the Application of Silicone Tulle Dressing
11. MP54 Procedure for the Application of Cavilon No Sting Barrier Film
12. MP 55 Procedure for the Application of Sugar Paste to Wounds
13. MP56 Procedure for the Application of Varidase Solution
14. RCHT Wound Care Guidelines
15. RCHT Infection Control Policy
16. RCHT Tissue Viability Referral Pathway
TRAINING CONTENT
 Theoretical knowledge will be obtained through completion of the Wound Healing
Competency Module. The majority of the information needed to complete the
module is contained within it, however, it is expected that the practitioner will
continue to add to his/her knowledge through wide reading, (see reading list),
reflection, analysis and continued updating. Each level builds upon earlier
knowledge and all practitioners must start at level one.
WOUND MANAGEMENT COMPETENCY MODULE
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SUMMARY SHEET TWO
 To ensure learning modules are completed to the required level practitioners will be
required to complete Learning Exercises contained within this pack and write a
reflective account of their learning experience at the end of each level.
 Practical training will take place in the clinical arena and / or study areas.
TRAINING RESOURCES
 Wound Healing Competency Module
 Wound Healing Resource Pack
 Wound Dressing Selection Model
 Tissue Viability Clinical Practice Educator / Nurse Consultant
 Education Centre Resource Room
 Post Graduate Centre Library
 Tissue Viability Link Practitioner
It is essential you make full use of your assessor / mentor and supervisor to help with
both theory and practice elements of the skill.
ASSESSMENT
 Where possible training should be completed within one month.
 Each healthcare worker will take responsibility for his / her own level of
competence and exercise clinical judgement before undertaking any aspect of this
skill unsupervised.
 Each practitioner shall undertake self-directed theoretical study using the contents
of the Module and additional material.
 Self-assessment must be continuous once the individual has attained competency.
 The period of supervised practice will be negotiated on an individual basis, enabling
the learner to develop confidence in the skill.
SELF DIRECTED LEARNING METHOD
This training package is designed to be used by:
 Individual health care workers looking to develop their own level of competence
with their line manager’s approval.
 Link practitioners and those competent at level three or level four, supporting the
development of colleagues.
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SUMMARY SHEET THREE
The format allows the Practitioner to direct his/her own learning in order to achieve the
required level of competency and supports the development of individuals working in
busy areas where study time is restricted. The practitioner should expect to complete
the module within 1 day, additional time should be allocated for further study,
reflection and supervised practice.
Wound healing is a complex phenomenon comprised of several key elements, which
need to be understood by the practitioner caring for patients with wounds. To allow
ease of use this module has been split into three sections. The practitioner must
complete each section to the required level to achieve competency.
Section 1 The Wound Healing Process and Factors Delaying Healing
Section 2 Wound Assessment and Classification
Section 3 Wound Cleansing and Dressing Selection
The theory sections of this pack must be successfully completed before supervised
practice commences. The learner will need to select an assessor to confirm that they
have completed the pack to the required standard. The assessor must fulfil the criteria
outlined above.
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WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL ONE
INTRODUCTION
Wound management is centred upon achieving the best possible outcome for the patient
with a wound, which, where possible, is complete healing. To achieve this the
practitioner must have an understanding of the stages a wound goes through as healing
takes place, the appearance of a wound at each stage of this process and the factors
delaying healing. He/she can then apply this knowledge when caring for patients with
wounds.
Level one outlines the stages of wound healing and normal appearance of wounds.
Factors which may delay healing and aspects of caring for the patient with a wound are
also considered, enabling the health care worker to develop an awareness of the causes
of chronic wounds and the experience of the individual with a wound.
LEARNING EXERCISE 1
Before you start the module answer the questions below:
What is a wound?
Give 3 causes of wounds



What happens when injury occurs?
Read the text below to see if your answers are correct.
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WOUND MANAGMENT COMPETENCY MODULE
SECTION ONE: LEVEL ONE
A wound can be described as:
“Any damage leading to a break in the continuity of the skin”
(Dealey 1999 p1)
It may occur in response to trauma, surgery, pressure or ulceration. The cause of a
wound may influence how it is treated and how long it will take to heal. For example
surgical wounds are expected to heal within six weeks, whereas leg ulcers may take
many months to heal.
Methods of Healing
First (Primary) Intention
Here the edges of the wound are brought together and closed with staples, sutures,
adhesive strips or glue. This can be performed when there is minimal tissue loss and
the wound is not infected (e.g. after surgery).
Secondary Intention
The wound is left open to heal from the bottom up. This occurs because of substantial
tissue loss or because the wound may be heavily contaminated with bacteria (e.g.
Pressure Ulcer). Healing will be slower and scarring will be larger.
LEARNING EXERCISE 2
Complete the chart below:
Wound Type Method of Healing
Abrasion on the palm of the hand
Stab wound caused by a clean knife
Sacral pressure ulcer
Surgical wound
Leg Ulcer
Skin Flap
Discuss your suggestions with your assessor.
WOUND MANAGMENT COMPETENCY MODULE
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SECTION ONE: LEVEL ONE
In healthy individuals following injury healing occurs as the wound progresses through
four well-recognised stages.
Stage 1
When injury occurs the skin and structures below may be damaged. This results in
bleeding and pain. Bacteria and debris can enter the wound. To reduce blood loss and
provide a protective covering for the wound, clotting takes place and a fibrin scab forms
over the site of injury.
Stage 2
The wound then becomes inflamed and painful, this is because blood vessels expand
allowing nutrients, oxygen and white blood cells to enter the damaged area, these are
essential throughout healing.
The role of inflammation is:
 To remove dead tissue from the wound
 To reduce the risk of the wound becoming infected
 To prepare the wound bed for healing
The signs and symptoms of inflammation are:
 Swelling
 Redness
 Heat
 Pain
 Loss of function of the affected area
If inflammation is severe or accompanied by other symptoms, it may indicate that
the wound is infected. When infection is suspected further advice must be
obtained.
Stage 3
At this point the wound is ready to regenerate new tissue, new blood vessel grow from
the wound edges and build upon a network of collagen fibres. The wound bed takes on
a bright red, lumpy appearance, this is known as granulation tissue.
At the same time the wound contracts inwards, reducing its size, and new pale pink skin
cells start to progress across the surface of the wound. Once the skin has covered the
surface stage three is complete.
WOUND MANAGMENT COMPETENCY MODULE
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SECTION ONE: LEVEL ONE
Stage 4
A covering of skin suggests the wound has completely healed, however, the tissues are
very weak and at high risk of breakdown. The final stage, where the tissues gain
strength and flexibility, is unseen, yet it may take several months or years to complete.
At this stage the scar becomes flatter and paler in appearance. The tissue is still at risk
of damage and may break down easily. When stage 4 is complete the wound is still
vulnerable and will never be as strong as healthy tissue.
LEARNING EXERCISE 3
Refresh your memory and review what you have just learned by answering the
questions below:
1. What is first intention wound closure?
2. What types of wounds might be left to heal by second intention?
3. How many stages of wound healing are there?
4. What stage allows for an influx of blood containing nutrients and white blood cells
to the wound?
5. At what stage does a wound appear healed when there is still a lot of activity going
on?
Well done, now check the answers with your as
sessor.
WOUND MANAGMENT COMPETENCY MODULE
SECTION ONE: LEVEL ONE
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FACTORS DELAYING HEALING
Healing can be delayed by factors present in the wound (such as infection), factors
within the patient (such as age) and factors on the outside (such as pressure).
LEARNING EXERCISE 4
In the boxes below list some of the factors which may influence wound healing (you
may use the Wound Care Guidelines to help you).
Factors at the Wound Factors within the Patient Factors in the Environment
You may have included:
Infection Age Pressure
Slough/Necrosis Poor circulation Inappropriate dressings
Stitches or fibres in the Nutritional status Strikethrough
wound Systemic illness Wound temperature
High exudate (e.g.diabetes) Medication
Smoking
Non-compliance
This list is not exhaustive. Discuss with your mentor other factors, which may delay
healing and compare your findings to the list in the wound care guidelines.
WOUND MANAGMENT COMPETENCY MODULE
SECTION ONE: LEVEL ONE
Infection
Infection is the infiltration of bacteria into the healthy tissue. Bacteria exist in many
wounds without causing a problem. When healing stops or the wound deteriorates
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infection may be the cause and the patient will need to be reviewed. Other signs of
infection are:
Abscess Delayed Healing
Cellulitis / inflammation Discolouration
Increased exudates levels Granulation which bleeds easily
Pus Abnormal pain
Odour Bridging
(Donovan 1998)
When any of these signs of infection are suspected further advice is required.
Slough/Necrosis
This matter may be yellow, green or black in colour. Whilst slough/necrosis is natural
its presence will delay healing and increase the risk of infection, (Bale 1997), therefore
it needs to be removed. Some dressings can support the removal of non-viable tissue
from the wound bed.
Stitches or fibres
The body may treat stitches or fibres in a wound as a foreign body, tissue will break
down around the fibre and healing will be delayed (Bale 1999). In some circumstances
sutures may require removal, although this must not be performed without consultation
from medical staff.
Exudate
Exudate is fluid produced by the wound to support healing. Whist some exudate is
essential if healing is to be achieved, too much exudate can cause damage to the
surrounding skin and delay healing (Young 2000). It is important to identify the cause
of high exudate levels and select adressing to control it appropriately.
Age
The ageing process cause changes to the skin making it more susceptible to injury and
more difficult to heal. Older skin requires care to reduce the risk of breakdown (Dealey
1994). When injury occurs care must be taken to use dressing which do not have strong
adhesives or further damage could occur.
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL ONE
Nutrition
A balanced diet is essential if healing is to be achieved (McLaren 1999). The old adage
\"You are what you eat!\" is certainly true when it comes to wound care. The patient
requires a good balanced diet with plenty of protein and energy foods. This is
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particularly important when the wound is exuding heavily as essential proteins may be
lost.
LEARNING EXERCISE 5
Answer the question in the box below. Use the Wound care Guidelines to support your
answer.
 What foodstuffs contain protein?
 What foods contain carbohydrate?
 What other nutrients play a role in wound heali g?
n
Dealey (1999) highlights studies which outline the importance of the health care worker
in maintaining nutritional status. An inability to access food, or receive assistance at
mealtimes can have a significant effect on well-being and one’s ability to heal.
Systemic Illness
Systemic diseases influence the development of wounds and whether healing can ever
be achieved. These include:
WOUND MANAGMENT COMPETENCY MODULE
SECTION ONE: LEVEL ONE
 Poor blood supply to the site of injury results from the application of pressure to the
site or systemic illness that influences the amount of oxygen in the blood being
delivered to the area. Loss of bllod supply reduces the delivery of nutrients and
oxygen to the tissue and has a significant impact upon healing.
 Diabetic patients are at risk of developing pressure damage on their feet and, due to
loss of feeling may be unaware of injury. Diabetic patients also experience reduced
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blood supply in the lower limbs, which can influence healing when injury does
occur.
 If a wound is malignant then it may never heal. Care needs to focus upon
controlling the symptoms to allow the patient to live as normal a life as possible.
 Rheumatoid arthritis and renal disease can delay healing. When arthritis is active
healing may be problematic.
LEARNING EXERCISE 6
Consider the patients you care for on a daily basis. In the box below give an overview
of 1 of the diseases they may experience. What impact would this illness have upon
wound healing?
Share you findings with your assessor and colleagues.
If healing is unlikely to be achieved the aims of wound care may change and focus
upon the control of symptoms, enabling the patient to live as normal a life as possible.
WOUND MANAGMENT COMPETENCY MODULE
SECTION ONE: LEVEL ONE
Smoking
Smoking causes the blood vessels to close and reduces the level of oxygen getting to
the wound (Dealey 1994).
Non-compliance
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Patients don't comply with treatments for a variety of reasons, which may relate to the
wound, their social circumstances, and/or their thoughts or feelings. Failure to accept
treatment may delay healing. Whilst it is important to allow patients to control their
experience, the health care worker is responsible for ensuring everything possible is
done for the individual.
Pressure
Pressure placed on a wound can delay healing and may result in further tissue damage.
(Dealey 1994). The relief of pressure is vital if healing is to be achieved.
Practitioners caring for patients with, or at risk of pressure damage should complete the
Pressure Ulcer Prevention Self-Directed Learning Pack and/or the Pressure Area Care
Module.
Dressing Selection
The aim of a dressing is to promote the optimum conditions for wound healing - a
warm, moist environment (Winter 1962). Therefore using an absorbent product, for
example, on a dry wound is not appropriate. Dressing selection should be based upon
nursing assessment of the conditions of the wound. The following factors also need to
be considered:
 Frequency of dressing changes
 Patient comfort / compliance
 Ease of use
 Cost
Dressing selection will be looked at in more detail in Section Three.
Strikethrough
Strikethrough is the term used for leakage of exudate through a dressing. When
exudate can escape from a wound then bacteria can travel the following way and the
wound is at risk of infection. If strikethrough occurs the dressing should be changed
immediately (Mulder et al 1998). It may be necessary to get further advice if the level
of wound exudate has increased.
WOUND MANAGMENT COMPETENCY MODULE
SECTION ONE: LEVEL ONE
Medication
Medication and treatment can influence the body's response to certain conditions and
healing may be delayed (Dealey 1994). The possible impact of any medications or
treatments on healing needs to be acknowledged in the care plan.
Temperature
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Cooling the wound surface delays cellular activity, and places the wound at risk of
infection (Davies 1999). To reduce the risk of potential problems dressing changes
should be kept to a minimum and any cleansing fluid warmed before use.
LEARNING EXERCISE 7
Highlight the factors which may delay healing in the chart below.
Granulation Oxygen Supply Inflammation Injury Slough
Scarring Pressure Infection Maturation Inappropriate
Dressings
Skin Condition High Exudate Blood Supply Diabetes Smoking
Sutures Poor Nutrition Adhesive Strips Mobility Pus
Incontinence Primary Rheumatoid Surgery Age
Intention Arthritis
Closure
Secondary White Blood Heat Scabbing Strikethrough
Intention Cells
Closure
List any factors which you feel may delay healing yet haven’t been discussed above.
Discuss your findings with your assessor.
WOUND MANAGMENT COMPETENCY MODULE
SECTION ONE: LEVEL ONE
THE PATIENT WITH A WOUND
The experience of having a wound is influenced by many factors including;
 The position of the wound
 The speed of healing
 Pain
 Odour
 The impact of the wound upo the lifestyle of the patient
n
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The patient may experience feelings of powerlessness or grief, as his/her body image is
changed (Dealey 1994) because of the wound. To overcome these feelings the patient
will need reassurance and support. The health care worker can help the patient
overcome these feelings through:
 Understanding the patient’s point of view
 Involving him/her in the care of the wound
 Providing information and support
Putting yourself in the patient’s shoes is the best way to understand his/her viewpoint.
Next time you see a patient with a wound consider the following:
 “How would I feel if I had to live with this wound?”
 “What its like not seeing your friends in case they detect your wound?”
Involving the patient in aspects of his/her care can help him/her to feel less helpless and
depressed (Seligman 1975). This may include encouragement to eat the right foods,
elevate the affected limb, relieve pressure or, sometimes, change dressings
independently.
Information is essential if an individual is to understand why dressings, nutritional
support etc are needed. However, there is limited written information available for
patients with wounds.
LEARNING EXERCISE 8
Explore your clinical environment. What information leaflets are available for patients
with leg ulcers, pressure ulcers or other chronic wound? Make a list of those you find
below.
WOUND MANAGMENT COMPETENCY MODULE
SECTION ONE: LEVEL ONE
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Level One, Section One Learning Exercises Completed:
Date______________________________________________________________
Signed_____________________________________________________(Student)
Signed_____________________________________________________(Mentor)
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WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL ONE
LEARNING RECORD
Demonstrate what you have learned through completing this Module. Using the text
and your answers to help you, give a brief overview of your knowledge of wound
healing as a level one practitioner (this page can be photocopied as required).
Level One, Section One Completed:
Date______________________________________________________________
Signed_____________________________________________________(Student)
Signed_____________________________________________________(Mentor)
WOUND MANAGEMENT COMPETENCY MODULE
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SECTION ONE: LEVEL TWO
INTRODUCTION
This section will build upon the previous level for the registered practitioner caring for
patients with wounds. It will allow the health care professional to develop competent
and confidence through developing a deeper understanding of the healing process,
factors influencing wound healing and, the patients’ experience.
LEARNING EXERCISE 9
Test your knowledge through completing the multiple choice questionnaire below.
 Wound healing occurs in 4 stages, these are:
a) Haemostasis, inflammation, proliferation, maturation
b) Clotting, inflammation, granulation, skin formation,
c) Destruction, inflammation, rebuilding and completion
d) Injury, bleeding, clotting, covering
 The purpose of inflammation is:
a) To cause pain so the patient is aware of injury
b) To remove debris, devitalised tissue and infiltrating bacteria
c) To promote the development of newtissue
d) To heal the wound
 Factors delaying healing:
a) Are due to outside influences
b) Stem from the individual
c) Are related directly to the wound
d) Arise from any of the above
 Nutrients required for healing include:
a) Protein
b) Carbohydrates
c) Iron
d) Vitamin C
e) All of the above
 Patients with wounds may experience
a) Euphoria
b) Helplessness
c) Loss of control
d) Isolation
e) Difficulty complying with recommended treatment
Well done – the answers are at the end of this section
WOUND MANAGEMENT COMPETENCY MODULE
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SECTION ONE: LEVEL TWO
WOUND HEALING
The healing process has been well documented by many theorists (Kindlen and
Morison 1999; Iocono et al 1998). It can be broken down into 4 stages.
 Haemostasis
 Inflammation
 Proliferation
 Maturation
Haemostasis
The purpose of haemostasis is to reduce blood loss. Injury results in exposure of
collagen and endothelial cells, which line the blood vessels. This stimulates platelets,
present in the blood, to clump together and stick to the sides of the injured vessels.
They form a temporary plug over damaged tissue, and, when the injury is not too
severe, may be sufficient to stop bleeding.
The walls of blood vessels are constructed of smooth muscle cells. They contract in
response to platelet activity, reducing the lumen of the vessel and enhancing the effect
of the platelet plug.
This process continues whilst a complex clotting cascade occurs. Resulting in the
production of cross linked fibrin which forms a clot over the site of injury (Kindlen and
Morison 1999).
Haemostasis is sometimes seen as an element of the inflammatory phase, (Iocono et al
1998), however it is a distinct process which differs considerably from inflammation.
Inflammation
Also known as the destructive or lag phase, inflammation is concerned with preparing
the wound bed for healing. The release of histamine, tumour necrosing factor,
substance P, (known to cause pain), and nitric oxide encourage vasodilation. Blood
vessels become permiable allowing white blood cells and fluid to enter the wound bed
(Kindlen and Morison 1999).
The first leucocytes to arrive in the wound are neutrophils (Iocono et al 1998). The
main role of these cells is to phagocytose and destroy bacteria. Later macrophages
(matured from moncytes) and lymphocytes support this process. Macrophages are very
powerful cells, they ingest and destroy debris and release many growth factors.
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
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May 2003

Macrophages may be considered the conductors of the healing process, stimulating
activity through the release of chemical stimulants throughout healing.
Whilst inflammation may be uncomfortable for the patient, it is essential if healing is to
be achieved, as it prepares the wound bed of the growth and regeneration of tissue.
Proliferation
Proliferation is concerned with the rebuilding of tissue at the site of damage.
Proliferation occurs in 3 stages:
 Granulation
 Contraction
 Epithelialisation
 Granulation
Granulation is so called because the tissue filling the wound takes on a red,
granular appearance. In response to factors released by platelets and
macrophages, fibroblasts arrive in the wound and produce ground substance and
collagen fibres. These provide structure and strength to the wound (Kindlen and
Morison 1999). Angiogenesis occurs as a network of new blood capillaries is
built around these fibres. Granulation tissue is formed in the base of the wound
and builds up to fill the cavity.
Table One
Characteristics of Granulation Tissue
Healthy Granulation Unhealthy Granulation
Bright red appearance Dark red appearance
Looped, granular appearance Jelly -like appearance
Moist Dehydrated
Shiny surface Dull surface
Does not bleed Bleeds easily
Rapid extends across the wound Slow proliferation
(Adapted from Flanagan 1998)
 Contraction
Centripetal forces pull on the granulation tissue within the wound to improve its
strength and structure. This causes the skin to contract inwards, reducing the
size of the wound. The mechanisms that control this process are difficult to
define (Kingsley et al 2002). However, many theorists believe fibroblasts
become myofibroblasts through the development of long actin fibres, these then
adhere to collagen and contract (Kindlen and Morison 1998). Contraction
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
JT TissueViability 27
May 2003

can considerably reduce the size of a wound and may reduce scarring. Its role
in the repair and regeneration of tissue should not be overlooked.
 Epithelialisation
Wound closure is achieved through the migration of epithelial cells across the
surface from the edges of the wound. These cells move in an ameobia-like
fashion over the granulation tissue. When epithelium from opposing boarders
meet the process of contact inhibition reduces activity of the cells (Garrett
1998).
Maturation
Also called the re-modelling phase, maturation takes place when the wound is
completely covered with new epithelial tissue. At this point one may feel healing is
complete, however a lot of activity continues below the surface of the wound, which
impacts upon the strength of the wound and appearance of the scar. Maturation may
take many months to complete and incorporates the re-organisation of connective tissue
such as collagen (Kindlen and Morison 1998), and reduction in the supplementary
blood supply needed to support the healing process, hence the scar appears flatter and
paler in appearance.
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May 2003

WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
LEARNING EXERCISE 10
Complete the chart below
Stage of Healing Active Cells
Haemostasis
Inflammatory Phase
Macrophages
Fibroblasts
Contraction
Epithelialisation
Macrophages
Fibroblasts
Myofibroblasts
WOUND CLOSURE
The method of wound closure is dependent upon the type of wound and condition of the
wound bed.
Successful wound closure can be achieved where there is minimal tissue loss and debris
is absent from the wound. Surgical wounds and clean traumatic wounds can usually be
sutured, tape, stapled or glued and allowed to heal by primary intention. Where there is
a risk of bacterial contamination, the extent of damage is difficult to determine, or the
amount of tissue loss wound make closure problematic the wound should be left to heal
by secondary intention or closure should be delayed.
WOUND MANAGEMENT COMPETENCY MODULE
JT TissueViability 29
May 2003

SECTION ONE: LEVEL TWO
Delayed closure allows for the treatment of infection and growth of granulation tissue
in the wound prior to suturing. Delayed closure is dependant upon the condition of the
wound bed, but is normally carried out about 5 days after initial injury (Whiteside and
Moorehead (1998).
FACTORS DELAYING HEALING
In a healthy individual wound healing usually occurs without difficulty. However
many variables can interrupt this process, resulting in the transition from an acute
wound to a chronic wound, (see Section Two, Wound Assessment and Classification).
This section will explore in greater detail some of the variables considered at level one,
and build upon one’s understanding of this complex phenomena.
As outlined in section one delayed healing can be due to systemic factors, at the wound
or within the patient, or due to environmental i fluences. These can be categoristed as:
n
 Intrinsic variables - systemic
 Intrinsic variables - local
 Extrinsic variables
INTRINSIC VARIABLES - SYSTEMIC
Intrinsic systemic variables relate to the patient, but not specifically the wound. They
are holistic factors which must be considered when determining whether an individual’s
ability to heal will be inhibited.
Intrinsic, systemic variables include:
 Age
 Nutrition
 Diabetes
 Uraemia
 Liver disease
 Medications
 Psychosocial factors
AGE
Age can increase the risk of tissue breakdown and delay healing as the skin becomes
thinner and more susceptible to damage. These changes may include:
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
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May 2003

 Reduction in the speed of replacement of epidermal cells
 Delayed inflammatory response
 Reduction in sensory perception
 Reduced ability of the skin to provide protection
(Kindlen and Morison 1999)
Whilst little can be done to reduce the effects of aging on the skin, acknowledgement of
tissue changes and increased awareness of the importance of skin care and prevention
of injury require consideration when caring for an older individual.
NUTRITION
Dealey (1999) suggests poor nutrition can significantly influence healing and outlines
the nutrients required to achieve successful wound closure, these are identified in Table
2.
To reduce the risk of inadequate nutrition influencing healing assessment should focus
upon identifying nutritional status and whether additional support or supplementary
feeding is required (see section two). Patients normally require 1500 – 2000 Kcalories
daily, however in the presence of certain conditions, e.g. pain, burns or infection,
metabolism increases and the body’s demands for nutrients is enhanced.
Ability to obtain the required nutrients may be influenced by several factors including:
 Age
 Bowel disorders (Crohn’s disease or ulcerative colitis)
 Gastrointestinal surgery
 Renal, liver or pancreatic disorders
 Arthritis
 Cerbrovascular disease (e.g. CVE, Stroke)
 Burns, trauma injury
 Infection or sepsis
 Carcinoma
 Acute or chronic pain
 Respiratory disorders
 Medication
 Emotional state
 Obesity
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May 2003

WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
Table 2
The Role of Nutrients in Wound Healing
Nutrient Role in Wound Healing
Carbohydrates Provision of energy for leucocytes,
macrophages and fibroblasts to function
Protein Immune response
Phagocytosis
Angiogenesis
Fibroblast production
Collagen synthesis
Wound remodelling
Energy production
Fats Energy production
Cellular activity and growth
Vitamin A Collagen synthesis and cross linking
Tensile wound strength
Vitamin B complex Immune response
Collagen cross linking
Tensile wound strength
Vitamin C Collagen synthesis
Tensile strength
Neutrophil function
Macrophage migration
Immune response
Vitamin E Reduces tissue damage secondary to the
formation of oxygen free radicals
Minerals: Copper Collagen synthesis
Leukocyte development
Iron Collagen synthesis
Oxygen delivery and energy production
Zinc Increased cell proliferation
Increased epithelialisation
Greater collagen strength
WOUND MANAGEMENT COMPETENCY MODULE
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SECTION ONE: LEVEL TWO
LEARNING EXERCISE 11
What factors may increase the risk of being undernourished. Write your answers in the
box below:
LEARNING EXERCISE12
Select 2 of the variables above:
What action can you take to reduce them having an effect on healng?
i
Write your answers in the box below, then discuss your findings with your mentor.
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
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May 2003

DIABETES
Diabetes is an endocrine disorder, where insufficient production of insulin inhibits the
body’s ability to metabolise carbohydrates, fats and proteins (Royle and Walsh 1992).
The disease has an impact upon the nervous and vascular systems, as well as the
healing process, placing the individual at risk of three major complications affecting
tissue viability.
Neuropathy
Neuropathy affects the peripheral nerves in the lower limbs and results in changes in
the bone structure of the foot, the development of dry, cracked skin, and loss of
sensation. Alterations in the bone structure result in increased pressure being placed on
the metatarsal heads during walking, hence callus builds up in this area. Ulceration can
occur where pressure is placed upon tissues between the callus and bones and, starved
of oxygen, they breakdown. Broken, cracked skin enables bacteria to enter the foot
causing infection, whilst damage to the sensory nerves reduces one’s awareness of
tissue damage (Edmonds and Foster 2000).
Peripheral Vascular Disease
When tissue damage occurs, the ability of the wound to heal is dependant upon the
circulation, providing oxygen and nutrients to the wound. Diabetes may also affect the
circulation, with small and large blood vessels becoming occluded (Ferguson et al
1996). Reduced circulation in the foot places the individual at increase risk of pressure
damage and, should ulceration occur, impacts upon the ability to heal.
LEARNING EXERCISE 13
What are the signs and symptoms of neuropathy?
What are the signs and symptoms of ischaemia?
Write your answers in the box below and compare your fi dings to those in Table 3
n
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
Table 3
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Signs and Symptoms of Peripheral Neuropathy and Ischaemia
in the Diabetic Foot
The Neuropathic Foot The Ischaemic Foot
Palpable pedal pulses Pulses may be absent or difficult to detect
The foot is warm to touch The foot is cold to touch
Ulceration occurs in areas under pressure Ulceration occurs on the peripheryof the
foot where the circulation is reduced
Evidence of callus build up No evidence of callus
Wound Healing
Research (Yue et al 1986) suggests diabetes can reduce the development of granulation
tissue and collagen production in a wound. This can delay healing and reduce the
strength of tissue when healing has been achieved, increasing the risk of further
breakdown in the area.
Care of the Diabetic Foot
Accurate management of the diabetic foot is based upon awareness of the problems
encountered by diabetic patients that place them at risk of foot ulceration. Information
is essential to reduce the risk of ulceration occurring and the health care professional is
responsible for assessing the individual’s level of knowledge and providing the
information he/she needs to reduce the risk of tissue damage.
A multi-disciplinary approach to prevention and management of foot ulcers has been
found to be the most effective (Edmonds et al 1999). Patients require regular
assessment of their diabetes and podiatry to reduce the build up of callus over bony
prominences.
URAEMIA
Mulder et al (1999) suggest renal failure has a negative impact upon the activity of
fibroblasts and endothelial cell growth reducing the speed of granulation tissue
formation. However, collagen formation does not appear to be adversely affected,
therefore the strength of a wound post-healing is not significantly reduced. Nonetheless
practitioners need to be aware that healing may be delayed in patients with Uraemia.
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
LIVER DISEASE
The cause of liver disease may influence the impact this has upon healing (Mulder et
al), although liver failure is associated with reduce fibroblast proliferation and collagen
JT TissueViability 35
May 2003

formation. Further research is needed in this area to enhance our understanding of this
phenomenon.
MEDICATIONS
Certain medications can have a significant impact upon healing. These include:
 Chemotherapy
 Radiotherapy
 Steroids
Practitioners need to remain aware of the impact of drugs on healing and recognise
when healing is slow due to medications.
PSYCHOSOCIAL FACTORS
LEARNING EXERCISE 14
In the box below write a list of the social and psychological factors that may delay
healing.
You may have included:
 Income
 Social Class
 Employment
 Compliance
 Understanding of the treatment
Discuss any other findings you have with your mentor.
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
Income and social class inevitably influence patients’ ability to heal, as they dictate
what nutrients are available for healing. Employment may influence the extent to
which a patient can adhere to treatment, for example, a patient who stands up all day at
work would find it very difficult to keep his legs elevated to relieve the symptoms of
venous hypertension.
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May 2003

Compliance is the extent to which a patient follows the recommendations of a health
professional (House 1996). It is a complex issue and the practitioner needs to explore
variables, which impact upon the patient’s experience to understand why he/she doesn’t
comply. Some of these are considered below.
Knowledge
Tonge (1995) suggests information is needed by patients to facilitate compliance.
Patients may be more likely to wear wound dressings, if they understand the benefits of
moist wound healing. Education needs to be delivered at a level that can be easily
interpreted by the patient. It is also a good idea to back up what is said with easy to
read information leaflets and allow the patient time to ingest the information and voice
any questions or concerns.
Peer Pressure
Patients are influenced by their friends and relatives when making decisions about care
(Tonge). When agreed with the patient, his/her peer group should also be provided
with information to enable them to support the patient through the decision making
process.
Empowerment
Taking control of the situation away from the patient can result in non-compliance.
Theorists (Tonge 1995;Hallett et at 2000) outline the importance of involving the
patient in the decision making process and allowing them control over their
experiences. Hallett et al suggest practitioners can take the following steps to support
compliance:
 Make specific enquires
 Be benevolent
 Encourage self-disclosure to gain insight into the patient’s experience
 Determine the patient’s level of knowledge
 Determine the patient’s commitment to taking appropriate action
 Maintain an attitude of positive regard throughout
 Give the patient a sense of personal responsibility
 Meet the needs and wishes of patients
 Use selective positive feedback
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
SYSTEMIC VARIABLES – LOCAL
Local systemic variables are factors associated with the wound that influence healing.
Many theorists are recognising the importance of preparing the wound bed to heal
through addressing these factors (Collier 2002). Factors to consider when preparing the
wound bed are:
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May 2003

 Prevention of control of infection
 Exudate management
 Removal of non-viable tissue
WOUND INFECTION
Many theorists suggest infection can be confirmed through calculation of the numbers
of bacteria present on the surface of a wound (Gilchrist 1996), as this has been
associated with successful wound closure. However, it is now well recognised that
diagnosis of wound infection is dependant upon the identification of clinical indicators
of infection.
The presence of bacteria on a wound does not confirm the presence of infection.
Indeed any wound more than a few seconds old is likely to have bacteria on the surface.
However, bacteria may infiltrate a wound at 3 levels:
 Contamination – where bacteria exist on the wound but do not replicate or
invade healthy tissue
 Colonisation – Bacteria exist on the wound and replicate, but do not invade
viable tissue, hence a host response does not occur.
 Infection – Replicating bacteria invade the wound bed, resulting in a negative
host response.
It is only when signs and symptoms of infection are identified that treatment is requires
and a swab should be taken (Flanagan 2000)
LEARNING EXERCISE 15
Refresh your memory, write the signs and symptoms of infection in the box below,
check your answers with the list in section one.
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
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What are the systemic signs of infection?
Using the Trust procedure for obtaining a wound swab, write a brief overview of the
technique in the box below.
SIGNS AND SYMPTOMS OF INFECTION
Inflammation or cellulitis
Infection is associated with the presence of inflammation or cellulitis. However, one
must take care to ensure this is a response to bacteria invasion, rather than the
inflammatory response that is part of the normal healing process. Severe or spreading
inflammation is usually an indicator that an infection is present, however, one should
also observe for other indicators of infection (Miller and Gilchrist 2001).
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
Wound deterioration
The most obvious sign that a wound is infected is a delay in healing or deterioration of
the wound, as healing will not occur when infection is present. Where no other clinical
signs are present and healing is not being achieved, infection must not be ruled out and
action should be taken to eliminate bacteria from the wound bed (Miller and Gilchrist
2001).
Increased Exudate
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Exudate production is a natural response to injury. However, a sudden increase in the
amount of exudates produced by a wound may suggest the wound is infected (Miller
and Gilchrist). This occurs as vasodilation occurs, allowing for the release of blood
plasma and leukocytes, which enter the wound to fight the infection.
Pus
Pus is a clear indicator that infection is present. However, pus is not always evident
and an absence of this fluid does not suggest the wound is not infected (Miller and
Gilchrist).
Unusual Pain
A change in the level of pain or discomfort the patient is experiencing indicates that a
change has occurred and may denote infection. Nonetheless one should ensure other
causes of pain, such as ischaemia, are eliminated. The presence of abnormal pain
should alert the practitioner to explore potential causes and act to eradicate them (Miller
and Gilchrist).
Granulation Tissue which Bleeds Easily
Where infection exists in a wound granulation tissue becomes more friable and bleeds
easily. It may also appear darker in colour and look unhealthy.
Odour
Odour is natural in many wounds and this may be exacerbated by the type of dressing
used (hydrocolloids can produce quite a distinctive odour). If the smell is offensive
then infection may be the cause.
Green Discolouration
Discolouration of the exudate may indicate the presence of infection.
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
Bridging
Bridging occurs at the base of the wound when infection is present. Epithelial cells
attempt to cover the wound when the tissue below is nto healing. The layer of
epithelium becomes detached from the wound and forms a tight “bridge” across the
base of the wound (Miller and Gilchrist).
Careful assessment is needed to identify infection. For example green discolouration
may suggest large numbers of bacteria exist upon the wound, however, if healing is
continued then the wound may just be colonised and intervention is not required
(Donovan 1998).
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Systemic indicators of infection may include pyrexia, tachycardia and raised white cell
count. These are valuable when identified in association with local signs and symptoms
(Donovan 1998).
TAKING A WOUND SWAB
Swabbing should only be performed when several of the above clinical indicators of
infection are present, or when the practitioners’ intuitive knowledge suggests infection
may be present. Swabbing in the absence of clinical signs of infection may give a false
positive result as bacteria colonising the wound may be detected. Swabbing should be
carried out in accordance with the Trust’s procedure and clinicians should ensure they
are familiar with this process, as the method of obtaining the sample, exposing it to
changes in temperature, or failing to get it to the laboratory in sufficient time, could
impact upon its viability and the results obtained.
LEARNING EXERCISE 16
Make a list of factors which may predispose a patient to wound infection.
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
Cutting (1998) suggests the following variables increase the risk of a wound infection
developing:
 The age of the wound
 Contuse tissue
 Current or previous irradiation
 The presence of a foreign body in the wound
 The presence of haematoma
 Size and shape of the wound
 The position of the wound
 Tissue ischaemia
 Devitalised tissue
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 Vasoconstriction due to medication
 Patient susceptibility
This list is not conclusive, if your findings differ from the list discuss them with your
mentor.
When caring for patients with wounds nurses need to consider whether any of these
predisposing variables are present, and, where possible, address them to reduce the risk
of infection occurring.
Managing Infection
The diagnosis of infection should be based upon the identification of clinical signs of
infection through careful assessment (see Section Two). This can then be supported via
obtaining a sample of pus or a wound swab. Antibiotic therapy should be commenced
as soon as infection is suspected, this is particularly important when an acute spreading
infection such as cellulitis is identified. Waiting until the swab results
are obtained can result in deterioration of the wound and impact upon the patients’
well-being.
LEARNING EXERCISE 17
If swabbing is an ineffective method of identifying infection what value does it have?
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
Wound swabbing
There is very little evidence to support any method of obtaining a wound swab.
However, it is generally believed that the method outlined in the Procedure for
Obtaining a Wound Swab at the end of this section produces the best sample. A wound
swab allows one to identify specific microbes present on the wound’s surface.
EXUDATE
All wounds allowed to heal through maintaining a moist healing environment will
produce exudate, however the amount of wound fluid produced may be critical in
determining the speed of healing. Whilst the wound bed should be moist an excess of
exudate can cause damage to the tissue and surrounding skin, resulting in maceration,
excoriation or irritant dermatitis. It is still difficult to determine how much exudate is
JT TissueViability 42
May 2003

required to promote the optimum healing time (Newton and Cameron 2003). High
levels of exudate can be due to the underlying aeteology of the wound, the type of
wound or a change in the condition of the wound, including:
 Venous Hypertension
 Congestive cardiac failure
 Hypoproteinaemia
 Oedema
 Lymphoedema
 Autolysis
 Infection
The control of exudate should focus upon identifying and, when possible, treating, the
cause, for example elevation of oedematous limbs can significantly reduce oedema, and
using appropriate dressings (See Section Three), can prevent maceration of the tissue.
SLOUGH/NECROSIS
LEARNING EXERCISE 18
What is necrotic tissue?
What impact does it have on the wound?
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
Sloughy necrotic tissue consists of dead leukocytes, fibrin, serous exudate and
deoxyribonucleaoprotein ( DNA Poston 1996). Theorists suggest necrosis:
 Creates an environment for the growth of bacteria
 Increases the risk of infection
 Delays epitheilalisation
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 Prevents wound contraction
 Obscures the depth of the wound and possibly underlying abscesses.
(Sieggreen and Maklebust 1997; Mulder 1995; Bale 1997; Hampton 1998)
Non-viable tissue should be removed using the most appropriate method of
debridement for the individual and the wound, this is dependent upon patient
assessment and the condition of the wound bed (See Section Two). Table 4 outlines the
benefits and drawbacks of several approaches to wound debridement
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WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
Table 4
Methods of Wound Debridement
Method of Debridement Benefits Drawbacks
Surgical Debridement Fast removal of necrotic Non – selective, healthy
Removal of necrotic tissue tissue tissue may be damaged in
by a surgeon in the the debridement process
operating department Can be distressing for the
patient
Expensive
Sharp Debridement Selective Requires rigorous training
Removal of superficial Practitioners must be aware
layers of non-viable matter of the limitations of their
knowledge
Larval Therapy Selective, rapid “Yuk factor”
The use of live maggots to debridement
Ingest debris
Varidase Rapid removal of Non-selective
An enzymatic product to sloughy/necrotic tissue Expensive
breakdown protein
molecules
Hydrogel / Hydrocolliod Selective Time consuming process
Promte the natural removal
of debris through autolysis
For further information on the impact of necrotic tissue and debridement see the Larval
Therapy Module or Wound Debridement Self- Directed Learning Pack.
LEARNING EXERCISE 19
Select words from the list below complete the following statement.
Wound healing is a complex process. The speed of healing may be dependent
upon the method of wound________________, with ______________intention
closure resulting in rapid epithelialisation and minimal scarring. Secondary
intention closure occurs where there is significant tissue loss. As a wound
heals it passes through 4 well-recognised stages these are:
_____________________, __________________________,
WOUND MANAGEMENT COMPETENCY MODULE
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SECTION ONE: LEVEL TWO
____________________, and ___________________. Problems occur when factors
which delay healing arise. These may be________________ or __________________.
Intrinsic factors may be ___________________, in that they arise from the wound bed,
or ___________________, because they result from systemic variables, such as
underlying illness. Identifying factors that delay healing, and, where possible taking
action to overcome them, can enhance the patient’s experience and may facilitate
healing.
Intrinsic Maturation Inflammation
Closure Extrinsic Primary
Proliferation Local Holistic
Haemostasis
LEARNING EXERCISE 9:
Answers 1) a 2) b 3) d 4) e 5) e
Level One, Section One Learning Exercises Completed:
Date______________________________________________________________
Signed_____________________________________________________(Student)
Signed_____________________________________________________(Mentor)
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WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL TWO
LEARNING RECORD
Demonstrate what you have learned through completing this Module. Using the text
and your answers to help you, give a brief overview of your knowledge of wound
healing as a level one practitioner (this page can be photocopied as required).
Level One, Section One Completed:
Date______________________________________________________________
Signed_____________________________________________________(Student)
Signed_____________________________________________________(Mentor)
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WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL THREE
INTRODUCTION
Well done on completing level one and level two. This element of the module explores
wound healing in greater depth and allows the practitioner to develop knowledge of
biochemical and molecular aspects of healing, gaining insight into the complexity of the
process.
THE WOUND HEALING PROCESS
The healing process is not only dependent upon the action of cells, but also chemical
and molecular mediators. The role of these chemicals in the healing process will be
considered below. However they are grouped as:
 Chemoattractants Chemicals that draw others cells into the wound bed to
promote healing. Some growth factors and cytokines
have chemoattactant properties.
 Growth factors Polypeptide molecules that bind to cell receptors and
Stimulate specific activity, for example cell replication or
production of collagen.
 Cytokines These are substances other than growth factors that
contribute to wound healing. Usually produced by
macrophages these chemicals work in association with
growth factors to 'fine tune' the healing process.
Examples include: interlukin-1 and tumor necrosing
factor -α.
 Matrix metalloproteinases (MMPs) MMPs or proteases are responsible for
the degredation of protein molecules in
the wound, for example fragments of
collagen left in the wound after injury are
broken down by proteases during the
inflammatory phase of healing.
 Tissue Inhibitors of MMPs (TIMPs) TIMPs are responsible for regulating the
activity of MMPs through inactivating
them. The activity of TIMPs reduces the
risk of degradation of healthy tissue.
(Waldrop and Doughty 2000)
WOUND MANAGEMENT COMPETENCY MODULE
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SECTION ONE: LEVEL THREE
Haemostasis
Bleeding before haemostasis is achieved is of value in removing bacteria and debris
present on the surface of a wound. The damaged cells release tumor necrosing factor
and nitric oxide which encourage platelet aggregation. This results in the formation of
a temporary plug over the damaged vessel and vasoconstriction occurs (Kindlen and
Morison 1999). Collagen present in the wall of blood vessels is exposed on injury.
Platelets attach to these fragments of collagen and clump together. This promotes the
platelets to release enzymes, cytokines, growth factors and chemoattactants that
stimulate the clotting cascade (Cutting and Tong 2003).
The Clotting Cascade
 Platelets adhere to collagen
 Thromboplastin is released from platelets
 Thromboplastin acts on prothrombin present in blood plasma to produce
thrombin
 Thrombin acts on fibrinogen in plasma to produce fibrin
 Fibrin is produced to streng then the clot.
(Cutting and Tong)
This process is mediated by a number of coagulation factors released as a result of
tissue damage. The absence of one of these factors could delay clot formation with the
patient experiencing prolonged bleeding. Once haemostasis is complete is in important
not to disturb the clot until the danger of haemorrhage has passed.
Fibrinolysis
Fibrinolysis occurs as the clot is disolved to prevent further clumping of platelets and
risk of unnecessary damage to the injured vessel. Fibrin degradation products in the
blood are responsible for this process (Kindlen and Morison 1999).
The Inflammatory Phase
Inflammation consists of 3 elements:
 Vasodilation
 Destruction of bacteria
 MMP actitivty
WOUND MANAGEMENT COMPETENCY MODULE
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SECTION ONE: LEVEL THREE
Vasodilation occurs in response to the presence of cytokines and chemicals released by
platelets. Blood vessels become permeable and allow fluid and leukocytes to enter the
wound. Pressure in the vessel is reduced, limiting leakage of blood from the wound.
Symptoms of inflammation such as heat, oedema and redness, indicate this process is
taking place (Kindlen and Morison 1999).
Platelets are described by Cutting and Tong as \"bags of chemicals circulating in the
blood\" (2003 p 12). They release vasodilators and chemoattractants, which, along with
growth factors, such as Platelet Derived Growth Factor (PDGF) and Transforming
Growth Factorβ (TGBβ), and proteins released by bacteria, attract neutrophils and
monocytes to the area. These cells may be detected in the wound within 2 minutes of
injury (Waldrop and Doughty 2000). They phagocytose bacteria and debris and,
through the release of growth factors, draw additional white cells to the area.
Monocytes mature to become macrophages, which may be considered the orchestrators
of the healing process. As well as destroying bacteria they produce an array of
cytokines and growth factors that stimulate healing. An absence of macrophages has
been found to delay wound healing (Waldrop and Doughty 2000).
Proteases (MMPs) are released into the wound by macrophages (Kinsley et al 2002).
They degrade damaged elements of the extra cellular matrix, including collagen
fragments (Cutting and Tong), allowing for re-modelling of the wound bed. The
activity of MMPs is controlled by TIMPs, an accurate balance between these 2
chemicals is also essential for successful healing.
The inflammatory process reduces the risk of wound infection and prepares the wound
bed for the growth and regeneration of new tissue.
LEARNING EXERCISE 20
Answer the questions below:
 What are MMPs?
 Give an example of a growth factor active in the inflammatory stage - briefly
explain its function.
 Why are macrophages so important in the healing process?
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL THREE
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The Proliferation Phase
During this phase interlinked processes allow the wound to fill with new connective
tissue, achieve restoration of the blood supply and cover the area with epithelial tissue.
Granulation
Granulation tissue consists of 2 key components: vascular supply and extra cellular
matrix.
 Angiogenesis The restructuring and formation of a new vascular system is
achieved through the process of angiogenesis. This occurs in
response to the interaction of an array of cytokines and growth
factors (Waldrop and Doughty 2000), such as insulin-like
growth factors (IGF) that attracts endothelial cells (Kindlen and
Morison 1999). Capillary buds sprout from venules at the
wound edges, forming hollow tubes that migrate across the
wound bed to become a network of loops weaving through the
extra cellular matrix. The speed of angiogenesis is dependent
upon the level of oxygen present in the wound bed. Hypoxia
stimulates secretion of an angiogenic factor by macrophages. In
an oxygen rich environment this factor is absent and growth of
new capillaries may be slower (Flanagan 1998).
 Matrix In response to chemoattractants produced by macrophages,
Deposition fibroblasts present in dermal tissue proliferate and migrate to the
site of injury. Fibroblasts are responsible for the production and
deposition of the extra cellular matrix, including collagen,
elastin, fibronectin and other connective tissues. Production of
collagen is stimulated by the cytokine interleukin-1 and other
growth factors (Kingsley et al 2002). Collagen is laid down in a
parallel fashion, whist this does not provide strength to the
wound, it facilitates angiogenesis (Cutting and Tong 2003).
Waldrop and Doughty (2000) note that collagen production is
dependent upon specific nutrients and oxygen availability,
therefore poor circulation or nutritional status can have directly
influence one's ability to heal and the tensile strength of newly
formed granulation.
Production of granulation tissue occurs until the wound bed is filled. Transforming
Growth Factorβ (TGBβ) and enzymes inhibit the proliferative phase to ensure optimum
healing and minimal scarring occurs.
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL THREE
Contraction
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Contraction can reduce healing time and scarring as it results in a reduction in the size
of the cavity to be filled. Whilst the mechanism of contraction is questionable many
theorists believe it occurs in response to changes in the construction and activity of
fibroblasts (Tejero-Trujeque 2001). Modified fibroblasts, myofibroblasts, produce
smooth muscle actin fibres, which give the cells contractile properties enabling them to
draw upon collagen fibres and pull the wound edges closer together. Myofibroblasts
disappear once this process is complete.
The level of contraction in a wound may vary, depending upon the mobility of
surrounding tissue (Kingsley et al 2002). Whilst contraction is seen as beneficial over-
contraction can cause severe scarring and inhibit joint mobility.
Re-Epithelialisation
In response to the release of growth factors from the extra cellular matrix, epithelial
cells at the edge of the wound divide and migrate across newly formed granulation
tissue. The absence of these factors in non-viable tissue prevents epithelialisation,
hence wound closure. Transforming Growth Factorβ stimulates contact inhibition,
which inhibits continued replication of the cells when they meet (Kindlen and Morison
1999).
The Maturation Phase
The process of maturation is dependent upon the breakdown and regeneration of new
collagen. This results in reformation of collagen in a random fashion in the wound
which builds strength into the tissues. It has been recognised that many growth factors
and cytokines play a role in this process including Transforming Growth Factorβ,
Platelet Derived Growth Factor and Tumor Necrosing Factor (Cutting and Tong 2003).
Whilst maturation increased the strength of scar tissue it may take several months to
complete. Once the healing process is complete the scar will only be 80% as strong as
uninjured tissue and requires protection from further breakdown.
LEARNING EXERCISE 21
Select 3 growth factors or cytokines that have a role in the healing process and
complete the chart below:
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WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL THREE
Cytokine / Growth Produced by: Acts upon: Effect
Factor
FACTORS DELAYING HEALING
This section will build upon level two, enhancing the practitioners knowledge of the
variables that influence healing. All variables are considered in more detail allowing
one to explore the impact of systemic and extrinsic variables on the wound bed.
INTRINSIC VARIABLES – SYSTEMIC
The systemic factors influencing healing examined in this section are:
 Age
 Nutrition
 Diabetes
 Medications
 Psychological variables
AGE
The skin’s protective mechanisms and body’s response to injury change as one gets
older. This is due to the natural ageing process and impact of the environment upon the
individual through out life. Changes to the skin occur which may result in increased
risk of injury and delayed healing. These include:
WOUND MANAGEMENT COMPETENCY MODULE
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SECTION ONE: LEVEL THREE
 Reduced production of epidermal cells
 Shrinkage of cells as they progress to the surface of the skin
 Thinning if the epidermis and dermis
 Thickening of elastin fibres
 Depletion of collagen content of the skin
 Reduction in the number of fibroblasts in the dermis
 Reduction in secretions from the sebacious glands
 Reduced activity of sweat glands
 Thinning of the arteries and capillaries
(Smoker A 1999)
These changes result in loss of tensile and potential for injury and delayed healing. The
practitioner must be aware of the importance of skin care and protection of the patients’
tissues. Skin should be observed for changes in appearance and texture and emollients
and moisturisers used, where necessary, to rehydrate the skin.
For more information on the care of older skin see the Skin Care Module.
NUTRITION
The presence of a wound can significantly increase nutritional requirements. Protein is
lost through excessive exudate production and additional energy is needed to cope with
the increase in metabolic demand (Casey 1998). Timmons (2003) highlights studies
that equate poor nutritional status with delayed healing.
To reduce the risk of poor nutrition influencing one’s ability to heal it is important to
assess the patient’s nutritional status. Casey suggests 5 factors should be considered by
staff caring for patients with wounds:
 Unrestricted access to food
 Appetite
 The swallow reflex
 Absorption of nutrients
 Energy intake and metabolic demand
LEARNING EXERCISE 22
Revist the factors that increase the risk of being undernorished in section 2. How will
these variables influence the factors outlined above?
WOUND MANAGEMENT COMPETENCY MODULE
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SECTION ONE: LEVEL THREE
Table 5
The Impact of Holistic Variables uponNutritional Intake
Age Arthritis Stroke Diarrhoea Sepsis
Mobility Depression Neuro- Bowel disorders Wound
Inability to Chronic illnessmuscular Pancreatitis healing
state likes Malaise diseases Vomiting Trauma
Poverty Gall Bladder disease Surgery
    
Access to Poor Appetite Poor Reduced High metabolic
food swallowing absorption demand
    
Reduced Reduced Reduced Reduced Reduced
Nutritional Nutritional Nutritional Nutritional Nutritional
Intake Intake Intake Intake Intake
(Adapted from Casey 1998)
Patients may experience one or more of the above.
Points to remember when performing nutritional assessment:
 Identify factors that can increase the risk of malnutrition
 Consider nutritional needs when planning care
 When necessary liase with the dietetics department to ensure nutritional
requirements are met.
 Evaluate the impact of nutritional assessment.
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL THREE
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DIABETES
Diabetic neuropathy affects the autonomic, motor and sensory nervous system.
Damage to the autonomic system reduces sweating and the skin becomes dry and
fistured. Changes in function of the motor nerves lead to changes in the bone structure
and foot shape, placing the foot at increased risk of pressure damage. Callus builds up
on the planter aspect of the foot. When ulceration occurs callus formation around the
wound can delay healing. Sensory loss results in an inability to feel pressure, pain, or
heat and patients may damage their feet without being aware of it.
Peripheral vascular disease may be distal and bilateral. The foot may be dusky red or
blue as blood pools in the arterioles. Palpation of pulses may be difficult, however,
small vessel disease cannot be ruled out even when pulses are present. Patients may
also develop calcification of the arteries.
Diabetes also impacts upon wound healing. In the inflammatory phase vasodilation is
restricted and there is a reduction in the number of leukocytes present in the wound.
During the proliferative stage collagen production is poor due to an absence of Platelet
Derived Growth Factor (PDGF), reducing the tensile strength of the wound bed. This
may be evident once healing is complete (King 2001).
Research has demonstrated that a multi-disciplinary approach to the management of
diabetic patients can reduce the risk of ulceration and amputation.
LEARNING EXERCISE 22
In the box below list the members of the multi-disciplinary team involved in the care of
patients with diabetic foot ulcers. What role would each individual play in reducing
the risk of ulceration or promoting healing?
Compare your answers with tho in Table 6
se
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WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL THREE
Table 6
The Role of the Multi-Disciplinary Team in the Care of Patients with Diabetic
Foot Ulceration
Health Professional Role
Consultant Endocinologist Management of Gylcaemic control
Podiartist Debridement of callus and non-viable
matter in diabetic neuropathy
Provision of insoles for pressure reduction
Nurse Dressings to promote healing
Pressure reduction/relief
Observation of changes to the condition of
the foot
Diabetes Clinical Nurse Specialist Support the patient in maintaining
glycaemic control
Dietician Dietary advice to promote healing whilst
maintaining glycaemic control
Orthotist Provision of specialist footwear
Vascular studies Evaluation of vascular circulation
Vascular surgeon Angioplasty
Advice on management of the wound
Tissue Viability Specialist Advice on wound management
Radiographer Identification of Osteomylitis
MEDICATIONS
Certain medications can increase the risk of wounds occurring and delay healing these
include:
 Chemotherapy Chemotherapy destroys DNA inhibiting cell division. It
directly influences the number of fibroblasts present in a
wound and their ability to produce collagen. Reducing
wound strength (Dealey 1999). Chemotherapy may also
reduce the number of leukocytes present in the wound,
placing it at increased risk of infection.
 Radiotherapy Radiation can cause tissue necrosis and delay wound
healing. It may also affect intact skin causing a severe
reaction (see skin care module).
 Steroids Steroids have an anti-inflammatory effect, reducing
protein synthesis, capillary growth, fibroblast
proliferation and epithelialisation (Dealey 1999).
WOUND MANAGEMENT COMPETENCY MODULE
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SECTION ONE: LEVEL THREE
The impact of these drugs on healing needs to be considered when monitoring the
progress of a wound. It may be necessary to acknowledge that long-term treatment for
active disease will reduce one’s ability to heal.
PSYCHOSOCIAL VARIABLES
Social isolation is thought to play a significant role in compliance as patients become
reliant upon visits from community nurses for companionship. Where social isolation
is a problem nurse need to consider resources to overcome this and attempt to reduce
dependence upon them.
Many psychological variables may influence compliance, including:
 Learned Helplessness
 Cognitive Dissonance
 Motivation
 Coping Mechanisms
 Locus of control
When a patient is failing to comply the issue should be explored in greater depth to
identify, and, where possible, eradicate factors that impact upon compliance. Many of
these variables can be addressed through developing an understanding of the patient’s
experience.
INTRINSIC VARIABLES – LOCAL
The importance of addressing holistic variables, which influence healing, cannot be
overlooked. Healing will never be achieved unless the factors considered above are
addressed. However, care of the wound bed is also essential to overcome molecular
contributions to delayed healing.
Wound Bed Preparation
Wound bed preparation is required where wounds fail to heal. The wound becomes
stuck in the inflammatory stage of healing (Schultz et al 2003) and/or is disrupted by
the presence of bacteria. Schultz et al highlight the differences between acute and
chronic wounds which need to be addressed before healing can be achieved, these are
identified in Table 7 below.
WOUND MANAGEMENT COMPETENCY MODULE
SECTION ONE: LEVEL THREE
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Table 7
The Environment of the Healing and Non-Healing Wound
Healing Wounds Non-Healing Wounds
High level of cell replication Low level of cell replication
Low level of inflammatory cytokines High level of inflammatory cytokines
Low level of proteases (MMPs) High Level of proteases (MMPs)
Competent, healthy cells Friable cells
Wound bed preparation may be viewed as the management of a wound to promote the
natural healing process or facilitate the effectiveness of further intervention (Schultz et
al 2003). There are three key elements of wound bed prep:
 Debridement
 Exudate control
 Control of bacterial burden
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WOUND MANGMENT COMPETENCY MODULE
REFERENCES AND SUGGESTIONS FOR FURTHER READING
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