Karen Floyd

Pathophysiology

Pressure ulcer

Decubitus Ulcer

Stage 3 Ulcer

A pressure ulcer is caused by external pressure being applied to prominent bony surfaces of the body such as the elbows, spine, heels, ankles, and in your husbands, case the coccyx. The ulcer formed when the capillary pressure within the tissue was exceeded, interrupting his circulation, and causing his tissue to go without oxygen which caused damage and tissue death (Anders, J. et al., 2010). In the case of your husband, a decubitus ulcer formed which was caused by his lying or sitting for an extended period without repositioning (McCance, Huether, Brashers, & Rote, 2014, p. 1625). Your husband has a stage 3 decubitus ulcer. This stage of ulcer is characterized by full thickness loss of skin with the first and second layer of skin both being destroyed (Ahmed, Papier, Whelan, & Whalen, 2016).

Types of Healing

Primary Intention

Secondary Intention

There are two ways a wound can heal. The first primary intention is the type of healing that we often see when we have surgery and the wound is closed with sutures or staples. These types of wounds have very little tissue loss, thus heal quicker than the type of wound your husband has. Your husbands wound will heal through secondary intention. With secondary intention, the wound has more extensive tissue loss, and the wound edges cannot be brought together, the wound will take longer to heal than a wound that heals through primary intention (Harper, Young, & McNaught, 2014). The wound healing process is a complex process, and undergoes four stages.

Stages of Wound Healing

Hemostasis

Inflammation

Proliferation

Maturation

Extracellular Matrix

Whether primary or secondary intention healing, all wounds go through the four stages of healing. The first phase, hemostasis begins upon being injured and aims to stop any bleeding. To do this the body

activates its emergency repair system the blood clotting system, and forms a dam to block the drainage. During this process, platelets come into contact with collagen, resulting in activation and aggregation. An enzyme called thrombin is at the center, and it initiates the formation of a fibrin mesh, which strengthens the platelet clumps into a stable clot (Maynard, 2016).

Next is the inflammation phase in which the focus is on” destroying bacteria and removing debris-essentially preparing the wound bed for the growth of new tissue” (Maynard, 2016). During this phase, white blood cells enter the wound, and destroy bacteria and remove debris. Once the white blood cells leave, macrophages come to the wound to continue clearing debris out. Macrophages also secrete growth factors and protein which attract immune system cells to the wound and help with tissue repair. It is during this phase, when your husband would experience pain, swelling, and heat. The third phase, the proliferation phase occurs when the wound begins filling in and covering the wound also known as epithelization. Granulation tissue fills the wound bed during this phase with connective tissue, forming new blood vessels. The wound margins begin to pull towards the center of the wound, and the epithelial cells begin to go towards the center of the wound bed until the wound is covered with epithelium. Once this phase is complete, the fourth stage, maturation can occur. In maturation, “the new tissue slowly gains strength and flexibility. Here, collagen fibers reorganize, the tissue remodels and matures and there is an overall increase in tensile strength” (Maynard, 2016). Throughout the wound healing process the extracellular matrix or ECM is pivotal in helping the wound to heal as it regulates and integrates many of the “key processes of healing” (. The ECM constitutes the largest component of normal skin and allows the skin to have “elasticity, tensile strength and compressibility.” In addition, with wounds, the ECM contains fibrin and fibronectin which provides “scaffolding to direct cells into the injury as well as stimulating them to proliferate, differentiate, and synthesis new ECM” (Schultz, Ladwig, & Wysocki, 2015).

Interventions

Methods to promote healing

Lab work

Increased and decreased levels.

Offloading wound

methods

Proper treatment

As the wound process is taking place, there are many things that can be done to promote wound healing. The first is obtaining lab work to identify any underlying factors that can slow wound healing. Such lab work includes but is not limited to a complete blood count (CBC), and Hemoglobin A1C (HBA1C) which looks at one’s level of glucose over the past three months. In addition, an albumin and pre-albumin level should be obtained to look at the amount of protein in your body. If levels such as glucose or white blood cells are high healing will be delayed. On the other hand, if one’s hemoglobin and hematocrit are low, the wound may not receive the oxygen rich blood it needs. If the pre/albumin is low the protein needed to promote wound healing is not available (Ahmed, 2016). Corrective measures much be taken to correct all abnormal labs whether it includes adding supplements, getting one’s diabetes under control by adjusting medications, or obtaining further testing to determine why levels such as a white blood count is high. Wound healing will be promoted by having your husbands labs within normal range.

Another factor that can inhibit wound healing is pressure to the wound. If you do not relieve the pressure that caused the wound, it will not heal. To do this proper positioning is key. Secondary to the wound, your husband will need to reposition more frequently, and avoid putting any pressure on the wound area. If in a chair, he should reposition often, and have a cushion on the chair. Repositioning can be as simple as standing up for a minute or two and then sitting down again, or simply shifting weight. If in bed you need to reposition a minimum of every two hours. One device that can help to prevent pressure is an air mattress. The air mattress settings are set per one’s weight and comfort. This device alternates pressure to redistribute pressure to promote wound healing, and prevent further breakdown. If an air mattress is not available, you can use pillows and other wedges to offload the area (Ahmed, 2016).

In addition to the above, it is vital that the proper treatment is in place. There are many types of wound dressings available, choice of which dressing to use should be based on several factors. When the doctors are selecting a wound dressing he/she needs to consider the amount of drainage, how deep the ulcer is, and the overall appearance of the wound. In addition, your husband needs to keep the skin around the wound as dry as possible (Ahmed, 2016). A wound vac can be used to promote healing in a wound that has stalled in the wound healing process. A wound vac delivers negative pressure to promote wound healing. As with any dressing keeping it clean and intact is vital, thus incontinence care should be done frequently, and the dressing checked frequently for integrity.

References

Ahmed, A., MD, Whelan, S., NP, Whalen, L., ANP, & Papier, A., MD. (2016, July 14). Stage 3

Pressure Injury – Pressure Ulcer Staging. Retrieved March 12, 2017, from

https://www.visualdx.com/visualdx/diagnosis/stage3pressureinjury?moduleId=44&diagnosisId=54505

Anders, J., Heinemann, A., Leffmann, C., Leutenegger, M., Pröfener, F., & von Renteln-Kruse,

W. (2010). Decubitus ulcers: pathophysiology and primary prevention. Deutsches Aerzteblatt International, 107(21), 371-2p. doi:10.3238/arztebl.2010.0371

Harper, D., Young, A., & McNaught, C. (2014). Basic science: The physiology of wound

healing.

Surgery (Oxford)

, 32 (Wound Management), 445-450.

Koi:10.1016/jmpsur.2014.06.010

Maynard, J. (2016, November 03). How Wounds Heal: The 4 Main Phases of Wound Healing.

Retrieved March 12, 2017, from

http://www.shieldhealthcare.com/community/wound/2015/12/18/how-wounds-heal-the-4-main-

phases-of-wound-healing/

McCance, K., & Huether, S. (2014). Pathophysiology: The biologic basis for disease in adults

and children (7th ed.). St. Louis, MO: Mosby.

Schultz, G., Ladwig, G., & Wysocki, A. (2015, August). Extracellular matrix: review of its

roles in acute and chronic wounds. Retrieved March 12, 2017, from

http://www.worldwidewounds.com/2005/august/Schultz/Extrace-Matric-Acute-Chronic-

Wounds.html