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Age

Skin, just like other tissues and organs, changes with age. Decreased

cellular activity during the aging process leads to decreased collagen

production thar results in less collagen organization in older individuals. Reduced collagen organization resulrs in decreased tensile strength of the skin that could result in greater damage after trauma

in the older individual. Other examples of skin changes with age

include delayed wound contraction, decreased epithelialization, and

delayed cellular migration and proliferation.56 Other comorbidities

that delay wound healing, such as diabetes, peripheral neuropathies,

and related vascular problems, occur with greater frequency in older

individuals.

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Lifestyle

A patient's lifestyle can have a great impact on the prognosis for

healing, decision-making regarding wound management, and preventive care. For example, occupations and hobbies that require prolonged standing may predispose some individuals to varicosities

and other venous problems. Individuals exposed to traumatic situations, such as construction workers, are also more likely to reinjure healing wounds. Behaviors such as cigarette smoking can impede

wound healing significantly because of the vasoconstriction that nicotine creates.

Nutrition

Good nutrition is necessary for the growth and maintenance of all

body tissues. Macronutrients, such as carbohydrates, fats, and proteins, and micronutrients, such as vitamins, are necessary for cell metabolism, division, and growth. Therefore, nutrition is closely

linked with all phases of healing.57 Generally, poor nutrition

decreases the body's ability to heal. Additionally, patients with burns,

wounds, or infection who are adequately nourished at the time of

their injury or the development of their wound may also develop protein-calorie malnutrition.

There are major metabolic abnormalities associated with injury

that can deplete nutritional stOres, including increased output of

catabolic hormones, decreased Output of anabolic hormones, a

marked increase in metabolic rate, a sustained increase in body temperature, marked increase in glucose demands, rapid skeletal muscle breakdown with amino acids used as an energy source, lack of ketOsis, and unresponsiveness to catabolism to nutrient intake.-�8 Protein-calorie malnutrition can delay wound healing and cause seriou health consequences in patients with wounds, especially if infection

exists. Poor nutritional status, whether due to decreased intake or

the stress response, can set off a series of metabolic events leading to

weight loss, deterioration of lean tissues, increased risk of infection,

edema, and breathing difficulty.58

These events can lead to severe debilitation and even death. Inadequate diet control in patients with diabetes exacerbates all symptOms of diabetes, including impaired circulation, sensation, altered metabolic processes, and delayed healing. A nutritional assessment by a

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registered dietitian, nutritional supplements, and careful monitoring

of the patient's nurritional status and weight are important components of a comprehensive assessment and treatment program for the patient with a wound.

In addition, therapists should work with other health care professionals to curb the systemic stress response. Removing necrotic tissues, treating infections, and ensuring adequate hydration and blood fluid volumes will help to limit physiologic stressors. Premedication before painful procedures and avoiding extreme temperatures help minimize stress. Exercise serves as an anabolic stimulus for muscle, facilitating a reduction of the catabolic state,58

Cognition and Self-Care Ability

There is an increased risk of infection and other wound healing

complications if neither the patient nor the caregiver has the cognitive or physical ability, or both, to properly care for a wound, including wound cleansing and dressing removal and application.

The patient'S or caregiver'S abilities, or both, have a great influence

in the choice of dressing(s) and on discharge planning. Certain

dressings require more skill than others to maintain. Complex

wound care can justify a stay at a rehabilitation hospital or skilled

nursing facility.

Vascular Statlls

Any compromised vascular status may contribute to the development

of delayed wound healing owing to a lack of oxygenation and nutrition to the tissues.

Medical Status

Generally, compromised health causes a decrease in the body's ability

to progress through the healing process. Pre-existing infection or a

history of cancer, chemotherapy, radiation, acquired immunodeficiency syndrome, or other immunodeficiency disorders can decrease the patient's ability to heal. Congestive heart failure, hypertension,

and renal dysfunction can also slow wound healing.

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Medications

Steroids, antihistamines, nonsteroidal anti-inflammatory drugs, and

oral contraceptives may delay wound healing, as can chemotherapy

and radiation. These medications can decrease the tensile strength of

connective tissue, reduce blood supply, inhibit collagen synthesis, and

increase the susceptibility to infection.59 Amicoagulants thin the

blood and decrease its ability to clot; therefore, the healthcare provider needs to diligently monitor bleeding during dressing removal and consider debridement methods that will not cause bleeding.

Chronic Wounds

In healthy individuals without comorbidities, an acute wound should

heal within 3 to 6 weeks, with remodeling occurring over the next

year. If a wound remains in one of the stages of healing without progression, it becomes a chronic wound.6o Chronic wounds are defined as wounds that have "failed to proceed through an orderly and timely

process to produce anaromic and functional integrity, or proceeded

through the repair process without establishing a sustained anatomic

and functional result. "61 The acute care therapist should be inclined

to search for underlying causes of delayed wound healing, especially

when treating a wound thar has not healed in more than 6 weeks.

Wound Assessment and Acute Care

Management of Wounds

The evaluation of a patient with a skin wound includes a general history (identification of factors that can delay healing), performing a physical examination (sensation, pain, ROM, strength, and functional mobiliry) and a specific examination of the wound itself.

History

In addition to the general chart and medical history review (see

Appendix I-A), the following information is especially relevant for

determining wound etiology and risk facrors, an intervention plan,

and potential outcomes:

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477

Wound History

• How and when did the wound occur?

• What interventions have been administered to the wound thus

far? What were the results?

•

Is there a previous history of wounds? If so, what were the etiology, intervention, and time frame of healing?

Risk Factors

•

Howald is the patient?

•

Is the patient cognitively intact?

•

Where and for how long is the patient weight bearing on areas

involving the wound site?

• What is the patient's occupation or hobby? How many hours

does the patient spend on his or her feet per day? What positions

and postures is the patient in throughout the day?

•

Does the patient smoke?

•

Is the patient generally well nourished? Is the patient taking any

supplements?

•

Has the patient experienced any weight loss or gain lately?

• If the patient has diabetes, is it well controlled?

•

Does the patient have an immunodeficiency disorder or a medical condition that increases his or her risk of infection?

• Does the patient have a medical condition that causes altered

sensation?

• What medications (including anticoagulants) is the patient taking? What are their effects on wound healing?

Psychosocial Factors

•

Does the patient have a good support system, including physical