Case Study: Wound Healing and Tissue Repair

You are a nurse working the day shift and have been assigned to five patients. One of your patients is an 89-year-old male with a stage III decubitus ulcer to his coccyx. The healthcare provider is planning to discharge him to a long-term facility today and would like you to discuss wound healing with him and his wife. Please use the following prompts to guide your analysis, and use evidence from the literature to support your answers.

1. Distinguish between the main types of healing: first-intention and second-intention.
2. Discuss at least three factors that can delay wound healing, and identify some strategies to improve wound healing.
3. Explain the four phases of wound healing, identifying the role that the extracellular matrix plays in the process.

For additional details, please refer to the Case Study Guidelines and Rubric document.

Case Study: Wound Healing and Tissue Repair

Wound Healing and Tissue Repair

The setting of the case study is focused around one of my typical days in the hospital. Usually, in a day shift, five patients are allocated to each nurse. On this particular day, among my assigned five patients, one of the patients is an 89 year old man, who has a stage III decubitus ulcer in his coccyx. These kinds of ulcers or pressure sores often develop from long periods of inactivity or pressure at the same spot. An ulcer in the coccyx could indicate a habit of sitting for hours on end. For his recovery, it is essential that

the wound heals properly. The plans and steps for the same will be discussed with him and his family.

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Types of Healing

Wound healing entails the replacement of missing structures and tissues within a wounded site. Pressure ulcers are a type of wound emanating from degeneration of skin and tissues owing to shearing and pressure forces. Just like regular wounds, pressure ulcers undergo the first, second and third intention healing processes. For the patient’s ulcer, it is essential to distinguish what kind of intention will be needed specifically for him. The first intention is characterized by the union of the sides of the wound with the attachment of tissues around the edges of the wounded site (Mercandetti & Cohen, 2019). The healing process is rapid where the dead space is eliminated with minimal scarring evident on the site. It is also referred to as the primary union of the wound. For the purposes of this wound, it should be progressed as per these unions only. The first course of action for the patient will be to apply the first intention of healing. After rejoining the site of the wound with adequate measure, it is likely that the wound will heal on its own. Most pressure sores get healed after the first intention only, and with proper care, the patient should be on the same road as well.

Second intention or granulation is realized where the first intention healing fails. The main reason behind failed primary union is the size of the site or the infection of the wound. Infection especially in a sutured wound can easily lead to a breakdown in an area that was initially healing well. It is often allowed in cases where attempting to heal the wound by first intention would cause infection (Mercandetti & Cohen, 2019). However, in the case of this patient, it can also be applied if the first intention fails. At times, the wound requires the removal of necrotic tissue to aid in healing hence the introduction of granulation to ensure the wound heals systematically starting with the inner layer and gradually healing of the surface. If for some reason the first intention fails, the second intention of healing will be undertaken in the case of the patient, by removing the dead tissue.

Alternatively, third intention or delayed primary closure is a type of healing practiced on wounds that occur from excessive trauma. A wound is left open after debriding to ensure it heals by second intention for a few days after which it is closed allowing healing by first intention. This allows the wound to heal and is often evident on wounds that have been neglected causing infections and excessive loss of tissues. However, it is unlikely that third intention healing will be required in this case. There is no substantial trauma in place for the patient, which will require closure of the third intention.

Factors Determining Wound Healing

Several factors determine the rate of wound healing. They include preexisting conditions such as diabetes. Diabetes is a common condition especially among the elderly, and is a major cause of delayed healing. Immunosuppression is another important factor. Compromised immunity is a key consideration when it comes to delayed healing. The inability of the body to fight infections for instance can increase the time it takes to heal. The patient should be tested both for Diabetes and his immunity system, and if required, adequate medication will be provided. These treatments will further aid in his healing. Smoking and alcohol use also affect wound healing with use of the same often leading to infections. However, there is no history provided to indicate that the patient partakes in such activities. Thus, those factors will not be considered here. Old age is another factor that can also increase the time it takes for healing. However, in this case, that is an unavoidable factor. Adjustments would need to be made for the same.

Other internal factors such as extracellular matrix (ECM) can cause issues as well. If the ECM cells in a patient is dysfunctional, healing takes a longer time or a stronger intervention. Strategies that can improve healing include proper nutrition, avoiding some of the risk factors such as smoking and alcohol use, and limiting movement – especially where the wound is likely to be affected directly by motion. However, this does not mean that all movement should be ceased, as inactivity may also delay the healing process. Adequate physiotherapy which does not directly affect the wound, should be undertaken by the patient during his stay in the long term care facility.

Phases of Wound Healing

Wound healing takes place in four stages. These stages are hemostasis, inflammatory, proliferation, and remodeling phases (Midwood, Williams & Schwarzbauer, 2004). Hemostasis is the first phase, and occurs immediately after injury. It entails clotting where platelets stick to the injured site. The clot plugs the wound preventing further bleeding. The inflammation phase entails elimination of damaged cells through phagocytosis. The patient presented himself to the institution during the inflammation phase. It can be derived from the wound that hemostasis was already over, and the patient has reported having the sore for a long time.

Proliferation phase follows next, with the growth of new tissue and wound contraction thereby shrinking the wound and facilitating healing. The remodeling phase allows realignment of collagen and removal of dead cells. With adequate care and treatment, the patient’s proliferation phase should start soon. The extracellular matrix is important in healing as it provides both structural and biochemical support for cells. Being a three dimensional network, it provides the support necessary for ensuring the integrity of body structures and the growth of tissue responsible for wound closure.

Conclusion

However, for all the phases of wound healing to happen in an adequate and time bound manner, the patient and his family should take the necessary steps of care. To begin with, keeping the site of the wound clean and taking the required medications timely are irreplaceable steps. The patient should also be cautious in his daily activities, so as not to further injure the site of the wound.

For the patient and the family to take adequate care of the issue, it is essential that they are informed about all the treatments and medications before they leave the institution premises. As the assigned nurse for the case,  it is my responsibility to teach the patient and his care giver all the process required to get his wound healed as well as answer all their questions.

NUR 315Case StudyGuidelines and Rubric Critical thinking is a habit of mind characterized by the comprehensive exploration of issues, ideas, artifacts, and events before accepting or formulating an opinion or conclusion. Case studies are meant to connect real-world scenarios with theoretical teachings. Youare expected to test assumptions and find creative ways to consider all the facets contributing to analysis of the case.Prompt:For each case study, besure to: Introduce main elements and concerns and identify the pathology.Use the associated questionsto guide your paperand explain the pathology in the development of a plan of care.Explain the role patient-care technologies (i.e., point of care testing, computer provider order entry, bar-coding medication administration, EMR/EHR) in caring for the individual(s). Apply critical thinking in analyzing and interpreting the data.Include evidence to support your analysis of the case. Write clearly and concisely, following standard rules of grammar.Guidelines for Submission:Your paper must be submitted as at least a 2-pageMicrosoft Word document with double spacing, 12-point Times New Roman font, one-inch margins, and at least two peer-reviewed sources cited in APA format.Critical ElementsExemplary (100%)Proficient (85%)Needs Improvement (55%)Not Evident (0%)ValuePathology: Introduction and IdentificationMeets “Proficient” criteria and uses industry-specific languageand is exceptionally clear and well-informedIntroduces the reader to specific themes and main elements of the assigned case study without any gapsand precisely identifies specific pathologyIntroduces the reader to specific themes and main elements of the assigned case studyand identifies the pathology, but with gaps in information presentedDoes not accurately introduce the reader to specific themes and main elements of the assigned case studyand does not identify the pathology15Pathology: Explanation and Plan of CareMeets “Proficient” criteria and uses industry-specific language to establish expertiseComprehensivelyexplains the pathological condition in the development of plan of care for the individual in the assigned case study withoutany gapsExplains the pathological condition in the development of plan of care for the individual in the assigned case study, but with gapsDoes not explain the pathological condition in the development of plan of care for the individual in the assigned case study20Response to QuestionsMeets “Proficient” criteria and seamlessly incorporates these responses into the submissionThoroughly addresses all prompts from the case study and comprehensively explores issues, ideas, and concernsAdequately addresses most prompts included in the case study,but does not explore issues, ideas, or concernsAddresses less than half of the prompts from the case study25
Patient-Care TechnologiesMeets “Proficient” criteria,and explanation is exceptionally clear and well-informedAccuratelyexplains the role of patient-care technologies (as appropriate) in caring for individuals identified in the assigned case study without any gapsAccurately explains the role of patient-care technologies (as appropriate) in caring for individuals identified in the assigned case study, but with gaps in information givenDoes not accurately explain the role of patient-care technologies (as appropriate) in caring for individuals identified in the assigned case study15Incorporation of ResourcesIncorporates more than two discipline-specific, peer-reviewed journal articlesand one source from an interdisciplinary, peer-reviewed journal. Viewpoints of experts are analyzed and well-informedIncorporates sources of evidence from at least twodiscipline-specific, peer-reviewed journal articlesIncorporates at least two sources of evidence from peer-reviewed journals,but fails to make connection to case study clearDoes not incorporateat least two sourcesof evidence from a peer-reviewed journal15Articulation of Response (APA/Mechanics)Submission is free of errors related to citations, grammar, spelling, syntax, and organization and is presented in a professional and easy-to-read formatSubmission has no major errors related to citations, grammar, spelling, syntax, or organizationSubmission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideasSubmission has critical errors related to citations, grammar, spelling, syntax, or organization that obstruct understanding10Earned Total100%