The Environment of the Patient and The Healing Process
Of all the factors that influence healthy wound healing, the patient’s own body and life-choices thus, the “environment of the patient” may be the most profound. Co-morbidity is a disease; process or habit that decreases energy available for wound healing and/or results in changes in the tissue and the body’s chemistry. In this article we will look at some of the most critical of these influences.
Research has long shown that the very young are rapid healers and that healing times steadily decline through the years. In addition, a body that is lean and muscular is abundantly perfused whereas adipose tissue, on the contrary, has sparser vasculature. Obesity may result in difficulty ensuring adequate perfusion and nutrition to the tissue.
Nutrition has a profound impact on the healing process. When protein is insufficient for normal metabolism, a state of negative nitrogen balance occurs. The body will break down tissue of less essential muscles and organs to use in supporting the functioning of more critical organs and processes. All traumas, including all tissue traumas such as chronic wounds, may raise the requirements for nutrients substantially above established RDA’s. Ensuring adequate protein is necessary for the healing process to occur. Water is the single most important nutrient for the body’s vitality. In addition to a possible low level dehydration from illness, fluid loss from the wound itself is often an overlooked consideration when managing fluid replacement.
Any source of stress including emotions of anxiety, depression, illness, injury, relationship changes and pain stimulates the sympathetic system. First, endogenously secreted cortisol and epinephrine inhibit the cascade of healing on multiple levels. Second, to the degree that this system is activated; the parasympathetic (responsible for wound healing and blood flow to non-immediate survival tissue) is depressed. Pain, the 5th vital sign, may interfere with a patient’s ability to move or stay in one position. Appropriate pain intervention must be part of a treatment plan to ensure the ability of a patient to be compliant with a treatment plan.
When a diabetic patient presents with a neuropathic foot ulcer, compliance with off-loading pressure on the ulcer is a critical factor in healing. If a patient does not wear their accommodative shoes, for example, during ambulation, the ability of the body to assist in healing is hampered. Patients with perfusion diseases need to stop smoking to assist in the care and treatment of their disease. Patients with pressure ulcers need range of motion exercises and frequent position shifts while venous stasis leg ulcer patients need edema management and sustained, graduated lower extremity compression to help with their treatment and eventual healing. Patients need to understand and agree to make behavioral changes in their actions to support a potential healing resolution.
Certain diseases may adversely affect the ability to heal. Diabetic patients face challenges in wound healing such as glucose management, neuropathic changes, visual and balance alterations that may alter their ability to heal. Any disease that affects quantity/quality of tissue perfusion or oxygenation such as blood dyscrasias (anemia, Polycythemia Vera, clotting disturbances, etc), Congestive Heart Failure, or Chronic Obstructive Pulmonary Disease affect the body’s ability to heal. Arterial Insufficiency may cause severe tissue hypoxia such that a minor injury as a scratch or bump can overwhelm the body’s ability to respond with sufficient vigor. In venous insufficiency, protein seeps into tissues over time resulting in impaired perfusion and fibrin cuffs that prevent perfusion and results in fluid congestion. This edema now becomes a barrier to the actual cells receiving necessary oxygen and nutrients. Other diseases and treatments that dampen the immune response will impact healing. AIDS, chemotherapy and steroid treatments will slow the inflammatory response. Compromised immune systems may also put the patient at risk for a colonization or infection potential in the wound beds.
Any time there has been prior tissue damage in an area whether from a prior chronic wound or radiation therapy, there will be both a decrease in that tissue’s resistance to further trauma and a reduction in the healing potential. Tissue areas that have healed from full thickness pressure ulcers will have only 70% of the tensile strength of unwounded tissue. Disorders of the renal system have a broad impact on collagen deposition causing both delayed healing and higher chance of dehiscence.
Our current usage of risk assessment tools such as the Braden or Norton Scale, allow an opportunity to examine some of these issues in regard to a specific patient. These tools when used to score as patient’s risk for skin breakdown will allow the practitioner to incorporate some prevention measures into a treatment plan to improve the healing scenario or quite possibly prevent any skin trauma.
In conclusion, we have seen that the environment of the patient may cause profound difficulties in wound healing. Identifying and understanding these co-morbidities will help you bring in important interventions and gain more realistic expectations for the healing process.
This article was written by Patricia Cornwell, RN BSN CWOCN