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Med-Surg · chapter 28 · Inflammation and Healing

Wound Healing Process

The 14 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 3 practice questions with the reasoning.

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Key points

  1. Acute versus chronic wounds

    For example, an acute wound progresses through the phases of healing without complication. In contrast, a chronic wound is a wound that fails to progress through the phases of wound healing in a timely fashion.

  2. Open wound tissue break

    Open wounds are another important category in nursing practice. They involve an external or internal break in the tissue.

  3. Partial-thickness wounds

    A partial-thickness wound is a superficial injury that involves the epidermis, dermis, or both. Partial-thickness wounds can present as a crater, abrasion, or blister.

  4. Full-thickness wounds

    In contrast, a full-thickness wound extends through all skin layers, potentially extending to the muscle fascia or bone. Stage 3, Stage 4, unstageable, and deep tissue injuries are examples of full-thickness injuries.

  5. Wound closure methods

    Wound closure from healing occurs through three methods: primary, secondary, or tertiary intention. Regardless of the closure method, a wound will progress and heal by moving through the four phases of wound healing.

  6. Primary intention closure

    Primary wound closure, also referred to as healing by primary intention, is the fastest type of wound closure. Primary intention refers to the healing of a wound or injury with clean edges that can be approximated, or brought close together.

  7. Secondary intention closure

    Healing by secondary intention occurs with wounds whose edges cannot be approximated or brought together, so the wound heals from the “bottom up” with granulation tissue. Secondary intention occurs when the wound cannot be surgically closed.

  8. Tertiary intention closure

    The term tertiary intention, also referred to as delayed primary intention, involves a plan to allow the wound to remain open. Reasons for the delayed closure could include waiting for the infection to resolve or preparing the wound for primary closure via a graft, flap, or skin substitute.

  9. Barriers to healing

    Several main risk factors that impede wound healing include age, immune status, perfusion, smoking, comorbidities, and immune and nutritional deficiencies. Comorbidities such as diabetes are directly linked to delayed wound healing.

  10. Wound bed preparation

    It is important for the nurse to assess the whole patient, not just the wound. Wound bed preparation is a nonsequential process of assessment, intervention, and evaluation that can be achieved through the acronym TIME, which stands for tissue, infection/inflammation, moisture, edges.

  11. Necrotic tissue barrier

    The presence of necrotic or devitalized tissue is a critical barrier to wound progression and healing; if the keratinocytes cannot migrate or granulation cannot fill a wound due to “roadblocks” of necrotic tissue, a wound will not heal.

  12. Moisture and epithelialization

    However, studies have shown, and best practices support, that a wound requires an amount of moisture to help facilitate the migration of keratinocytes to accelerate epithelialization (Nuutila Eriksson, 2021).

  13. Wound edge problems

    Wound edges may become callused or rolled, or they may develop maceration, undermining, or tunneling. All these conditions require intervention so the wound may progress through closure.

  14. Impending dehiscence signs

    Some signs of impending dehiscence include redness around wound margins and increasing drainage from the incision. The wound will also likely become increasingly painful.

Terms to know

chronic wound
In contrast, a chronic wound is a wound that fails to progress through the phases of wound healing in a timely fashion.
partial-thickness wound
A partial-thickness wound is a superficial injury that involves the epidermis, dermis, or both.
full-thickness wound
In contrast, a full-thickness wound extends through all skin layers, potentially extending to the muscle fascia or bone.
primary intention
Primary intention refers to the healing of a wound or injury with clean edges that can be approximated, or brought close together.
secondary intention
Healing by secondary intention occurs with wounds whose edges cannot be approximated or brought together, so the wound heals from the “bottom up” with granulation tissue.
tertiary intention
The term tertiary intention, also referred to as delayed primary intention, involves a plan to allow the wound to remain open.
wound bed preparation
Wound bed preparation is a nonsequential process of assessment, intervention, and evaluation that can be achieved through the acronym TIME, which stands for tissue, infection/inflammation, moisture, edges.
dehiscence
The separation of the edges of a surgical wound is called dehiscence.

Practice questions

Stuck on select-all-that-apply? How to take them one option at a time.

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Every question here, with the answer

  1. At 1800, a nurse reviews a draft note stating that an open wound is healing by secondary intention. The care plan specifies leaving the wound open until infection resolves, then closing it. Which replacement entry best reflects this plan?

    1. Wound is healing by secondary intention because it is currently open.
    2. Wound remains open pending infection resolution; delayed primary, or tertiary, closure is planned.
    3. Wound is healing by primary intention because approximation of its edges is planned.
    4. Wound is healing by secondary intention during infection treatment and will change to primary intention when closed.

    Answer: Wound remains open pending infection resolution; delayed primary, or tertiary, closure is planned.

    Planned delayed closure while infection resolves is tertiary intention, also called delayed primary intention. The first and fourth entries confuse an intentionally delayed closure with secondary intention, in which the wound heals from the bottom up because its edges cannot be approximated. The third entry describes primary intention before the edges have been brought together.

  2. At 1000, a nurse documents excessive moisture and macerated edges in wound A, and an inadequately moist wound bed in wound B. Which assessment statements accurately connect these findings to barriers to healing? Select all that apply.

    1. Maceration of wound A's edges suggests that additional moisture is needed.
    2. Inadequate moisture in wound B may inhibit cellular activity.
    3. The dry bed of wound B favors epithelialization by reducing moisture.
    4. Maceration of wound A's edges may reflect excessive moisture.
    5. Maceration of wound A's edges indicates that the wound edges are advancing.

    Answer: Inadequate moisture in wound B may inhibit cellular activity., Maceration of wound A's edges may reflect excessive moisture.

    Excessive moisture can macerate wound edges, while inadequate moisture can inhibit cellular activity. Drying the wound does not promote epithelialization; appropriate moisture supports the cellular migration needed for healing. Maceration is an edge problem requiring intervention, not evidence of edge advancement or a need for additional moisture.

  3. At 1900, a nurse finds that a surgical incision's edges remain together, but the margins are red, drainage has increased since the morning assessment, and the patient reports increasing incisional pain. No separation is visible. Which entry most accurately communicates these findings?

    1. Incision remains approximated despite redness, increased drainage, and increased pain; concern for dehiscence is deferred until separation is visible.
    2. Partial dehiscence is present, as demonstrated by redness, increased drainage, and increased pain.
    3. Incision remains approximated; redness, increased drainage, and increased pain are consistent with routine healing.
    4. Incision remains approximated, with red margins, increased drainage, and increasing pain; findings raise concern for impending dehiscence.

    Answer: Incision remains approximated, with red margins, increased drainage, and increasing pain; findings raise concern for impending dehiscence.

    Redness around the margins, increasing drainage, and increasing pain are described as warning signs of impending dehiscence. Documenting actual dehiscence would overstate the findings because dehiscence means separation of the surgical wound's edges. Calling these changes routine or waiting for visible separation overlooks the warning signs already present.

Where every quote comes from

Section 28.2 Wound Healing Process of Medical-Surgical Nursing by Christy Bowen, Bridget Carey, Jessica Palozie, Maren Reinholdt, OpenStax, 2024. Read the whole section free at openstax.org.

The textbook is licensed under CC BY-NC-SA 4.0. This page quotes it word for word and adds the headings, the order and the practice questions; references to the book's figures and stray spaces left by its formatting are removed. The page is shared under the same licence. Nothing here is sold.