Phases in wound

healing

Prepared by:
Yasmin Vellani
Clinical Nurse Specialist (Wound & Stoma Care)
RN,BScN, Diploma in Acute and chronic Wound
management
OUTLINE
 By the end of the session participants will be able to

1. Review types of wound healing

2. Define the stages of wound healing
3. Differentiate between the stages
REVIEW OF WOUND HEALING
 Three basic types of healing
 Primary Healing
 Delayed Healing
 Secondary Healing
HOW DO WOUNDS HEAL

 Research work shows that acute

wounds heal in four phases, and
it is believed that chronic
wounds must go through the
same phases.
 Some authors combine the first
two phases
PHASES IN WOUND HEALING
 Hemostasis
 Inflammatory Phase
 Proliferative Phase
 Remodeling Phase
KANE’S ANALOGY
 Uses an example of a damaged house, which provides a
wonderful framework to explore the basic physiology of
wound repair
HEMOSTASIS

 When the source of

damage to a house is
removed and before work
can start, utility workers
must come in and cap
damaged gas or water
lines.
HEMOSTASIS
 In wound healing damaged blood vessels must be sealed
 Platelets act as utility workers sealing off damaged blood
vessels by forming a stable clot
 Blood vessels constrict in response to injury, but this
effect ultimately relaxes
 Platelets secrete vasoconstrictive substances to aid in the
process
HEMOSTASIS
 Platelets aggregate and adhere to exposed collagen with
the help of ADP adenosine diphosphate which leaks from
damaged blood vessels
 Factors are secreted which stimulate the intrinsic clotting
cascade
 Hemostasis occurs within minutes of the initial injury
unless there are clotting disorders
INFLAMMATION PHASE
 Presents as erythema, swelling and warmth
 Often associated with pain

 Last up to 4 days post injury

INFLAMMATION PHASE
 In
Kanes analogy once the gas and water leaks are
capped the next step is to clean up the debris which is
done by non skilled workers
INFLAMMATION PHASE
 In wound healing the non skilled laborers are the
neutrophils or PMN’s (polymorphonucleocytes)
 Inflammatory response causes blood vessles to leak
releaseing plasma and PMN’s into the tissue
 Neutrophils phagocytize debris and microrganisms
providing the first line of defense against infection. (mast
cells)
INFLAMMATION PHASE
 The task of rebuilding a house is complex and requires
someone to direct this activity like a contractor
INFLAMMATION PHASE
 The macrophage acts as a “contractor” in wound
healing
 Macrophages phagocytize bacteria and act as a second
line of defense
 They secrete chemotactic and growth factors such as
 Fibroblast growth factor (FGF)
 Epidermal growth factor (EGF)
 Transforming growth factor (TGF)
 Interleukin-1 ( IL – 1) release cytokines also play an important role
in immune cell differentiation and activation
INFLAMMATION PHASE
PROLIFERATIVE PHASE
 Granulation stage starts approximately 4 days after the
injury and last till day 21 in acute wounds
 Pebbled red tissue in the base

 Replacement of dermal and subdermal tissue

 Contraction of wound
PROLIFERATIVE PHASE

 In Kane’s analogy, once the

debris is cleared the framers
move in to build the
framework of the new house
 Sub-contractors can install
new plumbing and wiring on
the framework
 Siders and roofers can finish
the exterior of the house
PROLIFERATIVE PHASE
 The fibroblast are the framers which secrete collagen on
which further regeneration occurs
 plumber cells are the pericytes which regenerate the
outer layers of the capillaries and the endothelial cells
which produce the lining. Angiogenesis
 Roofers and siders are the keratinocytes which start
epithelialization
PROLIFERATIVE PHASE
REMODELING OR MATURATION PHASE
 In Kane’s analogy, once the basic structure is
completed, interior finishing may begin.
REMODELING OR MATURATION PHASE
 In wound repair, the dermal tissues start remodeling to
produce greater tensile strength
 The principle cell “FIBROBLAST”

 Can take up to 2 years

REMODELING OR MATURATION PHASE
 SUMMARY
Phase Cellular and Bio-physiologic Events

1.vascular constriction
Hemostasis 2.platelet aggregation, degranulation, and fibrin
formation (thrombus)

1.neutrophil infiltration
2.monocyte infiltration and differentiation to
Inflammation
macrophage
3.lymphocyte infiltration

1.re-epithelialization
2.angiogenesis
Proliferation
3.collagen synthesis
4.ECM (extracellular matrix) formation

1.collagen remodeling
Remodeling
2.vascular maturation and regression
FACTORS INFLUENCING WOUND
HEALING
 WOUND HEALING
 Wound healing, as a normal biological process in the
human body, is achieved through four precisely and
highly programmed phases
 For a wound to heal successfully, all four phases must
occur in the proper sequence and time frame.
 Many factors can interfere with one or more phases of
this process, thus causing improper or impaired wound
healing.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2903966/
 NUTRITIONAL STATUS
 Wound healing requires an adequate
supply of macro and micronutrients.
 Deficiencies can result in poor wound
healing, reduced tensile strength,
wound dehiscence, and increased
vulnerability to infection and poor
quality scars.
 During the proliferative phase,
granulation, epithelialisation and
contraction all occur faster in a moist
environment. Therefore the patient
must not become dehydrated.
 CONT…
 Vitamin C deficiency
Failure of collagen synthesis and cross-linking
 Vitamin A deficiency
 Zinc deficiency
 Decreased fibroblast proliferation, collagen synthesis,
epithelialization and overall wound strength
 AGE

 The inflammatory response is reduced;

therefore the risk of infection is
increased.
 Collagen metabolism is reduced with the
resulting scar being more fragile and
there is less support for blood vessels
thus making them more prone to damage
(Desai, 1997).
 DRUGS

There are a variety of drugs that can impair the healing process,
for example:
 Corticosteroids and non-steroidal inflammatory drugs reduce
the normal inflammatory response.
 Corticosteriods impede the healing process by suppressing the
synthesis of fibroblasts and collagen and slowing down
epithelialisation.
 Contricosteroids can cause thinning of the skin.
 CONT…
 Aspirin and anticoagulants may
cause excessive bleeding with the
potential of a hematoma if not
given in the correct dosage.
 Immunosuppressive drugs reduce
leukocyte activity which reduces
the inflammatory response and
increases the risk of infection.
 Cytotoxic drugs interfere with cell
proliferation including cells
needed for wound healing.
 DRESSING
 The use of dressings, which adhere to the wound bed,
and the inappropriate usage of antiseptics can all lead to
the hindrance of wound healing.
 FOREIGN BODIES
 Foreign bodies in the wound may be
due to the presence of grit, parts of old
dressings, suture material, staples etc.
These set up an inflammatory
response, which may increase the
length of the inflammatory phase.
 WOUND TEMPERATURE
 Frequent dressing changes and the use
of cool cleansing solutions will reduce
wound temperature. Cell division takes
place at normal body temperature and
with a drop of 1°C it will take up to
three hours for mitotic cell division to
restart (Lock, 1980). This will
inevitably slow down the healing
process
 VASCULAR AND OXYGEN SUPPLY
 A good blood supply is needed for wounds to heal. Taking excessive
quantities of caffeine (coffee, cola drinks, or chocolate) or a high
nicotine intake (smoking) can lead to vasoconstriction and lead to
reduced tissue perfusion of the wound area. Smoking can also affect
epithelialisation rates and cause problems with scarring (Sian et al,
1992).
Shock, hypoxia, diseases such as anaemia and chronic obstructive
airways disease, or an impaired arterial blood supply may cause a
reduced supply of oxygen getting to the wound. Although
angiogenesis is stimulated by hypoxia, an adequate oxygen supply is
required by the wound. Without it collagen synthesis and
epithelialisation are impaired.
 OBESITY
 Wound dehiscence and wound infection is increased in an
obese person due to a decrease in perfusion to the wound
 INFECTION

 Healing is delayed as bacteria compete with macrophages and

fibroblasts for oxygen within the wound. There can be further
tissue damage from this inflammatory response and abscesses
may be formed. As the wound returns to the inflammatory
phase, healing is slowed down.
 DISEASES

 Various diseases have an influence

on the healing process such as:
 Diabetes - there is a high risk of
infection in diabetic patients. High
blood glucose levels will encourage
invading microorganisms to
multiply and hyperglycaemia has a
damaging effect on phagocytosis.
Both of these will increase the risk
of infection.
 CONT…
 Malignancy - patients may have chemotherapy or
radiotherapy. Radiotherapy can produce local skin damage
and slows down healing. It has a fibrosing effect on local
blood vessels as well as reducing the amount of fibroblasts
and endothelial cells (Cutting, 1994).
 Respiratory disease (e.g. chronic obstructive airways disease)
- The amount of oxygen to the wound bed is diminished so
causing a hypoxic state
.PSYCHOLOGICAL FACTORS

Isolation

Social
Motivation Other factors stigma

Negative
staff
attitudes
SOCIAL FACTORS

Poverty

Lifestyle

Housing

Cultural beliefs
 CONCLUSION

Wound healing is a complex process

which depends on many factors. The
important aspect to take care of all
above mentioned factors in order to
promote the healing.
THOUGHT OF THE DAY

The quality of a man's life is in

direct proportion to his
commitment to excellence,
regardless of his chosen field
of endeavor.”
― Vince Lombardi Jr.
ANY QUESTIONS