INTRODUCTION

A wound can be defined as ‘a cut or break in continuity of any tissue caused by injury or operation’ (Weller 2000) and, as with adults, wounds in children can occur for a variety of reasons. In general, wounds can be classified in two categories: acute and chronic. Acute wounds include injuries caused by trauma, e.g. road traffic accidents, scalds, bites, lacerations, burns, and those caused by surgical intervention. Chronic wounds in children include congenital abnormalities (ulcerated haemangiomas), underlying medical conditions (epidermolysis bullosa, EB), pressure ulcers and lesions caused by acute medical conditions (meningococcal septicaemia). It is important to remember that any wound can become chronic if the healing process is interrupted, e.g. by infection, and gets ‘stuck’ in either the inflammatory or proliferative phase of healing (Sibbald et al 2000).

Although children have the same physiological response to injury as adults, they can regenerate the cells required for the wound-healing process more rapidly, resulting in faster wound closure (Tendra Academy 2004).

The nurse’s role in paediatric wound care, therefore, begins with an understanding of the wound healing process and the factors which may affect healing. This understanding is paramount in making an accurate assessment of any child with a wound, as the subsequent treatment plan will be heavily dependent on the outcome of that assessment. The nurse, in collaboration with the multidisciplinary team, must be able to choose the appropriate wound management strategies for the child and their family. A fundamental part of this process is recognising the need for holistic, individualised, family-centred care.

RATIONALE

Children’s nurses learn to develop holistic nursing skills and this is no different in the field of wound management. The goals for holistic wound management in children are to control pain, reduce emotional discomfort and minimise the risk of scarring (Bale & Jones 2006). Many factors can delay and complicate healing: poor tissue perfusion and oxygenation, poor nutritional status, infection, underlying medical conditions and extremes of age (Bryant 1992). The principal objectives of wound care are, first, to restore the function of injured tissue and second, to do no damage during that process of restoration (Box 37.1).

WHAT IS HEALING?

Wounds heal in two different ways: by primary or by secondary intention. Healing by primary intention indicates a process in which the wound edges are closed as soon as possible using sutures, staples, steri-strips or glue. As there is no tissue loss, healing is rapid and usually occurs within 24–48 h. When wounds are closed in this way, granulation tissue is not visible and scar formation is minimal (Collier 1996). Surgical wounds without complications heal in this way. Healing by secondary intention occurs when there is tissue loss into the dermis and deeper layers of the skin. The wound edges are not opposed and tissue gradually regenerates from the bottom of the wound to fill the defect. This type of wound requires skilful and holistic assessment (Russell 2002a).

Healing occurs more rapidly in children than in adults for the following reasons:

• Formation of granulation tissue is faster

• Production of collagen and elastin is faster

• Quantity of fibroblasts in the wound is greater (Tendra Academy 2004).

PHASES OF WOUND HEALING

An understanding of the physiological process of wound healing is vital in making an accurate assessment of any wound; subsequent treatment will depend on the outcome of the assessment. There are three phases of wound healing:

1. The inflammatory phase

2. The proliferative phase

3. The maturative phase.

FACTORS AFFECTING HEALING

Conditions or factors that may compromise wound healing should be considered when undertaking wound assessment.

Nutrition

Adequate intake of fats, proteins and carbohydrates are required for optimal wound healing (Meghan & Barbul 2006). Encouragement must be given to the child to maintain an adequate oral intake while acknowledging cultural needs and avoiding unfamiliar foods (DoH 2003, Young 2006). Encouraging small amounts regularly may be preferable to having three large meals daily. Simple snacks such as yoghurts, cheese, and fruit can be offered at regular intervals throughout the day.

• Children who are deficient in nutrients as a result of illness, or disease, are susceptible to impaired healing:

– Vitamin C deficiency inhibits formation of collagen fibres and capillary development

– Protein deficiency reduces the supply of amino acids for tissue repair

– Zinc deficiency impairs epithelialisation

• Children with special needs may have difficulty eating, drinking and swallowing; skilled assistance is therefore needed to ensure adequate intake of nutrition

• The assistance of the dietitian is also useful to ensure nutritional requirements are being met (Shepherd 2003).