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CHAPTER ELEVEN: Factors That Impede Wound Healing

Rose L. Hamm, PT, DPT, CWS, FACCWS; Tammy Luttrell, PT, PhD, CWS, FACCWS

CHAPTER OBJECTIVES

At the end of this chapter, the learner will be able to:

  1. Identify wounds that are not healing due to the influence of impeding factors.

  2. Identify the impeding factors based on subjective and objective evaluations.

  3. Select the tests necessary to confirm suspected impeding factors.

  4. Adapt plan of care to minimize the effect of impeding factors on the wound healing process.

  5. Educate patients and care givers on strategies to minimize or eliminate effects of impeding factors.

INTRODUCTION

Chapter 3 on Evaluation of the Patient with a Wound presented the two questions that need to be answered in order to successfully treat a patient with a wound: (1) Why does the patient have a wound? and (2) Why is the wound not healing? Once a wound diagnosis has been determined and standard care has been initiated, the wound should progress through the stages of wound healing discussed in Chapter 2 on Healing Response. When progress is not observed, the second question—Why is the wound not healing?—becomes even more imperative to answer. Sometimes the wound will respond initially and make measureable progress, then stall again for no apparent reason. This chapter focuses on those factors that are known to impede wound healing, some more obvious than others, and provides suggestions on how to identify and minimize the effect on the healing process. The factors are categorized into infection, medications, nutritional deficits, comorbidities, and extrinsic/psychosocial behaviors.

TABLE 11-1 provides laboratory values, always a good starting place for solving the conundrum, with normal values, trends that are typical when a patient does not have the normal healing response, and clinical presentations that accompany abnormal lab values.

Table 11-1

Laboratory Values with Implications for Wound Healing

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Table 11-1

Laboratory Values with Implications for Wound Healing
Laboratory Test Normal Range Values Affecting Wound Healing Clinical Presentation
CBC
WBC 4.5–11 × 103/mm3

  • Increased

  • Decreased

  • Signs of infection, inflammation, necrosis, trauma, or stress

  • Failure to initiate immune response against bacteria
RBC

  • M 4.5–5.5 × 106/mm3

  • F 4.1–4.9 × 106/mm3

 Decreased Pale or anemic granulation or failure to progress
Hemoglobin

  • M 13.5–18 g/dL

  • F 12–15 g/dL

  • Decreased

  • Increased

  • Pale or anemic granulation or failure to progress

  • Failure to progress (patient may show signs of congestive heart failure or COPD)
Hematocrit

  • M 37%–50%

  • F 36%–46%

  • Decreased

  • Increased

  • Pale or anemic granulation or failure to progress

  • Signs of thrombi or emboli
Platelet count 150–400 × 103/mm3

  • Decreased

  • Increased

  • Bleeds easily, fatigue

  • Signs of infection or inflammation
AUTOMATED DIFFERENTIAL
Neutrophil rel 57%–67% of leukocyte count Increased Bacterial infection chronic inflammation
Lymphocyte rel 25%–33% of leukocyte count

  • Increased

  • Decreased

  • Signs of bacterial infection

  • Opportunistic infections
Monocyte rel 3%–7% of leukocyte count Increased

  • Tissue injury

  • Early healing response
Eosinophil rel 1%–4% of leukocyte count

  • Increased

  • Decreased (with ...

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