Relationship between Characteristics of the Wound and Healing Duration among Patients Treated during Home-Visits

In humans, wound healing is a vital but complex process governed by chronological yet overlapping stages, such as hemostasis, inflammation, proliferation, and remodeling. Because of the complexities of wound healing, it is prone to pausing at multiple levels. Wound healing can potentially be influenced by factors that affect cellular functions and physiologic responses. This research aimed to investigate the relationship between wound healing duration and demographic properties and characteristics of wounds among patients treated during home visits in Erbil, Iraq. To this end, a longitudinal correlational quantitative design was employed in the current study. A random sample of about 101 chronic wounds was found in 77 patients of both genders selected from all ages during home visits for around four years in Erbil. The professional nurse applied nursing management according to the nursing plan during home visits until the wound recovered. The total duration of wound healing was calculated and documented for each wound. Seventy-seven patients participated in the current study, with their mean±SD age being 58.02±16.29 years, ranging from 19 to 89. The median age was 60. More than half of the sample (54.5%) were ≥60 years, and 62.3% were males. Less than one-third of patients (31.2%) were of normal weight, 93.5% were married, 37.7% were housewives, and 35.1% were illiterate. Regarding the duration of wound healing, in more than one quarter (26.7%), it was delayed (took more than three months for healing). The longest mean healing time (20.06 weeks) was for pressure ulcers ( P <0.001), which was significantly higher than all the mean healing times of other types of wounds. The study showed a significant ( P =0.011) association between the mean healing time and the anatomic location of wounds, revealing that the highest mean healing time was for wounds located in the trochanteric area (21.10 weeks) or the sacrum (18.25 weeks). A significant association ( P =0.002) was also detected between the mean healing time and the edge of the wound, with the highest mean healing time (18.64 weeks) found in wounds with undermined edges. Furthermore, the mean healing time was significantly higher among those with infected wounds (14.59 weeks) than the mean (6.50 weeks) among those with no infection ( P <0.001). In conclusion, wound healing progression is an important but complicated process that healthcare providers use for patients during home visits. It is divided into phases, including hemostasis, inflammation, proliferation, and remodeling. The current study revealed that the healing time was affected by the anatomical site of the wound and took longer in pressure ulcers, undermined edge wounds, and infected wounds.


Introduction
In humans, wound healing is a vital but complex process governed by chronological yet overlapping stages, such as hemostasis, inflammation, proliferation, and remodeling (1).Because wound healing is so complicated, it often stops at more than one level.Wound healing can potentially be influenced by factors that affect cellular functions and physiologic responses (2).Wound healing is impaired by many causes, such as diabetes mellitus (DM).Many contributing factors may affect the healing of wounds, unlike other causes of tissue repair alteration.Depending on the number of diabetic patients, the impact of healing changes can be enormous.Chronic wounds are often aggravated by minor wounds and non-healing sores that are susceptible to infection.Infection commonly leads to gangrene and, eventually, the need for amputation (3).
Over the last 65 years, the elderly population has grown dramatically, increasing the risk of age-related pathologies, such as chronic ulcers, and the associated socioeconomic and clinical burdens (4).Many local factors in the sore itself may delay the healing process, such as infection or the presence of abnormal bacteria, desiccation, swelling, maceration, pressure, trauma, and necrosis (5).Radiotherapy is unavoidable and will affect some normal tissues.The long-term effects of such radiation may cause radiation damage that may persist for decades after radiotherapy.Wound healing issues are frequently underestimated in these patients (6).
Obesity affects one-third of the adult population in the United States (7).The primary concern with obesity is the increased heart workload required to supply oxygenated blood to body tissues.Ischemia may occur when the tissues are not perfused by the heart and thus contribute to tissue necrosis and wound healing impairment (8).Despite the beneficial action of steroids, such as dexamethasone, as immunosuppressive glucocorticoids, and antiinflammatory drugs in autoimmune disorders or asthma, they may affect the wound healing process and thus delay healing (9,10).
Organ transplant recipients are at risk because they are given antirejection drugs, such as CellCept and prednisolone, after surgery.The negative effect on wound healing comes from the tendency of steroid drugs to inhibit wound contraction and reduce tensile strength (8).Wound healing needs adequate nutrition.Many skin biological processes require nutrients for maintenance and proliferation.Competency in the mechanism of cellular requirements is required for wound healing (1,11).Adequate quantities of nutrients are required for the production of proteins, nucleic acids, and other factors involved in functional tissue differentiation and maturation.
This research aimed to investigate the relationship between wound healing duration and demographic properties and characteristics of wounds among patients treated during home visits in Erbil, Iraq.

Study Design
A longitudinal, correlational, quantitative design was employed in the current study to investigate the relationship between the wound healing duration and demographic properties and characteristics of wounds among patients treated during home visits in Erbil, Iraq.A random sample of about 101 chronic wounds was found in 77 patients of both genders selected from all ages during home visits for around four years in Erbil city.
The information gathered from the patients was in three parts: the patient's characteristics, the wound's characteristics, and the relationship between the wound healing duration and the wound's characteristics.
Patients with chronic wounds went to a professional nurse to get help with their health.During home visits, the professional nurse looked at the wound to see what kind of care it needed.Accordingly, the nurse began treating the wounds.
During home visits, the professional nurse used the nursing plan to treat the wound until it was completely healed.
For each wound, the total amount of time it took to heal was calculated and documented.

General Objective
This study aimed to find out the relationship between wound healing time and the wounds' demographic properties and characteristics among patients who were treated during home visits in Erbil, Iraq.

Specific Objective
The specific objectives of the current research were to illustrate the frequencies of the sample and investigate the association between the duration of wound healing and the medical history of the sample, the site of the wound, the grade of the wound, the edge of the wound, the tissue type of the wound, and the risk factors for wound healing.

Statistical Analysis
The Statistical Package for Social Sciences (SPSS) was used to calculate the frequencies and percentiles of the characteristics of patients and wounds.ANOVA tests were used to find out the relationship between the mean healing time and some patient characteristics (age, BMI (kg/m 2 ), occupation, and educational level) and wound characteristics.T-tests were used to determine the relationship between the mean healing time and patients' characteristics.
Fisher's exact test was used to determine the relationship between variables for those less than 5 in the cells for the schedules.
The P-value was used to determine the relationships between the variables as follows: A P-value of ≤0.05 was assumed to show a significant relationship.A P-value of >0.05 was assumed to show a nonsignificant relationship.A P-value of ≤0.01 was assumed to show a highly significant relationship.

Results and Discussion
The total number of patients was 77.Their mean±SD age was 58.02±16.29 years, ranging from 19 to 89.The median age was 60.More than half of the sample (54.5%) were ≥60 years, as presented in table 1, and 62.3% were males.Only less than one-third of the patients (31.2%) were of normal weight.The table shows that 37.7% of the patients were housewives, 93.5% were married, and 35.1% were illiterate.
Around one-third (31.7%) of the wounds were caused by pressure ulcers, and 24.8% were surgical wounds, as presented in table 2, which also shows other types of wounds.
As shown in table 1, as more than half of the patients were under the age of 60, the researchers' choice of patients who already had complicated wounds and were bedridden had an impact on the current findings.The highest proportion of wounds (45.5%) was in the foot region, which may be related to the main causes of foot ulcers: pressure ulcers in the heel region and neuropathic/DM ulcers.Regarding the duration of wound healing, in more than one quarter (26.7%), it was delayed (took more than three months for healing).This may be related to the nature and medical status of the sample, with more than half of the sample (54.5%) aged ≥60 years, and also to the level of education of the sample, which affects personal hygiene and skin care.The edges of more than half of the wounds (53.5%) were not attached.The table shows that the shape of 36.6% of the wounds was irregular.The tissue type was sloughy in 35.6% and necrotic in 32.7% of the wounds (Table 2).Table 3 shows no significant association between the mean healing time and age (P=0.569),BMI (P=0.842),occupation (P=0.222), or educational level (P=0.490).
It is evident in table 4 that the pressure ulcer had the longest mean healing time of 20.06 weeks (P<0.001),which was significantly higher than the entire mean healing times of other types of wounds, showing the effect of blood circulation on the healing process.No significant differences were detected between the mean healing times of other types of wounds (according to the LSD test).The table shows a significant (P=0.011)relationship between the mean healing time and the anatomic location, with the highest mean healing time found in wounds located in the trochanteric area (21.10 weeks) or the sacrum (18.25 weeks).This may be due to lower oxygen and blood supply in those areas due to pressure on the tissues.A significant association (P=0.002) was detected between the mean healing time and the edge of the wound, showing that the highest mean healing time (18.64 weeks) was when the edge was undermined.No significant association was also detected between the healing time and the shape of the wound (P=0.805).Table 4 shows that the highest mean healing time was detected when the tissue was sloughy (16.17 weeks) or necrotic (14.09 weeks), and the differences were significant (P=0.023).This result can be supported by what has been stated in research done in the UK, indicating that healing can be inhibited by the amassing of slough or necrotic tissue, a feature of chronic wounds (10).
It is evident in table 5 that there was no significant association between the mean healing time and the following variables: gender (P=0.909),marital status (P=0.201),smoking (P=0.445),stress (P=0.821),hypertension (P=0.234),diseases (P=0.850),medications (P=0.571),malnutrition (P=0.126),advanced age (P=0.450), and alcoholism (P=0.979).The mean healing time among those with infected wounds (14.59 weeks) was significantly higher than the mean (6.50 weeks) among those with no infection (P<0.001).This is in agreement with previously published works (10) and (11) that mentioned that if the inflammation of a wound is excessive, the process of wound healing may be prolonged.Finally, a significant (P=0.002)association was detected between immobility and the healing time, where it is evident that healing time is longer among immobile patients and that poor mobility can impede the healing process (10).The incidence of delayed healing happened in 26.7% of patients, as presented in table 6, which shows there is no significant association between delayed healing time and age (P=0.514),gender (P=0.510), or the educational level of patients (P=0.859).Wound healing is impaired with advancing age (10).Regarding the tissue type, the highest incidence of delayed healing was when the tissue was necrotic or sloughy (36.4% and 33.3%, respectively), and none of the wounds with epithelialization developed delayed healing (P=0.011).The accumulation of necrotic tissue or slough in a chronic wound promotes bacterial colonization and prevents complete repair of the wound (10).
The highest incidence of delayed healing (59.4%) was found in pressure ulcers, while all neuropathic ulcers healed within the first three months of the treatment (P<0.001).Continuous pressure on the area of the wound prevents blood nutrients and oxygen from reaching the attacked tissues and prevents the healing process.The incidence of delayed healing was also high (60%) when the wound was in the sacrum or trochanter, and the least (8.7%) was found in the feet (P<0.001).This is related to the status of the sample, as they were almost bedridden patients; therefore, there was more pressure on the trochanter and sacrum parts and less pressure on the feet.A significant association was detected with the edge of the wound (P=0.003) as the highest incidence existed when the edge of the wound was undermined.On the other hand, no significant association was detected between the shape of the wound and the healing time (P=0.248),as presented in table 7.

Table 1 .
Basic characteristics of patients

Table 3 .
Mean healing time by patients' characteristics (ANOVA test output)

Table 4 .
Mean healing time by wound characteristics (ANOVA test output)

Table 5 .
Mean healing time by patients' characteristics (t-test output)

Table 6 .
Incidence of delayed healing by age, gender, and educational level

Table 7 .
Incidence of delayed healing by wound characteristics

Table 8 .
Incidence of delayed healing by patients' characteristics *By Fisher's exact test