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COURSE OBJECTIVE: The purpose of this course is to provide healthcare professionals with an overview of wound care, including phases of healing and steps for addressing acute and infected wounds.
Upon completion of this course, you will be able to:
A wound is a damaged area of the body. Because this course addresses external wounds—damage that includes the skin—we begin with a review of the anatomy of skin.
Skin varies in thickness from less than one millimeter in the eyelids to greater than four millimeters on the soles of the feet, but everywhere, skin is composed of two layers, the epidermis and the dermis, underlain by a sheet of subcutaneous tissue (Habif, 2010).
The skin has two layers, the epidermis and the dermis, below which lies subcutaneous tissue. (Source: National Cancer Institute)
The outer layer of the skin is the epidermis. The deepest part of the epidermis is a row of germinative cells. Germinative cells are specialized stem cells that continually divide to give off keratinocytes, the main cells in the remainder of the epidermis. As they age, the new keratinocytes fill with keratin (a tough fibrous protein) and are pushed to the surface, where they die; thus, the outermost layer of the epidermis is made of flat, dead keratinocytes. The epidermis also contains melanocytes (pigment-containing cells) and immune system cells. The epidermis, a protective layer that is normally impermeable to water, does not have sufficient strength to hold sutures or staples.
There are no blood vessels in the epidermis, and it receives its oxygen and nutrients by diffusion from blood circulating in the underlying dermis. Hair, nails, sweat glands, and sebaceous glands are sunken epidermal appendages that lie in deep valleys in the dermis surrounded by a row of germinative epidermal cells.
During normal healing, the epidermis re-grows from germinative cells left in the skin at the edges of the wound. The growing cells are called epithelial cells, and the regrowth of the epidermis is called re-epithelialization.
Some wounds, such as surface abrasions (scrapes), are confined mostly to the epidermis. In epidermal wounds, a new epidermis grows from the germinative cells that surround the bottoms of epidermal appendages deep in the dermis. Epidermal wounds usually heal quickly with no scarring.
Partial-thickness wounds, such as deep abrasions, destroy or remove the epidermis and may also destroy part of the upper portion of the dermis. Islands of less depth within the wound bed may generate epithelial cell growth, but usually epithelial cells migrate from wound edges toward the middle of the wound. This new growth creates the new epidermis. Partial-thickness wounds usually heal without scarring.
The layer of skin directly beneath the epidermis is the dermis. A basement membrane separates these two layers. The dermis is mainly connective tissue and is therefore much stronger than the epidermis. The dermis varies in thickness across the surface of the body, but everywhere it is significantly thicker than the overlying epidermis.
The tissue of the dermis contains small blood vessels, lymph vessels, nerves with their endings, and the smooth muscle fibers of hair follicles. The dermis is also populated by a variety of individual cells including macrophages, fibroblasts (which synthesize the extracellular connective tissue components such as collagen to form a matrix that is the foundation for a scar), and mast cells (which release histamine and other molecules that increase inflammation).
The dermis is loosely stratified. The upper (most superficial) layer contains capillaries and sensory endings of nerves. The deepest layer has thick interlacing collagen and elastic fibers arranged in parallel rows. The extracellular fibers in the deep dermis are responsible for the strength and toughness of the skin. When a wound is closed with sutures, they are anchored in the strong connective tissue of the lower layer of the dermis.
Wounds that penetrate the dermis are true breaks in the skin. For the skin to regain its strength, new fibrous connective tissue must bridge these wounds; however, the new fibrous tissue—the scar—is never as strong as the original dermis. In full-thickness wounds, both the epidermis and the dermis are destroyed or removed. These wounds always heal with a scar.
Beneath the dermis is a layer of subcutaneous tissue containing fat. The thickness of the subcutaneous layer varies throughout the body. It is thickest along the anterior thigh and thinnest on the back of the hands.
Besides fat cells, subcutaneous tissue contains blood vessels, lymph vessels, and nerves. The subcutaneous layer is held together by a continuous sheet of fibrous membrane that runs parallel to the surface of the skin. This membrane is called the superficial fascia.
Beneath the subcutaneous tissue layer, structures (such as muscles and organs) are enclosed in their own separate connective tissue sheaths. The generic name for these sheaths is deep fasciae. Deep fasciae generally look off-white in fresh wounds. When treating a wound, tears in the deep fasciae are repaired whenever possible.
The subcutaneous tissue is a loosely organized compartment. When skin wounds extend deeper than the dermis, dirt is easily pushed into and spread within the subcutaneous tissue. When cleansing a wound that has penetrated deeper than the dermis, the subcutaneous compartments should be washed out thoroughly to reduce the risk of infection.
External wounds are named by the type of force that caused them. There are seven basic wound types: abrasions, lacerations, crushes or contusions, punctures, avulsions, burns, and ulcers. A traumatic wound is often a mixture of types.
Many parts of the human body can heal after being wounded, but few wounds heal seamlessly. The new seam, or patch, is called a scar. Scars are mainly connective tissue and cannot replicate the specialized functions of the original injured tissue. In the skin, scars are covered by a layer of epidermis (Habif, 2010).
Scars are imperfect replacements for damaged tissue, but scars are a natural result of healthy healing. Large wounds, wounds that heal slowly, and wounds involving extensive destruction of the surrounding tissues heal with large scars; nonetheless, these scars are not necessarily abnormal.
Normal scars can lead to problems. Even under the best healing conditions, some normal scars may end up interfering with the movement of the skin and the underlying tissue. In addition, some normal scars are unsightly.
When the healing situation is not ideal, scars are more likely to become problems. After poor healing, some scars become unnecessarily large or unnecessarily weak. For example, infections, tissue necrosis, sebaceous skin, and wounds perpendicular to natural lines of minimal skin tension will all lead to scars that are larger than normal. If a wound reopens before it is effectively sealed (called dehiscence), the scar will be wider and, usually, weaker. If too few capillaries grow into the forming scar tissue, leading to ischemia, the scar will be very weak and may develop into an ulcer.
At the other end of the spectrum, the wound patching process may go overboard and generate too many new cells or, more commonly, too much collagen in the scar. Such scars will enlarge and bulge from the wound. Scars built of too many cells (mainly fibroblasts) are called desmoids or aggressive fibromatoses. Scars built from too much collagen are either hypertrophic scars or keloids. When excessive scars form tight ridges along the skin and permanently interfere with normal movement, they are called contractures.
Hypertrophic scars are caused by excess deposition of collagen fibers in a healing wound. This overactive scar-making process is usually triggered by a prolonged regrowth (proliferative) phase during healing. This happens in burns, infected wounds, and wounds healing under tension. In hypertrophic scars, the excessive formation of collagen usually stops within a few weeks. The result is a scar that is thicker than normal and is raised above the plane of the skin, but unlike a keloid, a hypertrophic scar does not expand out beyond the actual wound. Hypertrophic scars, which usually get smaller spontaneously, can occur anywhere on the body.
Keloids are also caused by the excess deposition of collagen in a healing wound. Keloids, however, are benign tumors, and the tendency to develop keloids is inherited, patients with darkly pigmented skin being particularly susceptible (Wolfram et al., 2009). Unlike hypertrophic scars, keloids develop late in the healing process; they can show up months or even years after the injury. Keloids bulge out beyond the edges of the wound, and some keloids can get sizeable. Keloids, which do not regress spontaneously, are usually found on the upper half of the body.
A keloid scar that developed from a skin wound along the edge of the jaw. The tendency to develop keloids is a genetic trait. (Source: Leonard C. Sperling, MD.)
All scars go through a process of shrinking or contracting. Enlarged scars, however, sometimes contract excessively, becoming disabling or disfiguring ridges of connective tissue called contractures (Kamolz et al., 2009). When contractures form over joints, the scars can make bending difficult or impossible. Disabling contractures most commonly form across finger joints, along the neck, across the axilla, and across the antecubital fossa.
A contracture is a permanent fixture of the skin, and it cannot be repaired by stretching, massaging, or applying ointments, lotions, or creams. The most successful treatment for a contracture is to have it excised surgically. The physician may order physical therapy as part of after-care to prevent another contracture from forming.
More than one classification system exists to describe the phases of wound healing. Two of the most popular systems are:
The stages in both these systems are overlapping and constitute what is also known as the cascade of healing.
In a small clean wound such as a surgical incision, most of the healing processes are quick and take only a few days. In complex wounds, healing can take weeks. In all wounds, the scar matures and becomes stronger over the course of weeks, months, or even years.
The first set of events in wound healing is the reaction phase, which corresponds to the hemostasis and inflammatory phases. In this phase, blood clots seal the wound, creating hemostasis, while a normal inflammatory reaction begins to remove bits of dirt and debris.
This phase begins immediately after an injury, as blood vessels temporarily constrict and blood clotting begins. Soon, the local capillaries become excessively permeable, fluid flows out, and the tissues swell, producing edema. The blood coagulation process releases chemical activators from inside entrapped blood platelets; these activators increase the capillary permeability and attract wandering tissue cells (macrophages) and white blood cells.
The first white blood cells on the scene—polymorphonuclear cells, also called neutrophils—chew up debris and release chemicals that attract more white blood cells. The various biologically active molecules being released into the wound also hypersensitize the endings of local pain nerves, causing them to react to smaller amounts of chemical and mechanical irritation and thus making the wound site tender. Together, these processes produce local inflammation.
In superficial wounds, exudates may harden into a scab. Deep or large wounds, such as ulcerative pressure sores or burns, do not seal during this phase. Instead, the accumulating fluid, cells, and clotting materials form a pale yellowish viscous exudate which dries, forming a crust or, if stringy, a slough.
During this phase, neutrophils remove bacteria and debris. If the wound does not become colonized with bacteria, neutrophils stop entering the wound by about day 2 following the injury. Neutrophils live for less than 24 hours, so in a healthy wound, most neutrophils are gone by about day 3. In infected wounds, however, neutrophils continue to pour in, and as they die, they accumulate to form pus, thus prolonging inflammation.
Under healthy conditions, most of the new cells entering the wound after day 2 are mononuclear cells (monocytes), which are the second wave of white blood cells to migrate into a wound. Monocytes transform into macrophages. Macrophages are scavengers that continue to debride (or cleanse) the wound biologically by removing dead and dying bits of tissue, dirt, and bacteria. Macrophages also release growth factors, chemicals that stimulate the growth of fibroblasts, endothelial cells, and epithelial cells, all of which are players in the next phase of wound healing.
The next set of events in wound healing is the regrowth or proliferative phase. In this phase, new cells grow into the wound and begin to lay down the collagen and other extracellular fibers that will give strength to the scar. At the same time, new blood vessels are growing into the wound. Together, the newly forming cells, blood vessels, and loose extracellular matrix are called granulation tissue. Granulation tissue fills the base of an open wound (e.g., a pressure ulcer) during this phase of wound healing. Healthy granulation tissue contains newly growing blood vessels and should be beefy red with a bumpy, uneven surface.
The phases of wound healing overlap. Thus, even as white blood cells are cleansing the wound area in the latter part of the reaction/inflammatory phase, epithelial cells are moving over the granulation tissue from the cut edges of the wound to begin the regrowth/proliferation phase. These epithelial cells come from germinative cells in the adjacent skin, and the new epithelial cells will eventually give rise to the epidermis covering the scar.
If the granulation tissue is covered with a dry, scabby exudate, the epithelial cells migrate slowly under the scabby exudate, including any remaining blood clots that form the scab, becoming dark colored and rough textured. Eventually, these epithelial cells form the new epidermis and loosen the scab, which will crumble off the top of the scar.
If the granulation tissue is moist, the epithelial cells can move more quickly. For this reason, wounds that are kept moist heal more quickly than those that dry out. This fact forms the basis for the principle of moist wound healing.
When the wound area is not too large, epithelial cells repopulate the entire surface and generate a new epidermal covering; this process is called re-epithelialization. A healthy wound that has been closed (e.g., with sutures) has only a small area to be covered with epidermis, and it will re-epithelialize in less than two days.
When a wound has been re-covered with epithelium, it is impermeable to water. Over the next few days, the new epithelium continues to deepen and differentiate, and eventually, it becomes a typical epidermal layer.
Underneath the growing epithelial layer, the granulation tissue is thickening and solidifying. Within 48 hours after the injury, fibroblasts are filling the granulation tissue and laying down collagen and elastin fibers. Collagen is the principal structural protein of the body, and healthy tissue repair requires that new collagen be synthesized, deposited, and cross-linked (i.e., strengthened). Besides making collagen, fibroblasts also secrete sticky amorphous extracellular matrix molecules, the glycoproteins.
In a healthy wound, fibroblasts begin to fill the wound during days 2 to 4 after an injury. Fibroblasts grow especially well in the low-oxygen/high-lactate environment of a healing wound when it is still covered by an exudate or a scab.
The final set of events in wound healing is the remodeling, or maturational, phase. In this phase, the number of fibroblasts in the new scar decreases and the temporary dense capillary network thins. The scar tissue contracts, edema disappears, and the wounded region continues to strengthen and to adjust to the tensions applied during day-to-day life. This remodeling continues for 6 to 12 months.
As a wound heals, a special class of cells, the myofibroblasts, begins to pull the edges of the wound toward one another. Myofibroblasts are modified fibroblasts. Like fibroblasts, myofibroblasts secrete extracellular molecules. Unlike fibroblasts, however, myofibroblasts can contract like smooth muscle cells. Over a period of 3 to 4 days, the myofibroblasts in the scar contract and slowly shrink the wound (Ethridge et al., 2008).
Wound contraction usually begins after about a week of healing. The contraction is not only a surface phenomenon; the whole thickness of the wound edge is gradually pulled toward the center of the wound. Significant contraction occurs mainly in large wounds, such as ulcers, that are not yet entirely covered by a regrown epithelium.
The new scar is weak for the first five days. Its strength increases markedly over the next month as new collagen is laid down and then cross-linked. Nonetheless, most scars will never be as strong as the original tissues they replace. Scar strengthening and remodeling taper off after about a year.
The steps in the formation of a normal scar offer many opportunities for the process of wound healing to become sidetracked (Habif, 2010; Fonder et al., 2008; Ethridge et al., 2008). Even when all the steps do eventually occur, delays can cause abnormal healing.
Large wounds and wounds in which much tissue has been lost heal slowly and produce larger scars. Wounds containing dirt and debris have more problems healing than cleaner wounds. Poor blood supply to the injured area can slow or even stop the healing process. Of all problems, however, infection is the most common impediment to wound healing.
Infections always obstruct wound healing. Wounds that have been contaminated with significant numbers of bacteria and other foreign material are at risk for developing infections because such wounds are not easily cleansed by the natural scavenging processes of the reaction (inflammatory) phase of healing.
Within hours of an injury, neutrophils and macrophages migrate into the wound and begin removing debris. Large amounts of bacteria, however, cannot be removed within the normal reaction phase. When contamination persists, the influx of white blood cells continues, too. But these neutrophils die after 24 hours, and when they are continuing to infiltrate the wound because of persistent contamination, the dead neutrophils pile up and begin to clog the wound in the form of pus. Pus slows the formation of granulation tissue and the re-epithelialization of the wound, giving bacteria still more time to multiply. Furthermore, many bacteria secrete toxins that add to the tissue damage in the wound when it has become infected.
This sutured laceration (on the knee) may be a normally healing wound still in the inflammatory phase of healing, or it may be the beginning of a wound infection. (Source: Antonio M. de Gordon, MD.)
When bacteria are given enough time, they will build to the level of an infection. It is not always easy to recognize an infected wound in the early stages: to the untrained eye, normal healing can look like a pathologic process. To complicate matters, different types of wounds can show different clusters of signs when they are infected (Lipskey & Hoey, 2009; O’Meara et al., 2008). Nonetheless, all infected wounds will show at least some of the following signs:
Operationally, the dirtier the wound, the more it must be rigorously cleansed to avoid infection.
Antibiotic resistant strains of bacteria are a growing problem in dealing with infected wounds. Wound culturing can be used to determine if the infection is of a resistant strain. In the situation of nonhealing wounds, wound culturing may be necessary. (See “Nonhealing Wounds” later in this course.)
Re-injury can slow or stop wound healing. A new scar is weaker than the adjacent tissue, and the newest scars are the weakest. Pushes and pulls that would have no effect on healthy parts of the body can reopen a healing wound, even when it is protected by a well-made dressing. Similarly, if there is significant skin tension surrounding the wound (e.g., over a bent knee), the healing wound will not be able to seal tightly.
During normal healing, the granulation tissue develops a temporary dense capillary bed to provide sufficient fluid, nutrients, and oxygen to the growing cells. After the reaction (inflammatory) phase, oxygen is especially important for strengthening (i.e., cross-linking) the collagen in the developing connective tissue (Habif, 2010; Ethridge et al., 2008; Fonder et al., 2008). Anything that decreases the effectiveness of the local circulation will impede wound healing and weaken the scar.
Ischemia of a wound can arise from too much physical tension across the wound, ineffective oxygenation of the blood (anemia, lung problems, smoking), or reduced circulation (atherosclerosis, heart failure, kidney failure, vasoconstriction, too much pressure on the wound). Differences in the available blood supplies account, in part, for the fact that facial wounds tend to heal better than foot wounds.
The importance of local circulation to wound healing is reflected in the healthcare maxim “wounds that don’t bleed don’t heal.” Circulation brings oxygen, which aids healing. A wound that continues to bleed, however, is not proceeding to the next step in healing. A crumbling (friable) wound bed is not healing and may indicate infection.
Skin and its underlying tissues are normally under tension. Most skin in the body is being stretched, at least slightly, by the adjacent skin and the underlying structures, but the actual tension at any one location varies along the surface of the body. Movement changes skin tension: bending a joint stretches the overlying skin, while contracting a muscle tends to reduce tension in the overlying skin. Skin creases and skin wrinkles are indications of lines of least tension; on the face, the lines of facial expression are also lines of least tension. As a rule, the lines of least skin tension are perpendicular to the long axis of underlying muscles.
Skin tension is negligible along skin creases, moderate over relaxed joints and muscles, and high over bent joints (knees and elbows) and over the skull. During a cutting, ripping, or puncturing injury, the tension from the adjacent intact skin pulls the free edges of the wound apart. In places where the wounded skin is under greater tension, the wound gapes more widely and heals more slowly, and the resulting scar is relatively large. Obesity increases tension on the abdomen and difficulty due to movement of the panniculus (overhanging folds of subcutaneous fat), particularly to the sides and away from center line.
Lines of least skin tension on the body. The drawing also indicates the areas of the body where skin wounds have the highest risk of infection. (Source: Scott Moses, MD.)
Certain diseases are noted for causing poor wound healing. The most common of the problem diseases is diabetes mellitus. Scars formed by diabetics have less collagen, and the collagen that is laid down is more brittle than normal. Diabetes also damages blood vessels and makes the skin more prone to ischemia. The reduced circulation is especially notable in the feet, and foot wounds are notorious for not healing well in diabetic patients (see image below under “Chronic Nonhealing Wounds”).
To make matters worse, diabetes leads to peripheral neuropathy. Diabetic patients lose sensation in their fingers and toes, so diabetic injuries tend to go unnoticed in the extremities. Finally, diabetics have a weakened inflammatory response, and they are more susceptible than other people to developing tissue infections.
Malnourished people begin to break down their proteins as a source of energy, and this slows healing. Specific vitamin deficiencies also lead to poor wound healing. Vitamin A deficiency impedes the transformation of monocytes into macrophages, which can slow or halt healing. Vitamin C deficiency leads to weak collagen, which is the basis of scurvy. Vitamin K deficiency impairs blood clotting (Posthauer et al., 2010).
As people age, they heal more slowly. In older people, scars form with less and poorer-quality collagen, and older adults are more likely than the young to have wounds that reopen or dehisce (Reddy, 2008).
Patients who smoke have poor wound healing in addition to suffering a number of other skin problems (wrinkling, premature skin aging, higher risks of squamous cell carcinoma, psoriasis, and hair loss [Cao et al., 2011]). Smoking causes vascular constriction, which decreases circulation and leads to chronic wounds.
Patients who are dehydrated may have impaired kidney functions and reduced blood volume, leading to decreased blood pressure and perfusion, which can slow wound healing.
Medical care of wounds is an attempt to overcome obstacles to natural healing. In the course of managing a wound, we reduce the amount of contamination, minimize the area that must be filled by new tissue, keep the granulation tissue moist, and protect the healing area. However, healthcare providers’ efforts at facilitating wound healing sometimes introduce new impediments.
Wounds must be clean before they can safely seal themselves. In an attempt to close wounds quickly, doctors sometimes suture together insufficiently cleansed tissues. This leads to an infection and the dehiscence of the closure.
Another problem in wound closure is the use of suture material that is too thin and subsequently breaks. Sutures that are too thin or that are tied too tightly can also tear through the weakened skin at the edges of the wound.
Finally, if sutures, staples, or tapes are removed too early, the wound edges will not have developed sufficient adhesion, and the wound will reopen.
Certain drugs, solutions, and ointments slow wound healing. Doxorubicin (Adriamycin) given preoperatively inhibits postoperative wound healing. Glucocorticoids (e.g., prednisone) limit the proliferation of fibroblasts and the production of collagen, and thus steroids make scars relatively weak. Some antiseptic solutions (e.g., 10% povidone-iodine, 3% hydrogen peroxide, 0.5% chlorhexidine) can slow wound healing. Hemostatic solutions (e.g., ferric subsulfate, 30% aluminum chloride, silver nitrate) slow the healing of large wounds.
Risks versus benefits in specific circumstances must be evaluated when using the above potentially caustic solutions, and they should be used by an MD/PA/NP or under an MD’s direct supervision. Silver nitrate, for example, has a place in restarting chronic wounds with rolled edges.
Silver sulfadiazine cream is used only in infected wounds. Although early studies showed statistically faster healing rates when Neosporin ointment was used, bacitracin is more commonly used as an antibiotic ointment due to sensitivities to Neosporin. Moisturizing creams such as Eucerin and topical steroids such as triamcinolone should not be used in open wounds.
Ionizing radiation damages actively dividing cells. In wounds, the regrowing epithelium, the newly growing blood vessels, and the fibroblasts that form new connective tissue are likely to be damaged by a large dose of ionizing radiation. Normal x-ray imaging is usually not a problem. Cancer therapies, however, give relatively high doses of ionizing radiation, and in areas of the body exposed to radiation therapy, wounds heal poorly and infections are more common.
Staff and others entering an isolation room should always follow posted signs indicating the type of isolation and implement the appropriate additional protective measures. Disposable isolation gowns are worn with gloves for contact isolation, and masks are added for droplet isolation as well as for reverse isolation to protect patients with decreased immunity. Likewise, special gloves are worn when the patient has just received chemotherapy.
In hospitals, clinics, and medical offices, staff must use specially marked hazardous waste bags and disposal cans for any items grossly contaminated with bodily fluids. The general rule regarding “red-bag” (biohazardous) and ordinary waste is that if it will be wet when collected by the hauling service, it needs to go into the biohazard category. For example, a 4x4 with some blood on its surface that will dry in a few minutes can go into the general waste stream. That same 4x4 soaked and dripping needs to go into biohazard.
There may be differences between federal and state occupational health regulations regarding blood and other infectious material (BOIM) protocols for employees, nurses assistants, nurses, occupational therapists, physical therapists, etc. Such regulations may also be optional for physicians and others who are considered independent contractors.
Precautions and written protocols are for the protection of all caregivers and all patients. It is important to learn and remain up to date on such facility protocols and governmental regulations pertaining to these precautions.
Healthcare workers who will have contact with patients should be screened for infectious diseases (such as tuberculosis) when they are hired, and care should be taken to prevent bringing newly acquired infectious diseases to the workplace or on home visits. They should be up to date on their immunizations; this includes vaccination against measles, rubella, varicella, hepatitis B, and ongoing yearly influenza immunizations. Time frames for screening and immunization vary by state and by employer.
So-called “super bugs” are the scourge of wound care. Resistant strains of bacteria such as multidrug-resistant tuberculosis (MDRTb), MRSA (methicillin-resistant Staphylococcus aureus), and VRE (vancomycin-resistant Escherichia coli) are common in the general population. Along with C. diff (Clostridium difficile), which is easily transmitted via spores, these are the most commonly seen hospital- or clinic-acquired infections among staff as well as among patients. Any patient can also potentially carry the human immunodeficiency virus (HIV).
All personnel working on the first stage of wound care—inspecting, cleansing, closing, and covering—should wear protective eyewear, a surgical mask, and gloves that are not easily ripped. Gloves need to be removed properly away from the patient so any infectious material that becomes airborne does not reinfect the patient. Although they will be wearing face masks, medical personnel who have upper respiratory infections should further protect their patients by not talking or coughing while leaning over wounds.
Primary wound care means acute wound care—managing a wound the first time it is presented to a healthcare professional. Currently, we do not have the technology to repair a wound. Nonetheless, we can remove many obstacles that inhibit the body’s innate wound repair mechanisms.
Before modern medicine, many wounds did not heal. These wounds may have been too big, have involved too great a loss of blood, or have became infected. Today, we can give natural healing mechanisms a much better chance of success because we have the technology to stop serious bleeding, to cleanse the wound well, and to close surgically (or otherwise effectively protect) large wounds.
The procedures of modern wound care in proper order are: inspect, cleanse, close, and cover.
Here is a basic plan for treating acute wounds (Auerbach, 2012; Stone, 2011; Roberts & Hedges, 2011; Irion, 2009; Ethridge et al., 2008).
Wounds can be dramatic, but any life-threatening conditions must be treated first. These are issues related to airway, breathing, and circulation—the ABCs of life support.
After the patient has been stabilized, an inventory of his injuries is taken. The order in which they are to be treated is planned and prioritized, usually by the physician.
Follow the order of the treatment plan. When it is time to treat an external wound, a history is taken, including the cause of the wound and a description of the environment in which it occurred. The history should also include the patient’s chronic illnesses, medical conditions, current medicines, and allergies, as well as the immunization history for tetanus.
The physician (or the RN, nurse practitioner [NP], or physician’s assistant [PA] if protocols provide) inspects the wound, estimating its depth, the degree of contamination, and the internal tissues that are injured, if any. When there are injuries to internal structures (nerves, tendons, bones, muscles, ducts, organs), a surgical specialist is called in by the physician.
The physician or NP/PA next checks for significant neural or vascular damage. Caring for a wound will cause the patient pain; nevertheless, before an anesthetic is given, major nerves or blood vessels are checked for injuries. The injured area and the more distal areas of the body are tested for full sensation, full muscle movement, and adequate circulation. If any major neural or vascular problems are suspected, a surgical specialist is usually notified.
Now, the injured area is anesthetized by the physician. Any major bleeding will already have been stopped. At this point, any continued bleeding is stopped. Hemostasis is obtained by one or more of the following:
For wounds on the extremities, an inflated blood pressure cuff or a purpose-made surgical tourniquet may be used as a controllable tourniquet proximal to the wound.
Prepare the wound field by cleansing the area surrounding the wound, beginning at the center and working outward to avoid introducing additional contamination, clipping any interfering hair, and washing all the adjacent regions with an antiseptic solution. Drape the areas surrounding the wound.
With instruments (not gloved fingers), remove visible debris. If there is a possibility that metallic contaminants or pieces of broken bone have been missed, the wound may be imaged to search for debris. The wound is mechanically debrided, removing devitalized or shredded tissue, by the physician or RN/PT per protocols, state law, and only after specific training.
Then, the wound is irrigated with a warm cleansing solution, such as normal saline. Irrigation may be done by:
Scrubbing a wound by hand is called mechanical scrubbing or mechanical nonspecific debridement. It should only be performed by trained physicians, RNs, or PTs and in accordance with facility protocols. This type of debridement can be painful for the patient, and it may be advisable to administer a local anesthetic and/or an analgesic and/or sedation prior to the procedure. Medication should be administered in advance of the procedure, and the procedure begun only after the onset of action of the drug(s). Mechanical scrubbing with an antiseptic sponge is effective at removing bacteria and debris, but it is also damaging to the wound tissues.
Many cleansing solutions are available for wound irrigation. Sterile 0.9% saline (“normal saline”) is the standard irrigating solution. Another commonly used solution is 1% povidone-iodine (Betadine solution, not 10% Betadine scrub), which is then followed by flushing with sterile 0.9% saline solution.
Other cleansing solutions are not recommended for irrigation. For example, some antiseptic solutions that are very effective on intact skin can be too harsh for wounds (e.g., 5%, 7.5%, or 10% povidone-iodine; chlorhexidine gluconate [Hibiclens]; 3% hydrogen peroxide; alcohols).
After washing the wound, gently pat it dry with sterile gauze, beginning at the center of the wound and working outward, and then wipe the skin around the edges. Making an evidence-based choice on whether to close the wound, and if so, how to close it, can minimize the risk of infection. This choice may also determine the size of the scar.
When deciding about wound closure, physicians take into account the local skin tensions in the area of the wound (see “Local Skin Tension” above). In areas of high skin tension (e.g., on the scalp, along the front of the tibia), the edges of a wound are more easily pulled apart, and the wound gaps in the direction of the greatest tension (perpendicular to the lines of least tension). Skin tension will strain a healing wound, and it will widen the final scar. To achieve the thinnest scars, surgeons make elective incisions in or parallel to skin creases and perpendicular to underlying muscles. Physicians will try to make the long axis of the wound seam parallel to skin creases, perpendicular to underlying muscles, and along the local line of least skin tension.
There are three general plans for wound closures: primary closure, secondary closure, and delayed primary closure (Ethridge et al., 2008; Kimball et al., 2009).
A pressure sore healing by secondary wound closure. Periosteum of bone is visible in the top picture. Healthy granulation tissue covers the wound in the two middle pictures. Healing took several months. (Source: Charlie Goldberg, MD, © Regents of the University of California.)
Choosing among the three closure plans is a balance between protection, risk of infection, and size of the eventual scar. The immediate primary closure of a well-cleansed wound protects it from new contamination and allows the most control over the size and appearance of the final scar. In addition, immediate primary closure protects from drying any exposed deep tissues and structures such as nerves, blood vessels, tendons, or bones.
On the other hand, immediate primary closure of an unclean wound encourages the development of infection. Besides providing a protected environment for bacteria, wounds closed with sutures add new foci for infection, namely, the suture holes, the sutures themselves, and the tissue damaged by the sutures. Clean, unsutured wounds are less likely to become infected than unclean sutured wounds (Kimbell et al., 2009).
Indirect closures heal more slowly than direct closures. A healthy indirect closure provides a longer reaction (inflammatory) phase and a more thorough natural debridement. Moreover, if infection does develop in an indirect closure, there is direct access to the inside of the wound, so it can be debrided, irrigated, and treated with antibiotic.
Healing by secondary intention (i.e., helping a wound to grow closed without surgical closure) is also called open wound management. Certain of these wounds are candidates for negative pressure wound therapy (NPWT) (Ubbiak et al., 2008). Open wound management is considered for wounds that are:
While managing an open wound, the option of closing the wound directly during the first five days still exists. Secondary wound closure is sometimes the best compromise between immediately suturing a wound to prevent a large scar and leaving the wound open to prevent the development of infection. Waiting and watching is often the wisest course.
If the wound is complex, large, chronic, or highly contaminated, wound closure may be delayed by packing the wound with saline-moistened sterile gauze. In certain cases, negative pressure wound therapy (NPWT) is indicated, in which the negative pressure applied to the wound using sponge dressing and vacuum unit speeds healing and closure (Blume et al., 2008).
In wounds with exposed or injured internal structures, such as nerves, joints, or bones, a surgical specialist is consulted before a decision is reached on a closure plan.
For secondary (indirect) closure, the wound is packed and covered with a dressing. It is usually unnecessary to apply antibiotics. The packing material should be sterile fine-mesh gauze moistened with sterile 0.9% saline. The cover dressing should be a dry, thick absorbent sterile pad or pack of gauze pads. (See also the section on negative pressure wound therapy in caring for chronic wounds using this alternate method of secondary wound closure.)
From this point on, open wound management is sometimes an outpatient procedure. The patient, a household member, or a home healthcare nurse is enlisted to repack the wound with saline-moistened sterile gauze and to re-cover it with a dry dressing once each day or as ordered (see instructions below).
Depending on the severity of the infection, the patient may be discharged on either oral or intravenous (IV) antibiotics. In the former case, a registered nurse from a home healthcare agency will be involved in managing the IV medication and the medication delivery system. Although the physician may send a patient home with oral antibiotics, this is usually not necessary.
The wound should be evaluated professionally in 3 to 4 days, which is approximately the time when the healing process in an open wound is making the transition from the late reaction (inflammatory) phase to the regrowth (proliferative) phase. If there is no evidence of infection and if the edges of the wound can be pulled together without too much tension, the physician can then suture the wound closed.
The delay will have allowed time for nonviable tissue to become apparent, and the physician should debride and irrigate the wound again before closing it. A direct closure that has been delayed only a few days will produce a scar not much larger than if the wound had been directly closed immediately.
Even though the bleeding may have stopped earlier, subsequent debridement and cleansing may restart it; therefore, before directly closing a wound, the physician will make certain that all bleeding is stopped. If a hematoma or a seroma forms in a closed wound, it will push the edges apart, slow the healing processes, and increase the chance of infection. (A hematoma is a swelling containing a mass of blood which is usually clotted; a seroma is a clear serum-filled swelling.)
For closing a wound, current options include sutures, staples, tape, and adhesives, or a combination of any of these. Sutures are the best choice for wounds that are being pulled apart by tension from the surrounding tissues and for wounds that require detailed matching of the opposing edges.
Suturing is probably the most widely used direct closure technique, but stapling has become increasingly popular, especially for surgical incisions. When closing a wound with sutures, the edges of the wound layers are aligned carefully and held together strongly. The detailed nature of each wound dictates its particular suturing requirements.
Suturing takes skill and experience. In broad terms, the first step is closing the major deep tissues. Underlying soft tissue may be closed to eliminate dead spaces that may allow hematoma or seroma formation. The final step is closing the skin. The choice between absorbable versus nonabsorbable suture is influenced by considerations such as the strength required, the possibility of scar formation, and the cooperation of the patient with suture removal. To close the skin, jagged wound edges are matched carefully as long as the skin along the edges is still viable. The goal is to align the upper surface of the skin along the scar. Each stitch is gently tightened so that the edges are everted and touching but are not crushed together.
After closure, there should be minimal tension across the wound. Semi-permeable tape strips (e.g., SteriStrips, Clearon Skin Closures) may be placed to further reduce tension across a sutured wound. The physician will leave spaces between the strips of tape to allow fluid and exudate to escape and be absorbed by the overlying dressing.
Staples hold a wound together more strongly than sutures. Staples are also quicker. Moreover, metal staples are nonreactive, and they produce less inflammation and shorter healing times than sutures. On the other hand, metal staples are less comfortable for the patient, and they tend to leave a patterned scar. Metal staples should not be used on facial wounds or other areas where appearance is important.
Metal staples are less reactive than sutures, but they leave a patterned scar. Staples can also be made of absorbable suture-like material that is less scarring. (Source: Incisive Surgical.)
For small, superficial wounds such as minor skin tears, tape or purpose-made skin closures are often better than staples or sutures. They can be applied quickly and without additional anesthesia, pose very little added risk of infection, and are inexpensive. The best tapes for wound closure are nonwoven, unreinforced, and microporous. Tape and tape-like products are not as strong as staples or sutures, and do not work well for gaping wounds or for wounds that will be under tension, such as those across joints. In the case of adhesive allergies or sensitivities, use of skin protectants (such as Cavilon or SkinPrep) may help to reduce sensitivity to adhesives. Or, other closure methods may be selected instead.
To tape a wound closed, first stop all the bleeding and dry the edges of the wound. If the skin is oily or sweaty, wipe it thoroughly; you can even carefully use a solvent such as acetone to wipe the adjacent skin. Closely crop any hair around the wound.
When the adjacent skin is clean and dry, increase its adhesiveness by painting tincture of benzoin on the skin or applying skin protectants alongside the wound. Let the benzoin or skin protectants become tacky before putting on the tape. For skin tears, carefully tease any attached skin flap using a cotton tipped applicator to lay flat onto the open area, reapproximating its edges as much as possible.
Use a pre-cut tape (e.g., SteriStrips or “butterfly”) or cut a piece of sterile adhesive tape to a width of 1/4 inch (0.5 cm). Each strip should be long enough to extend beyond the wound about 1 inch (2.5 cm) on either side. Fix an end of each tape strip onto the skin at one side of the wound and across the wound to the closest area of intact skin.
Place the tape strips in parallel, like railroad ties, across the wound. Space the strips 1/8 inch (0.3 cm) apart to allow for wound drainage. After putting strips across the full length of the wound, lay a single long thin strip of tape along the ends of the cross strips on either side of the wound, like a railroad track on railroad ties. The long strips will help to keep the cross strips from peeling off the skin.
For skin tears, place strips perpendicular to the edge of the skin flap to hold it as closely as possible its original, intact position. This process may mean arranging strips in a semi-circular fashion. Use a cotton-tipped applicator to hold the skin flap in place while placing tape strips.
Tissue glues are ideal for closing small lacerations (Auerbach, 2012). Glues, however, are not as strong as sutures or staples. The decision to use glue is made by the physician or, as per protocols, the RN. In the first-aid setting, both tape and glue are frequently used for closing small lacerations by nonmedical people, as both are easily available.
Glued wounds need extra care: they cannot be immersed in water and they can only be rubbed gently. Glues are also disrupted by petroleum-based ointments and salves, which should not be used on glued wounds. Sometimes tissue glues cause a mild local inflammatory reaction.
Tissue glues slough off spontaneously after about 4 days, by which time the wound has usually healed sufficiently to remain sealed without the glue.
After the wound is closed, the surface is gently cleansed with moistened sterile gauze and the wound is covered with a sterile dressing and a protective bandage. Sutured/stapled wounds may need a nonadherent (e.g., Telfa) and possibly medicated (e.g., Xeroform Telfa) strip laid onto the wound prior to secondary dressing and bandage, depending on physician orders.
For skin tears, a colloidal water-based gel, such as Hydrogel, may be used to augment or replace a missing or incomplete skin flap. Then a dressing and a protective bandage are applied to protect and cover the wound.
Apply topical antibiotics or ointments only as appropriate. Antibiotic ointments are usually not used on a clean wound; they are best used only on infected wounds. Ointments will dissolve tissue glues and should not be put on wounds that have been closed with adhesives. For any wound, do not apply ointments containing corticosteroids, which impede wound healing.
Whether open or closed, the wound is covered with a dressing. A dressing is any covering applied to or over a wound. Dressings keep a healing wound warm and protected. They also keep the wound from drying out, while at the same time absorbing excess fluid and exudate, both of which can slow healing. On the other hand, once a wound is infected, a thick dressing will encourage bacterial growth; therefore, thick or impermeable dressings are not put over infected wounds.
A wound dressing usually has two layers. The primary layer is put directly on the wound surface, and it is used to keep the wound moist. The secondary dressing is the outer layer, and it is used to absorb excess drainage and to protect the wound. Ideally, the full dressing should protect the wound from bacteria and dirt while allowing water vapor to diffuse away from the wound.
A simple traditional dressing (Auerbach, 2012) begins with a primary, nonadherent layer. This may be:
Commonly, moist sterile saline gauze (i.e., moist-to-moist, not wet-to-dry) can also be used, especially if wound filler is needed.
Today, a wide variety of primary dressings are available beyond petrolatum gauze. The many choices of dressings should be considered when noting the type and amount of drainage, any infection present, patient tolerance for dressing changes, and cost/availability.
When choosing, tailor the primary dressing to the amount of drainage expected from the wound. A nondraining wound can be covered with an occlusive (impermeable) or semi-occlusive (semi-permeable) dressing such as a wound film (see the image below of wound film applied to a burn). A wound draining 1 to 2 ml fluid/day needs a semi-occlusive or an absorbent (nonadherent) dressing. A wound draining >3 ml fluid/day should have a very absorbent dressing.
|Wound fillers||Pastes, beads, gels, powders, granular
|Nonocclusive||Alginates (rope or flat)
|Occlusive||Moisture retentive foams
|Composite dressings (two or more dressings combined as one)
(sheet, gel, gauze that is impregnated)
|Transparent thin films||
(adhesive, moldable, wafer)
|Silver (gels or sheets)||
|Bacteriostatic (stop bacteria)||
|Platelet-derived growth factors||
(sheets, gels, pastes, particles)
|Activated charcoal dressing||
|Silicone sheet (with holes)||
|Gauze impregnated with
light oil emulsion
There are frequent changes in the many different companies’ dressings, names, and types, and so it is important to gather up-to-date information on dressing options before selecting a particular dressing. Some major dressing companies include Hollister, Convatec, Medline, 3M, Healthpoint, Johnson and Johnson, and De Royal; this is not a complete listing or intended as a recommendation of one brand over another.
Over the primary dressing, there is a secondary layer of thick, dry sterile gauze. The whole dressing is held in place by tape and/or rolled gauze depending on the contour of the body part.
Self-adherent surgical dressings can be used as a combination of primary/secondary dressing. These dressings are commonly called “island dressings,” as the primary dressing forms an island of dressing within the adhesive or secondary layer of dressing covering and surrounding it.
A bandage—an outer layer of dressing—is used to mechanically protect a wound. Bandages help hold the wound closure in place and can reduce tension across the healing scar. In addition, the compression provided by a bandage will reduce the open space (dead space) in a wound and thus discourage hematomas and edema. Bandages also protect against injuries to the healing wound by providing an additional layer of padding and by reducing the mobility of the wound area.
Surgical bandages can be made of pads or of cotton overlaid with tape. On the limbs, bandages can be made using an elastic wrap or gauze wrap. All bandages should be smooth and unwrinkled and should apply pressure equally across a wound. Fix the bandage in place with tape, minimizing tape directly on skin, and make sure it feels firm, but do not make the bandage so tight that it impedes circulation.
Consider securing dressings with a gauze roll rather than tape if the patient’s skin is fragile due to age or coexisting diseases such as diabetes or vascular impairment.
In general, changing a dressing daily allows for assessment of the condition of the wound and progress of the healing process. If there is a large amount of wound drainage or infection, dressing changes can be done more often than daily.
Changing dressings provides the opportunity to assess the appropriateness of the dressing. For wounds with minimal drainage, some dressings can last for a week before being changed depending on the location of the wound and activity type and level of the patient. Wounds with significant drainage should have secondary dressings that are sufficiently absorbent to back up the primary dressing in case of overflow of wound exudates. This may require extra gauze pads, sponges, or cotton.
Wounds require being at body temperature for healing to occur. It is important to be aware that any time spent in changing a dressing, or even cleansing the wound, will cool down the wound, which can then take several hours to come back up to body temperature after being re-covered. This may slow the healing process.
Repeatedly moving a wound by contracting nearby muscles will slow wound healing and increase the size of the eventual scar, so any nontrivial wound that is in a part of the body near a joint may be immobilized.
On the extremities, an injured area may be immobilized by splinting the nearby joints. Plastic or aluminum splints can sometimes be added to the outer bandages of a wound. Otherwise, a separate splint may be placed along the joint. At times, a plaster cast may be needed. Also available are joint immobilizers, which can be soft (like a sling) or rigid (like a knee brace).
Any splinting, etc., of joints is brief, and joints are more quickly mobilized currently than previously to prevent contractures or “frozen joints.” Other equipment may be utilized, especially by physical therapists, (i.e., CPM [continuous passive-motion machines]) to slowly move joints in an effort to avoid contractures/stiffening of joints.
Tetanus prophylaxis, rabies prophylaxis, or systemic antibiotics may be ordered in some circumstances.
For nonsurgical wounds, protection against tetanus must always be considered. Tetanus is a neurologic disease resulting from the poison produced by Clostridium tetani bacteria. This toxin causes uncontrollable, continuous muscle contractions. Even in the best hospital settings, tetanus has a fatality rate of 10% or more (Tiwari et al., 2011). For adults, the CDC recommends a routine booster dose of tetanus toxoid–containing vaccine every 10 years. Detailed, up-to-date recommendations for wound prophylaxis can be found on the CDC website (see “Resources” at the end of this course).
For tetanus prophylaxis, wounds are divided into two categories: clean minor wounds and major and/or tetanus-prone wounds. Clean-minor wounds are small, open lacerations made by clean objects in clean environments (e.g., an accidental cut with a clean scalpel) and are not considered tetanus-prone wounds. Major and/or tetanus-prone wounds include:
TETANUS PROPHYLAXIS DURING WOUND CARE (adults aged 19–64 years)
If the patient has had a complete three-dose primary series of tetanus immunizations and has had:
If the patient has not had a complete three-dose primary series of tetanus immunizations (or if primary immunization status is unknown):
All bites by mammals should be considered for rabies prophylaxis. Rabies is a viral disease with a typical incubation period of 1 to 3 months. Once symptoms appear, the disease is almost 100% fatal; therefore, prophylactic treatment of bites from potentially rabid animals is essential (Manning et al., 2008).
Rabies is most common in bats, raccoons, and skunks, and the disease is transmitted in saliva. Most human cases of rabies have come from bat bites. All mammals (and only mammals) can potentially be infected with rabies. Some increased risk factors include:
The decision to begin rabies prophylaxis depends mainly on the type of animal that caused the bite. Most patients will be able to state what bit them and whether the bite was provoked or unprovoked. Local public health officials or the CDC 24-hour rabies hotline can provide advice about rabies risk according to the location of the biting animal (see “Resources” at the end of this course). Public health officials will also try to find the animal if there is any chance that it might be rabid.
Rabies prophylaxis can be begun after the wound has been cared for, so there is time to consult and to make a well-informed decision. Physicians or other facility staff can call the hotline according to facility protocols.
People who may have been infected with rabies virus need both active and passive immunization. Active immunization comes from a 5-dose course of rabies vaccine injections; the effect begins within 7 to 10 days and lasts at least 2 years. Passive (direct) immunization comes from an injection of anti-rabies immune globulin; the effect begins immediately and lasts for a few weeks (Manning et al., 2008). Consult with local public officials and review the latest CDC recommendations for rabies prophylaxis.
The rule is to err on the side of caution. If prophylaxis has been started and subsequent tests find that the offending animal did not have rabies, the treatment regimen can always be stopped safely.
Although systemic antibiotics are often given to patients with acute wounds, most clinicians argue that antibiotics should only be given with a specific purpose in mind. Surgically, all open, fresh, accidental, or penetrating wounds are considered to be potentially contaminated wounds, and some physicians use this as a reason for giving anti–skin flora antibiotics such as cefazolin. On the other hand, emergency department physicians usually flag only certain wounds for systemic antibiotic prophylaxis (Stone & Humphries, 2011; Roberts & Hedges, 2009; Irion, 2009).
Wounds at high risk for infection commonly treated with systemic antibiotics include:
Systemic antibiotics are best given as early as possible during wound treatment, and the first dose should be administered intravenously or intramuscularly. There is no one standard antibiotic regimen for wounds at high risk of infection, and there is no universal agreement on how long the antibiotic prophylaxis should last. Consideration must be given regarding the new strains of bacteria that are resistant to the more commonly used antibiotics. In some cases, wound culturing and sensitivity testing is used if resistant bacteria are suspected.
For minimizing the risk of infection, systemic antibiotics cannot replace debridement and irrigation. If systemic antibiotic prophylaxis is ordered, the wound will probably be treated with indirect or delayed direct wound closure.
The basic wound care techniques detailed above need to be tailored to the particulars of each individual wound. Following are some cautions, changes, and additional techniques for specific types of wounds (Auerbach, 2012; Stone & Humphries, 2011; Roberts & Hedges, 2009; Irion, 2009).
Serious burns require treatment in a specialized burn center. Chemical and electrical burns should also be treated at a burn center. The following discussion is about the treatment of minor burns (Rosen et al., 2010).
To be considered a minor burn, the area injured must be a single small patch of the body outside of the hands, face, feet, armpits, popliteal region, or perineum. A minor burn cannot be across a major joint, and it cannot be in a band extending around any part of the body.
Infants, older adults, and patients with major medical problems may need to be hospitalized for burns that would otherwise seem minor. Burns may continue to worsen, especially in the case of radiation therapy burns, which can arise one week after treatment ends or as long as 20 years later.
RULE OF NINES
In estimating the percentage of the body that has been burned, one formula frequently used is termed the “rule of nines,” in which areas of the body’s surface are divided into 9% (or factors of 9%) of the total body surface area.
In the adult:
In the child:
Minor burns are limited to first- and second-degree burns. First-degree burns, such as sunburns, are called epidermal burns because the damage is mainly to the outermost layer of the skin. Epidermal burns are red and painful, but they do not blister. After about 2 days, the injured epidermis in a first-degree burn sloughs off (“peels”) as new epithelium grows underneath the damaged tissue.
Second-degree burns are called partial-thickness burns because they involve injury to the epidermis and part of the dermis. Partial-thickness burns form blisters, usually beginning a few hours after the injury. The tissue under these blisters is moist and pink, and it is extremely sensitive; even air currents can be painful. Superficial partial-thickness burns, in which the epidermis and the top portion of the dermis is affected, will heal in 2 to 3 weeks, leaving minor scarring with a lighter pigmentation than the surrounding skin. Deeper partial-thickness burns, involving epidermis and large portions of dermis tissue, will heal in 3 to 6 weeks and will leave significant scars.
Full-thickness burns are third-degree burns. They go all the way through the dermis, and they require treatment in a specialized burn center. In the emergency room, it can be difficult to distinguish between partial-thickness burns and full-thickness burns. Here are some general rules (Rosen et al., 2010; Malik, 2010):
In second-degree burn wounds, collapsed burn blisters can turn into protected areas in which bacteria can grow, causing an infection. The MD/PA/NP will make the decision to drain burn blisters or to leave them intact. Small burn blisters and burn blisters on the palms or soles are usually left intact. Large burn blisters and those over mobile joints are usually opened, and the blister roof is entirely removed by the physician. The open surface is then re-irrigated. Before beginning, pain control should be given, as partial thickness burns can be very painful and even sensitive to air flow.
As always, any mechanical or surgical debridement is done by physicians or specially trained nurses and physical therapists according to facility protocols.
Aseptic technique should be followed at all times due to the susceptibility of burns to infection. Gloves are to be worn and changed after removing old dressings, after cleansing the burn, and especially when applying new dressings. All old dressing materials, gloves, and items used in cleaning should be disposed of as bio-hazardous waste. These methods also protect the caregiver, as body fluids from the patient may carry contagious diseases.
A new burn should be cleansed immediately with cold tap water. A strong stream of cold water will lower the temperature in the burned area, irrigate the injury, reduce the pain, minimize edema, and slow some of the developing damage. Do not use ice or ice water, however (Rosen et al., 2010).
Dressings for burns should keep the wound moist and absorb excess exuded fluids. When the dressing is of a type that must be changed regularly, the dressing should not be allowed to stick to the wound.
First-degree wounds are irrigated and then overlaid with a nonadherent dressing, such as petrolatum-impregnated gauze. Second-degree wounds are covered in one of three ways:
This second-degree burn on the back of the hand has been debrided, washed, and covered with a synthetic occlusive dressing. (Source: Ross Bailey, Texas Christian University.)
Provide tetanus prophylaxis as ordered. Systemic antibiotics are not usually ordered for most minor burns. Second-degree burns remain painful, and oral analgesics (e.g., codeine, oxycodone) are usually prescribed. A reexamination is scheduled in 1 to 2 days. In the interim, when the burn is on an extremity, advise the patient to keep the extremity elevated to minimize edema. Describe the signs and symptoms of infection to the patient and advise him or her to report any problems immediately.
At the reexamination, remove the outer coverings (using sterile techniques) and inspect the innermost dressing. If the primary dressing is adherent to a fairly dry, pink wound bed, leave the primary dressing in place, following physician orders. Usually, physician orders will call for a new secondary dressing over the primary and to schedule another wound check in 5 to 7 days.
If the primary dressing is no longer sticking, if the wound is draining fluid, or if the wound looks infected, then remove the entire dressing. The physician may then choose to irrigate and debride the wound and treat the specific wound (Stone & Humphries, 2011; Irion, 2009; Roberts & Hedges, 2009).
When first- or second-degree burns have healed, the patient should moisturize the burn area once or twice daily with lotions, creams, or ointments and protect the area when outdoors, using clothing, hat, and gloves.
All animal bites pose a risk of infection (Manning et al., 2008; Patronek & Slavinski, 2009). The most critical piece of information about a bite wound is the type of animal that inflicted it. This will guide your choice of prophylactic medicines.
Bites by adult humans are some of the most serious. Human bites can transmit HIV and hepatitis, along with a variety of necrotizing bacteria. In addition, human bites are both crushing and tearing and are often made to the hand, where they injure tendons and joints.
Due to possible criminal proceedings or litigation, chain of custody may need to be followed for anything that might be considered as evidence. After protocols for appropriate authorities have been satisfied, examine the bite wound, noting underlying fractures and damage to tendons, ligaments, or joints. Finding tooth fragments is also a possibility. Photograph and label any tooth fragments, as appropriate.
Patients do not always get immediate medical care for bites. Those who present after a delay often do so because they already have signs and symptoms of infection. If an old bite wound shows evidence of a necrotizing infection—such as progressing redness, blistering, or blackened dying tissue—the patient should be hospitalized for extensive debridement and IV antibiotics.
The best way to prevent infection in bite wounds is aggressive cleansing. Then the wound is debrided as necessary by specially trained RNs/PTs or the physician and irrigated thoroughly.
Dog bites are typically a mix of lacerations and crushes, producing significant destruction to the tissues. These bites can require sharp debridement, ideally within a few hours of the injury. By contrast, cat bites produce deep, narrow puncture wounds, and the primary organism, pasteurella, grows rapidly, leading to a significant infection in a short period of time.
Whether to suture a bite wound is frequently a judgment call. Other than human and monkey bites, most bite wounds are minor, and of these, only about 10% will need suturing.
Of the serious bites, those with a high risk of infection are left open, packed, and watched. Human, monkey, and cat bites are always cleansed and left open. Dog bites to the hands, dog bite puncture wounds, and dog bites that crush tissues are usually left open. All bite wounds older than 6 to 12 hours are left open. In addition, bites to the hand, ear, or other areas in which tendon, joints, or cartilage are likely to have been injured are left open. All will be covered by an appropriate dressing.
Other large bites are cleansed vigorously and sutured by the physician to prevent new microbes from invading the deeper tissues.
For a bite wound, tetanus prophylaxis is always considered by the physician. For mammalian bites, rabies prophylaxis is also considered (see above). For a human bite, victims are considered for prophylactic treatments for HIV and for viral hepatitis if there is a chance the attacker was a carrier (not having symptoms but able to transmit virus). Human bites do not transmit HIV through saliva alone; blood inoculation is necessary. Hepatitis B has been transmitted by a human bite, possibly through infected saliva. (For recent CDC recommendations for HIV and hepatitis B prophylaxis, see “Resources” at the end of this course.)
As to prophylaxis for other organisms, systemic antibiotics are usually ordered for bite wounds that are not medically treated until 6 or more hours after the injury, for bites to the face, and for bites that have injured deep tissues such as tendons, joints, and bones. Antibiotic prophylaxis is ordered for all human bites. Bites by cats are deep puncture wounds and carry an especially high risk of infection; therefore, antibiotic prophylaxis is usually ordered for most cat bites. Dog bites to the hands, dog bite puncture wounds, and dog bites that have crushed tissue are also treated with prophylactic antibiotics.
A culture of the wound will not immediately identify an organism likely to cause an infection or its antibiotic susceptibility. The presumptively appropriate antibiotic is chosen by the type of animal that made the bite and later changed if necessary based on the results of the culture and sensitivity results. Many bites will include various species of staphylococcus, streptococcus, and corynebacterium. Dog bites are also associated with Capnocytophaga canimorsus, cat bites with Bartonella henselae and Pasteurella multocida, and rat bites with Streptobacillus moniliformis and Spirillum minus.
An infectious disease specialist may be consulted to decide on the proper prophylaxis or antibiotic treatment for a specific case.
Patients who present with an infected bite wound, especially when there is a necrotizing infection, will be hospitalized for treatment, including parenteral antibiotics. Likewise, bite wounds that include tendon, joint, cartilage, or bone injuries are to be treated in a hospital.
If a bite wound victim is treated and sent home, the patient should be told to keep the injured part elevated and immobilized and to monitor the wound for signs of infection. The wound should be professionally examined daily for the first 3 days and then every second day for two more visits.
Puncture wounds, especially of the foot, are commonly seen in emergency departments. Puncture wounds are difficult to cleanse and are prone to infection (Auerbach, 2012; Rosen et al., 2010).
The tissue is infiltrated with 1% lidocaine.
It is usually not possible to cleanse a deep puncture wound fully. Forceps are used to probe gently and then to remove debris. Puncture wounds in the hands, wrists, feet, or ankles can be near critical tendons, nerves, or muscles; to avoid damaging these structures, these wounds are not probed extensively. In other parts of the body, the top of the wound can be carefully opened (“unroofed”) to cleanse it more thoroughly. If the history suggests there may be internal debris, such as shattered glass or bits of metal, radiologic images are ordered to identify foreign objects.
Coring out (excising) or other forms of major debridement are only used when a puncture wound has a great deal of contamination or an existing infection.
The wound is irrigated under low pressure. Too much direct pressure will force contamination deeper into the tissues.
If the wound is wide enough (e.g., if it has been unroofed), it may be packed open with moist sterile gauze. Otherwise, it is simply covered with a protective dressing. In all cases, the wound is to be professionally reexamined in 2 to 3 days.
Be sure the patient is up-to-date with tetanus immunizations (see “Tetanus Prophylaxis” box above).
Even medically treated puncture wounds have a high rate of bacterial infection, frequently by Pseudomonas species. For this reason, anti-Pseudomonas cephalosporins, such as ceftazidime (intramuscular) or ciprofloxacin (oral), are often prescribed prophylactically.
It is hard to predict how well a puncture wound will heal, so a professional examination of the wound is scheduled in 2 to 3 days. Give the patient a list of the signs and symptoms of infection and instruct him or her to report to a medical professional if any problems develop.
The patient should keep wounded extremities elevated and should not put pressure on the wound (e.g., walking on an injured foot) until after the first follow-up examination.
If tenderness or infection is found in a puncture wound during a follow-up visit, cellulitis, septic arthritis, abscess, and osteomyelitis are considered. Imaging, including local bone scans, may be needed for a proper diagnosis of an infected puncture wound, and consulting a specialist is the best course of action.
High-velocity military weapons and shotguns produce severe blast injuries and extensive tissue damage. Such wounds require surgical debridement, irrigation, and sometimes fracture treatment. These patients need to be hospitalized and given at least 24 to 48 hours of IV antibiotics. On the other hand, low-velocity minor gunshot wounds can often be treated as outpatient cases, even when the wound includes minor fractures and retained bullet fragments (Tintinalli, 2011). In general, minor gunshot wounds are treated as puncture wounds.
Once a determination of a gunshot has been made, notification of appropriate authorities is required by law and should be accomplished in compliance with facility protocols.
The tissue is infiltrated with 1% lidocaine, and the wound is imaged for bullet fragments and for evidence of internal structural damage.
After protocols for appropriate notification have been satisfied, the surface tissue is debrided of powder burns by the physician/NP/PA or by a specifically trained RN according to facility protocols. Unless radiographic images show bullet fragments that are easily accessible, the wound should not be explored deeply for debris. Special care is taken when exploring wounds in the hands, wrists, feet, or ankles. Excising the wound is rarely a good plan for gunshot injuries. Photographs and samples should be taken and handled to maintain chain of custody of possible evidence.
When a gunshot wound creates a complete tunnel through the body (a “through-and-through” wound), the wound is irrigated with high pressure. If the wound does not have an exit, the wound is irrigated under low pressure; too much direct pressure can force contamination deeper into the tissues.
If the wound includes bone fractures or involvement of tendons, ligaments, and/or nerves, an orthopedic surgeon is consulted. Otherwise, the wound is packed and left open by the physician and covered with a protective dressing.
Unlike other types of puncture wounds, minor gunshot wounds have a low infection rate. In general, antibiotic prophylaxis is not needed.
The patient should be advised to keep a wounded extremity elevated and should not put pressure on the wound (e.g., walking on an injured foot) until after the first follow-up examination. Give the patient a list of the signs and symptoms of infection and instruct him or her to report to a medical professional if any problems develop. A professional reexamination of the wound should be scheduled in 1 to 2 days.
Small wounds of the tongue and the mucosa of the mouth heal quickly. Larger wounds may require the attention of an oral surgeon.
The teeth near the wound are examined because they may be loose or fractured. Radiographs of the jaws may be ordered if the nature of the injury and/or the patient’s signs and symptoms suggest bony involvement. Comparison to previous dental images, either at the time of injury or on follow-up visits, may be useful if they are available.
Small lacerations will probably not need closing. Large wounds and wounds involving underlying structures need to be repaired. After thorough irrigation with saline, the muscles are reapproximated with absorbable sutures (e.g., 5-0 Vicryl) by the physician. Then, with a minimum number of absorbable sutures, the overlying mucosa is closed. For wounds with extensive damage, an oral surgeon is consulted by the physician.
Wounds limited to the inside of the mouth are slightly more likely to become infected than similar external wounds. When the wound penetrates through to the outside skin, however, the infection rate doubles. Prophylactic antibiotics are prescribed for large or complex wounds inside the mouth and for penetrating (through-and-through) wounds.
The patient should be instructed to rinse the wound with warm salt water (1/2 teaspoon salt to 4 ounces of water) 2 to 3 times daily.
After their primary treatment, most patients with external wounds can be sent home. At that point, secondary wound care begins, and its success depends on the cooperation of the patient.
It is important to take time to explain what the patient can expect over the next few days and what things the patient should do. If the patient, family, and/or family surrogates have little or no English proficiency, written and verbal instructions should be provided in the appropriate language per facility protocols.
Any serious or infection-prone wound must be reexamined professionally in a few days. Schedule the follow-up examination before discharging the patient and ensure that the patient is aware of and apparently able to keep the appointment.
If a wound is complex or prone to infection (such as a bite wound), schedule the patient to have the wound reexamined by a professional in 1 or 2 days. Wounds that have been left open and that are being considered for a delayed closure are to be reexamined in 4 to 5 days. Otherwise, schedule a return visit for suture, staple, or tape removal and have the patient monitor the wound and report to a healthcare professional any signs of infection, any re-injury, or any other problems.
The patient will be given specific guidelines for recognizing an infected wound, but not all patients will be able to use these guidelines effectively. If it is suspected that the patient may not recognize an infected wound, a reexamination is scheduled in 2 to 3 days.
The proper time to remove wound sutures is decided case by case. A general timetable is:
Staples can usually be removed somewhat earlier than sutures. If any absorbable sutures have been used, inform the patient that these will not need to be removed.
TEACHING PATIENTS WHAT TO EXPECT
Patients should be told what to expect during and after wound healing. Some helpful information to give a patient includes:
A written set of instructions explaining how to care for the healing wound is given to the patient. Included in instructions are signs and symptoms of an infected wound and instructions regarding showering, bathing, and swimming. Healthcare facilities generally develop protocol-based preprinted instruction sheets for each specific type of wound.
Patients should be instructed on watching for signs and symptoms of an infected wound. These include:
Elevating the injured area will minimize swelling, reduce any throbbing pain, and speed up healing. If the wound is on an arm or a leg, tell the patient to try to keep the injured area elevated during the first 2 days. For injuries to the hand or forearm, the patient should consider wearing a sling.
Tell the patient:
Patients with wounds will probably be sent home with a protective dressing. Minor wounds and many sutured or stapled wounds will not need these coverings after 2 days. The coverings can then be discarded and the wound left uncovered. If there is drainage, the wound is best covered.
In most cases, patient’s can be advised that when treating the wound, cleanliness is needed but sterility is not.
A sutured or stapled wound without a dressing can be cleansed gently twice a day with soap and water, beginning 2 days after the suturing or stapling. A major goal of these washings is to remove the crusting that develops from the wound exudate. Such a wound can remain uncovered starting on day 3.
When the wound is inside the mouth, have the patient rinse the injured area at least 3 times daily with warm normal saline solution (9% saline).
For wounds that need continued covering, for the first 2 days at home, the patient should keep the wound dressing clean and dry and change the dressing only if it gets dirty or becomes saturated with exudate. Beginning on day 3, the wound can be cleansed and the dressing changed daily. After a week, most of these wounds can be left uncovered.
CHANGING A DRESSING AT HOME
In the first 1 to 2 weeks, patients should not take aspirin or other nonsteroidal anti-inflammatory drugs such as ibuprophen (Advil, Motrin) or naproxen (Alleve) because these decrease the strength of the scar and increase the risk of developing a hematoma. Patients on low-dose (81 mg, once daily) aspirin therapy or any therapeutic anticoagulant medication need to have their risks and benefits assessed by the physician on a case-by-case basis.
As alcohol may interfere with or interact with medications given, such as antibiotics and analgesics, and may increase bleeding, patients should be informed on an individual basis as to alcohol consumption.
For serious, infected, and nonhealing wounds, a professional should handle the secondary care.
As a general rule, wait 48 hours before the first dressing change unless the dressing becomes saturated with wound exudate. After the first dressing change, change the dressing when it becomes dirty or saturated with wound drainage or other fluid. In order to heal or to continue healing, the wound must be at body temperature. Frequent dressing changes allow the wound temperature to drop and slow the healing process by the amount of time wound temperature takes to return to normal body temperature. Be sure to follow MD/NP/PA orders as written.
When a dressing becomes filled with fluid, microbes can diffuse through it and into the underlying wound. Therefore, any wound coverings that become saturated with drainage need to be changed. Dressings over heavily draining wounds may have to be changed frequently. Wounds can be reassessed at any dressing change to update the type of dressing needed to control drainage. Be sure to get orders for any new dressings to be used.
A dressing change includes gently removing the dressings, cleansing the wound as ordered (usually using sterile water or normal 0.9% saline), patting the wound dry, applying any skin protectant needed for periwound skin, as ordered, and putting on a fresh dressing. If the dressing sticks to the wound during removal, replace it with a less adherent type of primary dressing. Be sure to have the orders changed accordingly.
On Monday morning home health nurse Judy arrives at the home of patient John for her usual appointment to change the dressing on a stage III coccyx pressure ulcer. She has been working with John’s stalled, old wound for 2 weeks and brings in the dressing materials she has been using per MD orders. As she turns and repositions the bedbound patient to change his dressing, she notices serosanguineous drainage spots on the bed linen and the saturated dressing. She knows this wound has had only scant serous drainage prior to today.
After cleansing and measuring the wound, noting a reddened bumpy wound bed, Judy places sterile 4 x 4s in the wound and phones the MD. She gives a detailed description of the wound and the amount and nature of the discharge, informing the MD of the difference from the previous visit’s wound bed and drainage. After discussing with the MD her ideas for a new dressing, Judy receives orders for a two-layer, more absorptive dressing. She charts all the above, including lack of odor and lack of periwound erythema, along with the patient’s vital signs.
Granulation tissue is the loose collection of fibroblasts, inflammatory cells, and new blood vessels that forms in the bed of open wounds during the regrowth (proliferation) phase of healing. Healthy granulation tissue looks beefy red with bumpy, irregular surfaces. Epithelial cells use granulation tissue as a surface to move along as they re-cover the wound. The regrowth (proliferation) phase usually lasts between 4–24 days. When wounds are left open to heal by indirect closure, the regrowth phase is prolonged.
Sometimes, in any wound, especially those for which growth factors or other healing stimulants have been used, the granulation tissue has sufficient time to overgrow the top of the wound and become a barrier to the growing epithelial cells. Excess granulation tissue (also called exuberant granulation tissue, or hypergranulation) forms most often in scalp, temple, and lower leg wounds.
For a wound to heal properly, excess granulation tissue should be removed. Debridement can be a painful process; prior to any tissue removal, the patient should be medicated for pain. To clear the wound, the physician or an RN/PT with specific training will scrape out the granulation tissue down to the bed of the wound, level with the surrounding skin. Then, the wound is irrigated. Excess granulation tissue can be treated with silver nitrate, but this caustic substance should be handled with care by a physician or specially trained RN/PT.
Hypergranulation can also be corrected by changing the cause, which can be added growth factors, etc., or excessive moisture in the wound. Finally, the wound is protected with sterile gauze (Habif, 2010) and/or covered with an appropriate sterile dressing per physician orders.
The edges of a closed wound must be held together long enough for a strong natural seal to form. If sutures or staples are removed too early, the wound will reopen (dehisce), and the final scar will be unnecessarily wide. When planning to remove staples or sutures, first remove one or two and check the strength of the developing seal between the skin edges. If the seal seems too weak to stay closed without help, or if the wound is on a point of high stress (such as a major joint), replace the removed sutures or staples with tape strips.
Also check for the healing ridge by feeling alongside each side of the incision. The healing ridge extends approximately 1 cm on each side of the wound and becomes evident 5–9 days after closure for up to 15 days. This ridge indicates new collagen synthesis and is felt as an area of tissue firmness (induration) under the skin.
When preparing to remove sutures or staples:
To remove sutures:
If sutures have been left in place too long (usually >10 days), they will leave holes (epithelial tracts) that can become infected and that may heal with an unsightly pattern of scars. If small abscesses develop in the epithelial tracts, inform the MD/PA/NP and apply warm moist compresses after the sutures have been removed. The abscesses should clear quickly, and antibiotics are rarely needed.
When the suturing has been complicated—such as when nonabsorbable subcuticular (under the skin) sutures have been used or when there are special cosmetic requirements—an experienced professional should decide on the removal schedule and should then carry out the removal. In the hospital setting, the physician/NP/PA will give orders to remove sutures/staples.
Staples can usually be removed using a wound staple remover somewhat sooner than sutures. When staples are removed from any part of the body, they are often replaced with tape strips to continue protecting the healing seam.
Technique is important for good results. Assess first for bent/crooked/ingrown staples. Reassure the patient that removal is not painful but that a small amount of discomfort is to be expected. Counting the number of sutures/staples as removed can be important if the initial number of sutures/staples is known.
Scars are the natural patches produced in a healing wound. In the skin, scars are made of unspecialized fibrous tissue covered by a layer of epidermis (Habif, 2010).
In the first few days after an injury, closed skin wounds are being knit weakly together by the forming scar tissue. By about day 5, the basic architecture of the wound patch has been established, and from then on, the healing process consists largely of strengthening and remodeling the scar.
Scars can take 6 to 9 months to mature. New scars tend to be red and thick for a month or two before gradually become less vascular (i.e., paler), less bulky, and flat. It can take as long as 5 years for a scar to reach its final color.
The width of the scar can be minimized by thorough debridement, by careful suturing (avoiding inversion of the skin edges), by removing excess granulation tissue, by good secondary wound care (especially by keeping the wound from becoming infected), and by removing sutures promptly.
Some maturing scars manufacture too much collagen. These scars are either keloids or hypertrophic scars. Keloids are benign tumors that grow beyond the bounds of the wound and do not regress. The tendency to form keloids is genetic, and there are, at present, no preventive measures. (See image of a keloid scar earlier in the course.)
In contrast, hypertrophic scars, which are thick but do not grow outside the edges of the wound, usually get smaller spontaneously. Hypertrophic scars are produced in wounds that are under tension, such as those parallel to underlying muscles. By reducing the tension on a wound, hypertrophic scars can often be prevented or minimized.
Hypertrophic scars are also produced in wounds that have a long reaction (inflammatory) healing phase an in which re-epithelialization has been delayed, such as is the case in many burn wounds. For burn patients, continuous pressure (constant pressure lasting 6 to 12 months) can help to reshape and flatten hypertrophic scars. Specialized secondary pressure dressings are available for hypertrophic-susceptible and burned areas such as the face and hands.
Infected wounds become red, warm, tender, and swollen; they may ooze pus and have a disagreeable smell (Rosen et al., 2010; Ethridge et al., 2008). If a closed wound becomes infected, the physician may decide to remove the sutures, staples, tape, or glue and to reexamine the wound for debris. Once the wound is open and its true condition evident, a treatment plan can be developed.
In the case of an infection involving a large proportion of the wound and/or extending into deeper tissue or structures than the original wound, the patient may need an extensive debridement, done under anesthesia in the controlled environment of the operating room.
In the case of less extensive infection, wound care may be done in the office/clinic setting or at bedside in the hospital. The wound is irrigated and packed with moist sterile gauze, covering the wound with the appropriate secondary dressing. Apply warm compresses if ordered. The physician will order the appropriate antibiotics to be given. Recleanse and repack the wound at least once daily, as per physician orders, and plan to let the wound heal by secondary intention, without closure.
If patients develop sepsis (blood poisoning), they must be hospitalized. Sepsis is an inflammatory response to infection, including fever or hypothermia, tachycardia (rapid heart rate), and decreased blood flow to internal organs. If untreated, sepsis may lead to shock, altered mental status, organ failure, jaundice, and death.
Some wounds that have been sutured closed over extensive subcutaneous tissue dissection and debridement can develop a temporary inflammatory reaction in which they become red and edematous although they are not infected. If the MD/PA/NP suspects this problem, he or she may remove one or two stitches or staples to lessen the tension, gently expressing or aspirating any fluids, pack the area with sterile gauze, and then cover with the appropriate dressing. In this case, cleanse the wound daily and pack/apply dressings as per physician instructions. This type of inflammatory reaction will decrease within 48 hours.
Chronic wounds are those that fail to heal when expected. Usually these wounds are stalled in the inflammatory (late reaction) phase (see figure below). Large wounds heal slowly, but even large wounds typically heal within 3 to 4 months.
A chronic nonhealing ulcer on the foot of a diabetic patient. (Source: Frank DiMauro, MD, University of North Carolina.)
Wounds do not heal well if they are infected, edematous, or ischemic. In chronic nonhealing wounds, these problems are often secondary to broader health disorders, such as diabetes, venous blockage, arterial insufficiency, malnutrition, cigarette smoking, or excess alcohol consumption. Therefore, when dealing with a chronic wound, begin by assessing the entire person, with the goal of improving overall health. Meanwhile, find and facilitate work on the specific direct impediments to the healing of the wound (Fonder et al., 2008; Kurd et al., 2009; Khanolkar et al., 2008; Faglia et al., 2009).
The wound bed can give clues as to the basic approach to a chronic wound.
Report any of the above findings to the practitioner for orders on how to proceed.
Wounds that refuse to heal after special care may have unusual infections such as fungi or have developed destructive processes such as carcinomas. When a wound resists healing, consider having it cultured and biopsied (Lipsky & Hoey, 2009). When culturing a wound, the wound should first be cleansed with NS (0.9% normal saline) or sterile water and patted dry. Cleansing eliminates normal skin flora from the wound. Any new exudates coming from the wound should be cultured using a wound culture swab at the deepest area of the wound or where most of the exudate is found.
All open wounds contain some bacteria, but ulcers and other chronic wounds frequently have an excess bacterial burden, even when the surrounding tissue has not developed overt infection (cellulitis). Moreover, given sufficient time, chronic wound bacteria become coated with polysaccharides that form a biofilm that keeps antibiotics at bay. Therefore, many chronic wounds need a new debridement followed by thorough irrigation (Attinger et al, 2010; Mote & Malay, 2010; Cardinal et al., 2009).
Debridement appears to help any chronic wound that has not produced much granulation tissue (Paul et al., 2009; Fonder et al., 2008); the classic treatment for most chronic wounds is debride, irrigate, pack with moist gauze, and leave open for natural (indirect) closure. The wound is covered with the appropriate dressing as per MD/PA/NP orders.
Selective debridement is usually preferred over nonselective, as nonselective debridement may remove new cell growth as well as slough and eschar.
Autolytic debridement is a highly selective but slow form of debridement. Autolysis involves the body’s own macrophages and enzymes to selectively reduce eschar and necrotic tissue from healthy tissue. Using dressings which retain moisture (such as hydrocolloids, transparent films, and hydrogels) allows a moist environment for this natural debridement process to occur. Benefits are that autolytic debridement does not require special training and is the safest form of debridement (Ethridge et al., 2008). Autolytic debridement is contraindicated in patients with compromised immunity or if a wound has a large amount of necrotic tissue, is infected, or is a large pressure ulcer with undermining.
Enzymatic debridement using a collagenase enzyme applied to necrotic tissue areas can be effective, but it is only to be used when there is no urgent clinical need for removal of necrotic tissue. The same contraindications apply as in autolytic debridement. This type of debridement is used mostly for small-area debridement.
Biological/biosurgical debridement (maggot therapy) uses sterile maggots applied to the wound bed. These larvae produce a mixture of enzymes and broad spectrum antimicrobials. This method is faster than autolytic or applied enzyme debridement and is selective, but some level of discomfort can be noted. While wild maggots are never recommended, many people are uncomfortable with even the sterile maggots provided by medical supply companies. Maggot therapy is only to be used where permitted and carried out by specially trained physicians/RNs/PTs (Margolin & Gialanella, 2010; Paul et al., 2009).
Do not use maggot therapy where blood vessels are exposed, in acute infections, in wounds requiring frequent inspections (maggot therapy usually lasts 1–3 days, but sometimes may last up to 4–5 days.), in wounds with necrosis of bones or tendons, or in areas with low circulation that impairs healing.
Sharp/surgical debridement is by far the fastest method of debridement but can be practiced only by certified healthcare professionals who are specially trained in this procedure. It requires sterile instruments and aseptic technique and should always be preceded by pain control and patient consents (Dryburgh et al., 2008).
Acute wounds may need only initial debridement along with removal of debris, but research on chronic wounds shows added benefits of sharp debridement in removing slough and eschar in the base of the wound, as well as nonmigrating hyperproliferative rolled edges (epibole) that have stalled the wound healing process (Cardinal et al., 2009; Etheridge et al., 2008).
Use with caution in immune or vascular compromised patients. Sharp debridement is contraindicated with anticoagulant therapy, bleeding disorders, or if stable, hard, dry eschar exists in ischemic limbs (Dryburgh et al., 2008; Faglia et al., 2009). Where there is eschar, assess wound daily for edema, malodor, tenderness, erythema, or crepitance. If any of these conditions are found, consult a vascular surgeon urgently. If these symptoms exist and debridement is approved by the patient and consistent with goals of care, sharp debridement can be performed cautiously.
Physical Therapist Steve receives an MD order to “remove any slough and eschar” from a stalled chronic wound on a patient in the hospital “using a scalpel” (sharp debridement). Steve knows he does not have training and certification as per his state’s law to perform sharp debridement, even with an MD order. He also knows that his hospital has not yet set up protocols for anyone other than MDs to perform sharp debridement. Steve calls the MD and explains that he does not have training and certification to perform sharp debridement. He also states that to his knowledge there is no protocol at the hospital for anyone but MDs to perform sharp debridement. The MD states she will come to the bedside of the patient with this wound, perform the debridement, and write wound care orders for the patient.
Pressure ulcers (formerly known as decubitus ulcers or bedsores) are the most common type of chronic wound in the hospital or long-term care setting (Bluestein & Javaheri, 2008). In a pressure ulcer, injury is caused by local ischemia from the continuous compression of capillaries. This compression happens when a patient has been lying or sitting on any surface without turning or being turned frequently and without pressure redistribution techniques (e.g., repositioning the patient frequently, use of pillows to “float” heels, propping the patient at a 30-degree angle to avoid pressure to major pressure points, etc.).
Patients at risk for pressure ulcers are identified when entering the hospital, and appropriate beds/mattresses and other standard pressure redistribution techniques are utilized.
A pressure ulcer is usually worse than it appears from the surface. Skin is more resistant to pressure than is underlying tissue, and in a pressure ulcer a small skin wound can be the top of a larger injury in the subcutaneous tissue and muscle below. As the deeper tissues break down, hidden pockets form, and these spaces will shelter bacteria from superficial cleansings (Stekelenberg et al., 2008).
Pressure ulcers usually need debridement, irrigation, packing with moist gauze or specialty dressings, and coverage using appropriate bandage per MD/PA/NP orders. As with other wounds, appropriate dressings are chosen based on the amount of exudate and appropriate absorbency. Frequency of dressing changes is based on the type and availability of dressing chosen. Most orders also allow for dressing changes as needed for strikethrough drainage (Reddy et al., 2008).
Also important is the use of techniques for redistribution of pressure and of special mattresses for patients at risk for pressure ulcers (Stechmiller et al., 2008).
Medicare Denies Payment for Avoidable Pressure Ulcers
Beginning in October 2008, Medicare no longer reimburses healthcare facilities for costs of treatment of avoidable pressure ulcers acquired during the patient’s stay in the facility. This underscores the importance of vigilance and prompt attention when signs of these ulcers first arise.
Unavoidable pressure ulcers are seen as those for which all known and appropriate measures have been taken to avoid development of a pressure ulcer on the documented, noncompliant patient (or on a patient who is dying who has skin organ failure), or worsening of a documented suspected deep tissue injury, which will naturally evolve from preexisting damage to underlying soft tissue due to pressure or shear into externalized damage, such as a blister or even eschar.
Three types of lower extremity ulcers are commonly seen in hospitals, clinics, and home health settings: arterial ulcers, venous leg ulcers, and diabetic/neuropathic ulcers.
Arterial ulcers are found on patients with peripheral artery disease (PAD), a decrease of blood flow in the arteries. These arteries become blocked or narrowed, which reduces blood flow to the extremities first, especially the lower extremities. Arterial ulcers are caused by ischemia, oxygen and nutrient deprivation, and as a result of decreased circulation. Additional predisposing factors are diabetes and advanced age.
Arterial ulcers are usually found on tips of toes, between the toes, over the phalangeal heads just proximal to the toes, at sites subjected to pressure or rubbing of shoes, and around the outer (lateral) malleolus.
Wounds characteristic of arterial ulcers have even margins with a “punched out” look. The wound bed is pale and deep. Tissue around the wound is blanched or purpuric (having some purplish mottling). Exudates from these wounds are minimal, if any. Toenails are usually thickened, and there is loss of hair to the thin, shiny skin on the ankle and foot. Temperature to the lower extremities will be decreased and toe/pedal pulses will be diminished or absent.
Patients complain of pain that progresses as PAD increases, from episodic (intermittent claudication, or cramping in the lower extremity, which stops about 10 minutes after activity stops) to nocturnal or postural pain (i.e., when extremities are elevated) to resting pain (which occurs in any position and may eventually develop necrosis gangrene). PAD patients may hang a foot off the edge of the bed or will sit up with legs down to stop postural pain. The lower extremities will pale on elevation but display dependent rubor (redness) when down.
At the last stage of PAD, pain is severe, as is the arterial blockage. Cellulitis (infection of the connective tissue of the skin) may develop. As the tissue dies, necrosis begins at the tip of the toes. Gangrene then develops. A distinct line between gangrenous and healthy tissue, as a result of the inflammation caused by irritation from the dead tissue, is an important diagnostic feature of dry gangrene. Gangrene is dark brown to black, with tissue forming a hard mass. If untreated, the gangrenous portions eventually will separate, and the toe will be lost. If unstable (wet) gangrene is present, it will progress, causing extreme pain and destroying more tissue.
Treatment is to improve circulation to the lower extremities by stent placement in blocked arteries (which is temporary at best and usually done on patients who are not good surgical candidates) or revascularization by means of arterial bypass grafting. Only then can true progress be made by treating wounds locally. Otherwise, ulceration and gangrene is progressive and leads to amputation if circulation is not corrected. The best diagnosis of this condition is the angiogram/arteriogram. Usually, ankle-brachial index (ABI) is determined using a Doppler prior to the invasive angiogram.
If stable gangrene is present, the area must be kept dry, with no debridement. Tincture of benzoin, skin prep, or alcohol is painted onto the area and allowed to dry. If unstable gangrene is present, sharp debridement is necessary. Due to lack of circulation, infection is difficult to resolve using antibiotics. Care must be taken to avoid pressure or rubbing of extremities by ill-fitting, tight shoes.
Patient Eugene comes into the clinic for a routine checkup. Eugene tells RN Mary of pain in his legs, stating the pain keeps him awake at night. As RN Mary shows the patient to an exam room, she asks if the pain occurs at any other time and how long he has had the problem. Eugene states he also has the pain when he sits in his recliner and leans back with his feet elevated. In the exam room Mary asks Eugene if she can see his legs and feet. Upon quick examination Mary notes an open area on the tip of Eugene’s right great toe and on his right inner malleolus. She also notes the cool temperature of his leg compared to the other leg and less hair at his right ankle compared to the left leg.
RN Mary recognizes these symptoms as possible early arterial insufficiency with possible arterial leg and toe ulcers. She informs the NP of these symptoms and the NP performs an ABI (ankle brachial index) test to determine if Eugene might have arterial insufficiency.
Venous leg ulcers, also commonly called venous stasis ulcers because of the pooling of blood in the veins, are a result of venous insufficiency in which blood leaks backwards in the veins, stagnating in the lower extremities. The most commonly held theory of the cause of this problem is damage to the valves of the lower extremity veins. A buildup of fluids in the lower extremity and leakage of blood into the tissues creates hemosiderin staining, which is a darkened, brownish discoloration to the lower leg.
Venous hypertension, obesity, history of DVT (deep vein thrombosis), decreased activity, pregnancy, advanced age, and congestive heart failure (CHF) are all risk factors for the development of venous ulcers. There may be some evidence of previously healed ulcers.
Wound margins are irregular, and the wounds are superficial, with fine slough. Exudate from these wounds is frequently moderate to heavy. Wound bed tissue is ruddy with granular texture. Venous ulcers usually occur on the medial (inner) leg, ankle, and medial malleolar area. The patient may feel moderate to little pain, which may be relieved by elevating the lower extremities. The skin surrounding the wound may be scaling and weeping (but can be thin and dry). If left untreated, venous ulcers will continue and get larger. In patients with advanced venous stasis, firm edema may be present and will resist compression. Physician orders must be obtained for all dressings, as usual.
Compression therapy is usually indicated, consisting of wrapping the leg in a particular fashion, with compression usually greatest at the ankle and least at the calf. Compression therapy is contraindicated in patients with CHF. The patient is instructed to elevate the legs as much as possible. An ankle/brachial index (ABI) is determined, and the degree of compression is established based on the score. The greater the score (up to 0.9), the higher the pressure of compression wrapping. If the patient is nonambulatory, the compression wrap is designed to be higher at rest. If the patient is ambulatory, the pressure is lower at rest and higher for the calf, called the working pressure, when the patient walks. Physician orders will specify the type of compression to be used. If the wound is heavily infected, compression will not be used until infection is resolved.
For topical wound care of venous ulcers, dry eschar is usually debrided by sharp/surgical or enzymatic debridement (scoring of tough eschar facilitates enzyme penetration). Slough to the wound bed can be debrided with enzyme. If the wound bed is red and granulated, maintain a moist, not wet, environment. If bacterial levels are high, silver products, topical antiseptics, cadexomer iodine, or antimicrobial dressings may be used. Skin replacements are used successfully on venous ulcers. If the exudate is minimal, foam type dressings may be used; but if the exudate is heavy, absorptive dressings (such as alginate), specialty absorptive dressings, or NPWT may be used. Scaly, dry peri-wound skin may respond well to moisturizers or Vaseline-impregnated gauze dressings.
Some patients may have a mixture of both arterial insufficiency and venous insufficiency. ABIs in these cases will be 0.6–0.8. In the case of mixed arterial/venous insufficiency, topical management is still governed by the amount of exudate, but skin replacements may not be successful.
Patients with uncontrolled diabetes for a long time eventually develop neuropathies (diseases of the nervous system). Most common is peripheral neuropathy, causing decreased sensation mainly in the legs and feet. If care is not taken to monitor feet and to wear proper footwear, problems with the feet may occur in patients with diabetes. If peripheral neuropathy develops, even the smallest unnoticed foot wound may become a diabetic ulcer.
Diabetic/neuropathic ulcers are usually found on the plantar (sole) aspect of the foot, under the heel, over the metatarsal heads, or on the toes (see image earlier in this course). Margins of these wounds are even, and the wound bed is deep. There may be granular tissue present unless the patient has peripheral vascular disease (PVD). Exudate (drainage) from the wound is low to moderate. A characteristic callous surrounding the wound bed may be present and indicates that the patient has not offloaded but has continued to walk on the foot. The foot may be warm but with diminished or absent feeling. There will frequently be foot deformities with moderate to good pulses. There may be atrophy of subcutaneous fat.
Sharp debridement of the wound and surrounding callous tissue is important to the management of these ulcers. Thorough, deep debridement as much as necessary is indicated. Frequent debridement is routine, commonly done weekly. Any dry, stable eschar is left intact, but unstable necrotic tissue is removed as completely as possible.
After debridement, with a granulating wound bed, dressings should support moist wound healing and should not be occlusive, as diabetic wounds have a high risk for infection. If the wound is infected, silver products or cadexomer iodine are appropriate as primary dressings. Once infection is resolved, topical growth factor that is human platelet-derived or other biological wound coverings (skin replacements) may be effective.
Off loading is imperative; use of special boots, cut-outs, and dressings for protection is appropriate. Daily foot inspection is important, especially between toes. Lotions to feet are good for dryness, but never between the toes. Moisture between toes can lead to skin breakdown and/or fungal infections. Osteomyelitis occurs in 60% of diabetic foot ulcers, as infection spreads easily from foot ulcer soft tissue to the foot bones.
Some chronic wounds become stalled in the reaction (inflammatory) phase of healing (Reddy et al., 2008; Bluestein & Javaheri, 2008). Typically, these wounds exude fluid that is low in constructive molecules, such as growth factors, and high in destructive molecules, such as proteases (Beidler et al., 2008; International Consensus, 2011). The destructive factors constantly impede the construction of the extracellular matrix that is the foundation of healthy granulation tissue. To get healing back on track, the excess fluid produced by these wounds must be wicked away.
Negative-pressure dressings (also called vacuum-assisted closure devices or sub-atmospheric pressure dressings) are labor-saving devices that remove excess fluid from wounds while improving healing time (Blume et al., 2008; Ubbiak et al., 2008). A negative-pressure dressing is made of a special sponge (or with some units, gauze dressing) fitted into the wound and covered by a special plastic film. A suction tube is applied through a hole made in the plastic film and connected to the sponge or gauze via a disc. When the NPWT unit is turned on, a vacuum is applied to the tube, and it continuously sucks fluid from the wound. The vacuum also pulls the plastic film tightly over the top of the wound, sealing the wound from the environment, protecting the wound from outside contaminants, and keeping the wound warm.
In addition to removing excess wound fluid, reducing the growth medium for bacteria, and removing wound inhibitory factors, a negative-pressure dressing encourages contraction of the wound and granulation around the wound, reducing edema, encouraging development of local circulation, and providing more oxygen and nutrients to the cells. The pull of negative pressure on cells has been demonstrated to stimulate new cell growth. Studies show NPWT to be very effective early in treatment of deep pressure sores by reducing the depth of the sore via granulation and also as an aid to healing of chronic pressure ulcers.
For complex wounds, it may be necessary to continue use of negative-pressure for as long as 3 weeks. NPWT dressings are usually changed every 48–72 hours and sometimes more frequently for heavily infected wounds or heavily exudating wounds, depending on MD orders (NPUAP, 2009; Blume et al., 2008; Ubbiak et al., 2008).
FDA GUIDELINES FOR NPWT USE
In February 2011 the FDA issued updated guidelines on avoiding serious complications in the use of NPWT:
In the hospital, RN Sherry’s patient complains of new pain at the dehiscence site where the negative pressure wound therapy (NPWT) dressing is in place. Looking at the larger volume of fluid collected in the canister than that of the previous day, and the bright red color of the larger amount of fluid in the collection tubing, Sherry becomes alarmed.
Sherry calls the MD to alert him to the situation. The MD orders the NPWT halted and an H & H bloodwork lab drawn, and arrives at the patient’s bedside within one half hour after Sherry’s call. The H & H shows a marked decrease in hemoglobin level over the previous day’s test. The physician applies pressure over the area using sterile gauze 4 x 4s after removing the NPWT dressing and orders further tests.
Skin grafts, even when they are not permanent, can help some recalcitrant wounds to heal. Artificial skin, laboratory-grown skin, skin substitutes, and growth factors are more commonly available now to cover, protect, and facilitate the healing of wounds that are not able to epithelialize themselves (American Burn Association, 2009). In addition, the application of constructive biochemical molecules such as growth factors has proved useful in inducing healing in chronic wounds (Barber et al., 2008; Demidova-Rice et al., 2011). Solutions of these molecules are becoming more widely available.
E-Stim is the use of an electrical current to transfer energy to a wound. It is used in stalled or dry wounds to mimic the body’s bioelectrical system “current of injury,” which occurs when first wounded and can jump-start or speed up the wound healing. E-Stim essentially reinitiates the inflammatory process of healing. Electrodes are placed in moist wound bed and on moist skin a distance away from the wound to complete the circuit.
Effects attributed to E-Stim include increased oxygen and nutrient transport to the wound, reduction of edema and pain, and increased fibroblast and collagen development. It may be useful for pressure ulcers, venous ulcers, surgical wounds, donor sites, burn wounds, and others. E-Stim is not to be used in presence of a cardiac pacemaker, malignancy, osteomyelitis, and when electrodes would be placed near the heart, larynx, carotid sinus, and other areas. Physical therapists usually administer this treatment.
Ultrasound is used to increase the elasticity of collagen, decrease muscle and joint stiffness, decrease pain and muscle spasms, decrease edema, increase O2 transport, and accelerate wound healing. US is used on chronic wounds, pressure ulcers, venous ulcers, and trauma wounds. It is not indicated in cases of infection, osteomyelitis, profuse bleeding, severe arterial insufficiency, or necrotic wounds.
Healthcare professionals who advise patients over the telephone should know straightforward answers to basic questions. Here are a few important questions and answers about taking care of external wounds. Avoid anecdotal information and stay with approved guidelines to avoid liability issues.
Q:When do I need to get medical treatment for a wound?
A:Wounds that can be treated at home are:
Wounds that should be checked by a doctor are:
Q:My little boy fell off his bicycle. He doesn’t have any cuts, but he has scrapes on his leg and a big bruise that is swollen. How should I take care of it?
A:Wash the scrape well with soap and water. Ice packs will reduce the swelling. Even when there are no cuts, a bruise tells you that there is some injury inside the leg. A big bruise can indicate damage to a bone or a joint, especially when the area is swelling. Therefore, take your child to a doctor, clinic, or hospital as soon as possible.
Q:What should I do if I am bitten?
A:You should see a doctor immediately. In addition, notify the police so that the animal can be watched for signs of disease. Bites by people can be extremely serious, so don’t delay seeing a doctor.
Q:I have a cut, but it doesn’t seem too deep. How should I take care of it?
A:First, stop the bleeding. Press directly on the cut with your hand for 5 or 6 minutes. Try to keep the wounded part elevated; rest it on a table or a chair and don’t let it hang down. If after 6 minutes the wound is still bleeding freely, see a doctor.
When the bleeding has stopped, wash the wound thoroughly with mild soap and a strong stream of tap water. Let the water flood the wound as rapidly as possible for at least 3 minutes. Pat the area dry. Look to see if there is any dirt or debris inside. If you see anything in the wound, continue trying to wash it out with tap water. If you cannot get the wound clean, try scrubbing it gently and then wash it again under strong tap water. If the wound remains dirty, see a doctor.
At this point, if you have a clean wound with only a very small amount of bleeding, coat the wound with an antibiotic ointment, such as Neosporin or triple antibiotic ointment. Then put a sterile gauze pad or a large bandage over the ointment.
Keep the injured area elevated as much as possible, and do not put pressure on it for the first day. If the wound begins bleeding again, see a doctor.
Over the next few days, watch for these signs and symptoms of infection:
If these or any other unusual things happen, see a doctor. Otherwise, you can take the bandage off after 2 days. The healing wound will not be very strong for about 5 days, so protect it for the rest of the week.
Q:What should I do for a burn?
A:A serious burn needs immediate medical care. Electrical and chemical burns always need medical attention. Burns that injure more than one place on your body and burns on your hands, face, feet, armpits, or groin need to be seen immediately. Any burns to babies or children or to older adults need medical attention. Finally, if you have any medical conditions (such as diabetes) or if you take any drugs (such as prednisone) that make it harder for your body to heal, then get medical help for your burn.
If you have a small burn, immediately put the wound under a strong stream of cold running water for a minute or two; then run cold water on the injury for another 10 minutes at a slower speed. Cold water will reduce the damage of a burn, and it will keep down the swelling, lessen the pain, and wash the wound. Do not use ice or ice water, which can cause further damage. After washing the wound, put cool, wet compresses on it. To ease the pain, apply an over-the-counter sunburn ointment that contains the anesthetic lidocaine; avoid ointments with benzocaine.
Minor burns, such as sunburn, will make your skin red but will not cause blisters. After a day or two, the injured skin will peel off and there will be new healthy skin underneath without a noticeable scar. If blisters develop on a burn wound, see a doctor.
Q:How do I know if a wound is infected?
A:See a doctor if you have any of these signs and symptoms of an infection:
Q:How long should a wound hurt?
A:This depends on the size and type of wound, but a wound that is healing should hurt less and less each day.
Q:I have been bitten by an animal. Will I get rabies?
A:If you are bitten by an unknown or sick animal, see a doctor immediately.
In most places in the United States, rabies is uncommon. In theory, though, any bite by a mammal (cat, dog, bat, raccoon, skunk, rat, etc.) can transmit rabies to a person. Small pets, such as mice, gerbils, hamsters, and guinea pigs, almost never have rabies. Pet dogs, cats, and rabbits rarely have rabies.
Wild animals and strays have a higher chance of having rabies, especially if the animal attacks you for no reason. It is important to describe to the doctor and to the police what kind of animal bit you and what was happening when you were bitten. The doctor can then decide whether you need protective medicines. People who get protective medicines will not develop rabies even when they have been bitten by an animal with the disease.
Q:What kind of treatment will I get in an emergency room for a wound?
A:The doctor or nurse will examine your injury. They will numb the pain and then cleanse the wound of debris and injured tissue. They may take x-rays to search for any debris they could not see and to check for broken bones. Cleansing solution will be sprayed into the wound to wash it thoroughly. Then, either the wound will be stitched closed or it will be filled with moist sterile gauze and covered with a bandage.
You may be given antibiotics to protect against infection, and you may get a shot to protect against tetanus. Except for very serious injuries, you will probably be sent home with instructions for taking care of your wound. You may also be scheduled for a wound check-up in a few days.
Q:Does aloe lotion help a wound to heal?
A:Rubbing herbal medicines made from the aloe vera plant on wounds is a common home remedy. Scientific studies show that aloe preparations do not help infected wounds to heal. The wound should be covered with a dressing to keep it from drying.
CDC: Recommendations for hepatitis B prophylaxis
CDC: Recommendations for prophylaxis for those with HIV
CDC: Recommendations for rabies prophylaxis
CDC: Recommendations for tetanus prophylaxis
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