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Health Topic:  WOUND CARE

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WOUND CARE

  DESCRIPTION
 
A wound is any break in the skin, such as a surgical incision or an accidental injury that results in tissue injury.  This topic deals with the immediate care of an accidental wound and the ongoing care of an accidental or surgical wound.

  OVERVIEW
 
Wounds resulting from injury include abrasions, lacerations, and puncture wounds.  Trauma may also result in a jagged edge or tearing tissue injury.  Abrasions are wounds to the skin that scrape the skin; they may go through the epidermis, and occasionally the dermis.  A surgical incision is the intentional disruption of normal structural continuity made with a cutting instrument, such as a scalpel or trochar.  It results in a straight edge or puncture wound.
 
The skin is the body's first line of defense and helps protect the body from environmental factors such as bacteria, viruses, fungi, extremes of temperatures, and other factors.  The skin is made up of two layers, the epidermis and the dermis.  The epidermis is the outer part of the skin.  Under this is the dermis, which is primarily connective tissue attached to the epidermis.  Under the skin is the superficial fascia layer that encloses the subcutaneous tissue.

A break in the skin's integrity, from either an injury or surgical incision, leaves it susceptible to infection.  Skin infections range from localized, superficial infections to severe systemic, life-threatening infections.  The signs and symptoms vary depending on the site, cause, and the extent of the infection.

The wound healing process involves several stages including coagulation, inflammation, collagen metabolism, wound contraction, and epithelization.  Delaying any of these stages can result in a weak closure and dehiscence.  The appearance of any resulting scar can be affected if the healing process is prolonged.  Immediately after a wound occurs, the wound edges retract, but over the next three to four days, the edges contract, moving toward the center of the wound, as part of the normal healing process.  This is not the same contraction that results in a visible contracture with scar shortening.
 
Factors that adversely affect wound healing include malnutrition, advanced age, obesity, use of steroids and chemotherapy, and conditions such as diabetes mellitus, immunosuppression and chronic renal failure.  Other factors that may contribute to wound infections from an accidental wound include: an injury that is not treated within  four to eight hours, contamination with devitalized tissue, foreign matter, saliva, soil, or feces; blunt or crush injury; high-velocity missile injuries; and a high risk wound location such as the hand, foot or lower extremity.  The material used to repair a wound, whether it is with sutures, staples, tape, or tissue adhesion can contribute to an infection, some more than others.

Wound healing occurs by primary, secondary, or tertiary intention.  Primary or first intention wound healing is the immediate therapeutic closure of a wound and occurs when there is minimum tissue loss and the wound edges are smooth and can be closely approximated, i.e., a surgical wound.  Secondary intention or spontaneous wound healing is when the wound is intentionally left open and is utilized for wounds with excessive contamination.  Sometimes a person may choose not to seek medical care for a wound, and that wound also closes by secondary intention.  The wound edges close with epithelization and contraction of the wound.  Tertiary intention or delayed primary closure is utilized for wounds that are known to be contaminated and likely to become infected.  The wound is left open and treated with multiple debridements and sometimes antibiotics, and then is closed after four to five days

An acute wound usually regains 30 percent of its strength by three weeks.  It may take six months for the wound to regain 90 percent of its strength.

Suture materials for closing incisions and lacerations are chosen by their properties.  Suture can be monofilament or braided, and can be made from cotton, silk, catgut, or several synthetic materials including nylon, Dacron, and polypropylene.  Monofilament is most common for skin closure as it causes less tissue reaction, and is more comfortable for the patient.  Absorbable sutures do not have to be removed, but offer less tensile strength than non-absorbable.  A suture is considered absorbable if it starts to break down within 60 days of placement.  Most sutures used for closure of skin are non-absorbable and have to be removed after a certain period of time.  The most common suture materials for closing of the skin include nylon and prolene and sometimes silk.  Silk causes tissue reaction, but is easy to work with, is comfortable for the patient, and has good tensile strength.  Nylon and prolene have memory, and spring back to their original shape when released.  For this reason, they are difficult to work with, and sometimes require several more knots than sutures like silk to keep them from untying and releasing.

Other materials used for closure of the skin include tape, staples, and tissue adhesives.  Tape is very easy to work with, but does not afford a nicely approximated scar.  Tape does not usually need to be removed.  Staples cause very little tissue reaction, but are not always comfortable for the patient, and have to be removed, which is also uncomfortable.  They have good strength, when used on a linear wound, but do not offer accurate approximation.  Tissue adhesive is the newest of closure materials.  Tissue adhesive is easy to place, is sometimes used with sutures, and provides for a neat accurate approximation of the skin.  It does not have good tensile strength, so cannot be used in areas where there is tension on the wound.  If used with a subcuticular absorbable suture, more tensile strength is offered, but still considerably less than with regular sutures.  Tissue adhesives do not need to be removed, provide their own dressing for the wound, and appear to be antibacterial reducing the chance of infection.  The disadvantage to tissue adhesives is that the patient cannot go swimming with tissue adhesive in place, and ointments cannot be used on the wound.

  CLINICAL PRESENTATION
 
Some wounds can be cleansed at home and a clean dressing applied.  Other wounds require consultation with a healthcare provider including:

  *    Bleeding continues after ten minutes of direct pressure, or comes in spurts
*    Laceration is gaping, deep, or jagged
*    Laceration is one inch or longer
*    Laceration is over a joint
*    Wound can not be cleaned, is very dirty, or has a foreign body embedded
*    Laceration on face or any cosmetic concern
*    Abrasion that covers a large area
*    Loss of mobility or sensation accompanying the injury
*    Tetanus immunization not up to date
*    Puncture wounds
*    Laceration on hand and concern about permanent loss of function
 
  MANAGEMENT
 
Proper care of minor wounds is necessary to avoid infection and other complications.  The first action is to stop bleeding by applying firm pressure with a gauze pad or a clean cloth.  A puncture wound should be allowed to bleed momentarily without direct pressure to help flush the wound.  All wounds need to be cleaned by allowing cool water to run over the wound or washing gently with a clean wet washcloth.  Soapy water can be used around, but not in the cut.  The wound area should not be scrubbed vigorously.  Alcohol or hydrogen peroxide should not be used to clean a wound, as they may cause tissue damage.
 
Wounds not requiring medical attention can be held together with a thin strip or two of tape to keep the edges close together.  If there is doubt about the necessity for sutures or stitches, a healthcare provider should be consulted.  The quicker the wound is sutured, the better the healing and the less the chance of infection.
 
All wounds that have been treated by a healthcare provider should be cared for according to the provider's instructions.  Wounds cleaned and taped at home can be cared for using the following guidelines:

  *    Wash the hands before caring for any wound
*    Elevate an injured extremity above the heart for the first 24 to 48 hours following the injury.  Elevation helps to reduce the edema and pain, in addition to speeding the healing process
*    Cover suture or staple closed wounds for the first 24 to 48 hours.  If the wound is in an area likely to get dirty, such as a hand or foot, a dressing may be necessary for several days
*    Showering is usually safe after 24 hours, even if the wound gets wet
*    Clean the wound gently every day to remove debris and crusting.  Wounds should not be vigorously scrubbed.
*    Change the dressing at least once a day
*    Scalp wounds without a dressing can usually be gently rinsed a few hours after the wound is closed, and can be washed after one or two days
*    No bathing or swimming is allowed for wounds closed with tissue adhesive or tape strips, showering is permitted.  The area should be gently blotted dry.
*    No ointment should be used on wounds closed with adhesive.
 
Wounds from surgery should be cared for following home care instructions provided by the surgeon.  Wound care usually includes keeping the incision clean and dry for the first 24 hours.  After that brief water exposure is typically allowed (as in a shower or bath with the wound out of the water).  The incision should be patted dry.  Wash hands thoroughly before a dressing change.  Dressings should be discarded in a paper or plastic bag.  If bleeding occurs, pressure with a clean dry gauze should be applied until the bleeding stops.  If the wound continues to bleed for more than ten minutes, the surgeon should be called.

Suture or staple removal times vary depending on the location of a laceration, skin tension, blood supply, healing rates, and cosmetic reasons.  Face sutures are usually removed in three to five days, but tape strips may be applied for a few more days.  Scalp and trunk sutures are usually removed in seven to ten days.  Sutures or staples in areas subject to high tension, such as joints, are left in place for ten to fourteen days.

Steri-strips are usually left on until they fall off.  If they haven't fallen after two weeks, they should be removed.  Tissue adhesive will usually fall off in five to ten days.  The adhesive must not be scratched or picked at.

  POTENTIAL COMPLICATIONS/HEALTH RISKS
 
Wounds exposed to the sun can become red, while scars that have not been exposed to the sun usually turn white after a period of time.  During and following wound healing, sun or a tanning booth exposure should be avoided.

Infection is always a possibility with any wound.  Some animal bites are especially prone to infection.  For this reason, cat bites are not usually closed.  Dog bites may or may not be closed.  The sooner a wound is cared for, the less likely there will be an infection.  Inflammation with redness and edema around the area are a part of healing.  If there are signs or symptoms of an infection, a healthcare provider should be consulted.  It can be difficult to distinguish inflammation from infection.  Signs and symptoms of wound infection include:
 
  *    Localized redness, warmth, and swelling
*    Increasing pain
*    Purulent or foul smelling drainage
*    Red streaks extending out from wound
*    Fever over 101.5 F (38.6 C)
 
  PREVENTION/SCREENING
 
Everyone must be protected from tetanus.  If it is needed, immunization against tetanus should be given as soon as possible after a wound occurs, usually with 72 hours.  Following a wound, tetanus immunization is indicated for the following:

  *    No immunization against tetanus ever, or incomplete series of immunizations
*    10 years since the last immunization
*    More than five years since the last immunization, and the wound is dirty (dirt, soil, saliva or feces in wound)
*    It is unknown when, or if the tetanus immunization has been given
 
Wounds caused by animal bites may make an individual susceptible to rabies.  If there is a strong suspicion the animal may have had rabies, a series of rabies immunizations may be required.  Immunization can be avoided if a domesticated animal such as a dog or cat can be isolated for 10 days to see if they develop symptoms of rabies.  Rabies immunizations rarely need to be given.

  REFERENCES/BIBLIOGRAPHY
 
Marx. (2002). Rosen's emergency medicine: Concepts and clinical practice. (5 th ed.). Retrieved April 27, 2004 from www.mdconsult.com

Roberts. (2004). Clinical procedures in emergency medicine. (4 th ed.). Retrieved May 11, 2004 from www.mdconsult.com

Rakel. (2002). Textbook of family practice. (6 ed.). Retrieved May 11, 2004 from www.mdconsult.com

American Academy of Family Physicians (AAFP). (2002, October). Cuts, scrapes and stitches: Caring for wounds. Retrieved May 11, 2004 from www.familydoctor.org

American Academy of Family Physicians (AAFP). (2005, April). Cuts, scrapes and stitches: Caring for wounds. Retrieved December 5, 2005 from www.familydoctor.org

American Academy of Family Physicians (AAFP). (2005, July). Incision care. Retrieved December 5, 2005 from www.familydoctor.org

The Patient Education Institute. (2005). MEDLINEplus Health Information. X-plain(TM) Incision care. Retrieved December 5, 2005 from www.nlm.nih.gov


Orig. Date: 8/93
Rev. Date: 1/02, 1/03, 6/03, 5/04, 7/04, 12/05
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