Types of Wounds: Open and Closed Wounds

• A wound is defined as damaged skin or soft tissue, resulting from injury (trauma). Tissue trauma includes cuts, blows, poor circulation, strong chemicals, and excessive heat or cold.
• There are two basic types of wounds: open and closed.
• In an open wound, the surface of the skin or mucous membrane is no longer intact.
• In a closed wound, there is no opening in the skin or mucous membrane, typically resulting from blunt trauma or pressure.

Types of wounds

• Incision: A clean separation of skin and tissue with smooth, even edges.
• Laceration: A separation of skin and tissue in which the edges are torn and irregular.
• Abrasion: A wound in which the surface layers of skin are scraped away.
• Avulsion: Stripping away of large areas of skin and underlying tissue, leaving cartilage and bone exposed.
• Ulceration: A shallow crater in which the skin or the mucous membrane is missing.
• Puncture: An opening of skin, underlying tissue, or mucous membrane caused by a narrow, sharp, pointed object.
• Contusion: Injury to soft tissue underlying the skin from the force of contact with a hard object, sometimes called a bruise.
• Regardless of the type of wound, the body immediately attempts to repair the injury and heal the wound.
• The process of wound repair proceeds in three sequential phases: inflammation, proliferation, and remodeling.

Inflammation and healing

• Inflammation, the physiologic process immediately after tissue injury, lasts approximately 2 to 5 days.
• The purposes of inflammation are to limit local damage, remove injured cells and debris, and prepare the wound for healing.
• Inflammation progresses through multiple stages.
• Classic signs and symptoms of inflammation include swelling, redness, warmth, pain, and decreased function.
• Leukocytosis (an increased production of white blood cells) is confirmed and monitored by counting the number and type of white blood cells in a sample of the client's blood. The laboratory test is called a white blood cell count and differential count. Increased production of white blood cells, particularly neutrophils and monocytes, suggests an inflammatory and, in some cases, infectious process.
• Neutrophils and monocytes are primarily responsible for phagocytosis, a process by which these cells emigrate from blood vessels to consume pathogens, coagulated blood, and cellular debris.
• Consumed substances are enclosed within lysosomes, enzymatic sacs inside the phagocytes that digest the engulfed matter.
• Collectively, neutrophils and monocytes clean the injured area and prepare the site for wound healing.
• Proliferation (a period during which new cells fill and seal a wound) occurs from 2 days to 3 weeks after the inflammatory phase.
• Characterized by the appearance of granulation tissue (a combination of new blood vessels, fibroblasts, and epithelial cells) that forms in the bed of an open wound. Granulation tissue has a somewhat irregular surface and looks bright pink to red because of the extensive projections of capillaries in the area.
• Granulation tissue grows from the wound margin toward the center. It is fragile and easily disrupted by physical or chemical means. As more and more fibroblasts produce collagen (a tough and inelastic protein substance), the adhesive strength of the wound increases. Toward the end of the proliferative phase, the new blood vessels degenerate, causing the previously pink color to regress.
• Epithelial cells fill the wound from its base with new tissue and vasculature and can typically fill any size wound.
• Remodeling (a period during which the wound undergoes changes and maturation) follows the proliferative phase and may last 6 months to 2 years. During this time, the wound contracts and the scar shrinks.

Factors affecting wound healing:

• Type of wound injury
• Expanse or depth of wound
• Quality of circulation
• Amount of wound debris
• Presence of infection
• Status of the client's health
• The speed of wound repair and the extent of scar tissue that forms depend on whether the wound heals by first, second, or third intention.

Wound closure intentions

• First-intention healing: Also called healing by primary intention, is a reparative process in which the wound edges are directly next to each other. Because the space between the wound is so narrow, only a small amount of scar tissue forms. Most surgical wounds that are closely approximated heal by first intention.
• Second-intention healing: The wound edges are widely separated, leading to a more time-consuming and complex reparative process. Because the margins of the wound are not in direct contact, the granulation tissue needs additional time to extend across the expanse of the wound. Generally, a conspicuous scar results. Healing by second intention is prolonged when the wound contains body fluid or other wound debris. Wound care must be performed cautiously to avoid disrupting the granulation tissue and retarding the healing process.
• Third-intention healing: The wound edges are intentionally left widely separated and are later brought together with some type of closure material. This reparative process results in a broad, deep scar. Generally, wounds that heal by third intention are deep and are likely to contain extensive drainage and tissue debris. To speed up healing, they may contain drainage devices or be packed with absorbent gauze.

Wound healing complications:

• Adequate blood flow to the injured tissue is key.
• Factors that may interfere include compromised circulation, infection, and purulent, bloody, or serous fluid accumulation that prevent skin and tissue approximation.
• In addition, excessive tension or pulling on wound edges contributes to wound disruption and delays healing.
• The nurse assesses the wound to determine whether it is intact or shows evidence of unusual swelling, redness, warmth, drainage, and increasing discomfort.
• When assessing the wound, it is important to look for undermining, erosion of tissue from underneath intact skin at the wound edge; slough, which is dead tissue on the wound surface that is moist, stringy, yellow, tan, gray, or green; and necrotic tissue, which is dry, brown, or black devitalized tissue. The latter two must be removed to facilitate wound healing (see the later discussion on debridement).
• Two potentially serious surgical wound complications include dehiscence (the separation of wound edges) and evisceration (wound separation with the protrusion of organs). These complications are most likely within 7 to 10 days after surgery and may be caused by insufficient dietary intake of protein and sources of vitamin C; premature removal of sutures or staples; unusual strain on the incision from severe coughing, sneezing, vomiting, dry heaves, or hiccupping; weak tissue or muscular support secondary to obesity; distention of the abdomen from accumulated intestinal gas; or compromised tissue integrity from previous surgical procedures in the same area.

Wound Assessment

• When wound disruption is suspected, the nurse positions the client to put the least amount of strain on the open area. If evisceration occurs, the nurse places sterile dressings moistened with normal saline over the protruding organs and tissues.
• For any wound disruption, the nurse notifies the physician immediately and must be alert for signs and symptoms of impaired blood flow, such as swelling, localized pallor or mottled appearance, and coolness of the tissue in the area around the wound.

Wound management:

• Surgical wounds result from incising tissue with a laser or an instrument called a scalpel.
• The primary goal of surgical or open wound management is to reapproximate the tissue to restore its integrity.
• Involves changing dressings, caring for drains, removing sutures or staples when directed by the surgeon, applying bandages and binders, and performing wound irrigations.

A dressing (the cover over a wound) serves one or more purposes:

• Keeping the wound clean
• Absorbing drainage
• Controlling bleeding
• Protecting the wound from further injury
• Holding medication in place
• Maintaining a moist environment

Types of Dressings

• Gauze dressings: Made of woven cloth fibers. Their highly absorbent nature makes them ideal for covering fresh wounds that are likely to bleed or wounds that exude drainage. Unfortunately, gauze dressings obscure the wound and interfere with wound assessment. Unless an ointment is used on the wound or the gauze is lubricated with an ointment such as petroleum, granulation tissue may adhere to the gauze fibers and disrupt the wound when removed.
• Transparent dressings: Clear, acrylic film wound coverings. One of their chief advantages is that they allow the nurse to assess a wound without removing the dressing. In addition, they are less bulky than gauze dressings and do not require tape because they consist of a single sheet of adhesive material.

Hydrocolloid, Hydrogel, Alginate, and Collagen Dressings

Hydrocolloid dressings, such as DuoDerm and Tegasorb, and hydrogel dressings, such as DuoDerm and IntraSite, are self-adhesive, opaque, air- and water-occlusive wound coverings. Hydrocolloids contain granules of gelatin or pectin in the matrix of the dressing (Fig. 28-10). The granules in hydrocolloids become gelatinous when in contact with exudate in a wound, keeping the wound moist.

• Moist wounds heal more quickly because new cells grow more rapidly in a wet environment.
• If the hydrocolloid dressing remains intact, it can be left in place for up to 1 week. Its occlusive nature also repels other body substances, such as urine or stool. Properly sized generously, allowing at least a 1-in margin of healthy skin around the wound.

Dressing changes

• Health care providers change dressings when a wound requires assessment or care and when the dressing becomes loose or saturated with drainage. Reinforcing a dressing prevents wicking (absorbing or drawing) microorganisms toward the wound (see Chapter 10).

Drains

• Tubes that provide a means for removing blood and drainage from a wound, promoting wound healing by removing fluid and cellular debris.
• The current trend is to insert drains so that they exit from a separate location beside the wound and avoid a direct entry site for pathogens.

Open drains

• Flat, flexible tubes that provide a pathway for drainage toward the dressing. Draining occurs passively by gravity and capillary action. Sometimes, a safety pin or long clip is attached to the drain as it extends from the wound to prevents the drain from slipping within the tissue. As the drainage decreases, the physician may instruct the nurse to shorten the drain.

Closed drains

• Tubes that terminate in a receptacle. Some examples of closed drainage systems are the Hemovac and the Jackson-Pratt drain.
• Closed drains are more efficient than open drains because they pull fluid by creating a vacuum or negative pressure and they pull fluid by creating a vacuum or negative pressure.

Vacuum-Assisted Closure

• Negative pressure wound therapy (NPWT), also called vacuum-assisted wound closure (VAC), systems continuously or intermittently apply pressure to the system, which provides a positive pressure to the surface of a wound.

Sutures, Staples, and Adhesives

• Suturesare knotted ties that hold an incision together, are generally constructed from silk or synthetic materials, such as nylon and staples (wide metal clips) perform a similar function.
• Staples do not encircle a wound like sutures; instead, they form a bridge that holds the two wound margins together.
• Tissue adhesives (liquid stiches or surgical glues) are used to close minor and major wounds and adhesives can result in lower rates of infection, less scarring, no needlesticks, and no stitches to remove when compared to sutures and staples.

Bandages and Binders

• A bandage is a strip or roll of cloth wrapped around a body part, used for holding dressings in place, especially when tape cannot be used or if the dressing is extremely large, supporting the area around a wound or injury to reduce pain, and limiting movement in the wound area to promote healing.
• A binder is a type of cloth cover generally applied to a particular body part, such as the abdomen or breast. Bandages and binders are made from gauze, muslin, elastic rolls, and stockinette.

Roller Bandage Application

• The nurse holds the end in one hand while passing the roll around the part being bandaged, wrapping from a distal to proximal direction, avoiding gaps between each turn of the bandage, exerting equal but not excessive tension with each turn, keeping the bandage free of wrinkles, securing the end of the roller bandage with metal clips, and checking the color and sensation of exposed fingers or toes often.

Debridement

• Removing dead tissue to promote healing and can be achieved by sharp,enzymatic, autolytic and mechanical means

Irrigation

• Used to remove contamination and debris

Hydrotherapy

• Water that contains antiseptic that softens the dead tissue

Heat and Cold Applications

• Both heat and cold have various therapeutic and can be used in several ways including an ice bag, collar, chemical pack, compress, and aquathermia pad. Heat: provides warmth, promotes circulation and speeds healing and reduces pain. Cold: reduces fevers, prevents swelling, controls bleeding and numbs sensation.
• Extremes of temperature can be dangerous and should be regularly assessed and closely monitored.

Pressure Ulcers

• Pressure ulcer, also referred to as a decubitus ulcer, is a wound caused by prolonged capillary compression that is sufficient to impair circulation to the skin and underlying tissue which mostly appear over bony prominences. Pressure Ulcer Stages:
  • Stage 1: intact skin but reddened or darkened skin with the hallmark of cellular damage is skin that remains red or darker and fails to resume its normal color when pressure is relieved.
  • Stage 2: red and accompanied by blistering or a skin tear (a shallow break in the skin) without slough resulting in to colonization and infection of the wound.
  • Stage 3: Shallow skin crater that may extend to the subcutaneous tissue. It may be accompanied by serous drainage, undermining, slough, or purulent drainage (white or greenish fluid) caused by a wound infection. The area is relatively painless despite the severity of the ulcer.
  • Stage 4: Life-threatening characterized by tissue that is deeply ulcerated, exposing muscle and bone, and necrotic tissue may be evident. The dead or infected tissue may produce a foul odor and if an infection is present, it easily spreads throughout the body, causing sepsis (a potentially fatal systemic infection).

Risks for Developing Pressure Ulcers

• Inactivity
• Immobility
• Malnutrition
• Emaciation
• Diaphoresis
• Incontinence
• Vascular disease
• Localized edema
• Dehydration
• Sedation
• Age greater than 70 years (more likely to have fragile skin)
• Obesity
• Smoking
• Not having enough nutrients in the diet
• Having chronic conditions that can restrict blood circulation or limit mobility
• Prevent and treat pressure ulcers and implementing measures reduce conditions under which pressure ulcers are likely to form.

Nursing Implications

• Clients with surgical wounds, pressure ulcers, or other types of tissue injury are likely to have acute pain, altered skin integrity risk, altered skin integrity, altered tissue perfusion, pressure injury risk, and infection risk.

Gerontologic Considerations:

• Wound healing is delayed in older adults.
• Age-related changes that affect wound healing include diminished collagen and blood supply and decreased quality of elastin, necessary components for wound repair.
• The risk for thermal skin injury is increased in older adults with impaired tactile sensation or sensory nerve damage because of circulatory or neurologic disorders.
• Age-related changes result in increased susceptibility to pressure ulcers and shear-type injuries in older adults from thinning dermal layer of skin, and decreased subcutaneous tissue.
• Absorbent undergarments may contribute to skin breakdown in older adults because they may not allow for air circulation due to damage and possible skin breakdown caused by urine or feces next to the skin..
• Special precautions for Older adults with diminished mobility include heel and elbow protectors, pressure relief pads and mattresses, and a strict routine of changing the client's position