Wound Management Overview

Wound Management

• Wound is defined as a break or disruption in the normal integrity of skin and tissues.

Learning Objectives

• Define different types of wounds
• Describe the physiology of wound healing
• Identify factors affecting wound healing
• Outline wound complications
• Describe wound management
• Educate patients on wound healing promotion

Types of Wounds

• Incision: Cutting or sharp instrument; wound edges are close and aligned.
• Contusion: Blunt instrument; overlying skin intact, injury to underlying soft tissue; possible bruising or hematoma.
• Abrasion: Friction; rubbing or scraping epidermal layers of skin; top skin layer is abraded.
• Laceration: Tearing of skin and tissue with blunt or irregular instrument; tissues not aligned; often with loose flaps.
• Puncture: Blunt or sharp instrument puncturing skin; intentional (venipuncture) or accidental. Foreign object entering skin/mucous membrane.
• Penetrating: Foreign object enters skin/mucous membrane and lodges in underlying tissue; fragments can scatter. Destroys skin layers.
• Burns (thermal, chemical, irradiation): Destroys skin layers.
• Pressure ulcers: Compromised circulation secondary to pressure.

Wound Classification

• Clean: Non-traumatic site; uninfected; no inflammation; no break in aseptic technique.
• Clean-contaminated: Entry into respiratory, alimentary, genitourinary tracts or oropharynx without unusual contamination (appendectomy). Minor disruption of aseptic technique.
• Contaminated: Open, newly injured traumatic wounds; gross spillage from gastrointestinal tract; major break in aseptic technique; enters genitourinary or biliary tract with infected urine or bile.
• Dirty: Traumatic wounds with delayed repair, devitalized tissue, foreign body, or fecal contamination; acute inflammation with purulent drainage during procedure.

Wound Healing Physiology

• Wound healing is a tissue response to injury.
• Injured tissues are repaired by physiologic mechanisms that regenerate functional cells and replace connective tissue with scar tissue.
• The process involves phases.

Phases of Wound Healing

• Phase 1 (Hemostasis): Occurs immediately after injury. Involved blood vessels constrict; blood clotting begins via platelet activation and clustering. Blood vessels dilate briefly after initial constriction. Capillary permeability increases, allowing plasma and blood components to leak out (exudate), causing swelling and pain. Increased blood flow causes heat and redness. A clot forms, protecting the injury. Platelets release substances to stimulate other cells to migrate to the injury.
• Phase 2 (Inflammatory): Follows hemostasis; lasts 4-6 days. White blood cells (leukocytes) move to the wound; leukocytes arrive to ingest bacteria and cellular debris. Macrophages arrive 24 hours later to ingest debris and release growth factors, which promote new blood vessels and epithelial cells. Acute inflammation characterized by pain, heat, redness, and swelling. Patients often have a mildly elevated temperature, leukocytosis (increased white blood cells), and general malaise.
• Phase 3 (Proliferation): Known as the fibroblastic, regenerative, or connective tissue phase; lasts several weeks. New tissue (granulation tissue) fills the wound space primarily through the actions of fibroblasts. Capillaries grow across the wound to provide oxygen and nutrients. Fibroblasts form fibrin that stretches through the clot. A thin layer of epithelial cells forms across the wound, and blood flow across the wound is restored. Granulation tissue forms the foundation for scar tissue development; highly vascular, red, and bleeds easily. Collagen synthesis and accumulation peak in 5-7 days.
• Phase 4 (Maturation): The final stage; begins about 3 weeks after injury and may continue for months or years. Collagen that was haphazardly deposited remodels; the healed wound becomes stronger. New collagen deposition compresses blood vessels in the healing wound, so that scar tissue forms (avascular, does not sweat, grow hair, or tan). Scar tissue is strong but less elastic than uninjured tissue. If a scar is over a joint, it may limit movement.

Factors Affecting Wound Healing

• Local factors:
  • Pressure: Disrupts blood supply, interferes with blood flow, delays healing.
  • Desiccation (drying): Cells dehydrate and die; crusting occurs; healing delayed.
  • Maceration (overhydration): Moisture causes pH change, bacterial overgrowth, skin infection or erosion.
• Systemic factors:
  • Age: Children heal faster; older adults may have more chronic illnesses, impede healing.
  • Circulation/oxygenation: Blood flow and oxygen delivery crucial for nourishment and toxin removal; may be impacted by obesity.
  • Nutritional status: Requires adequate proteins, carbohydrates, fats, vitamins, and minerals to rebuild cells, promote tissue repair. Healing slowed with poor nutritional status or fluid imbalances.

Wound Complications

• Infection: Bacteria invading the wound at any time.
• Hemorrhage: From a slipped suture, dislodged clot, stress at suture line, operative site, infection, or erosion of a blood vessel by a foreign body.
• Dehiscence: Partial or total disruption of wound layers.
• Evisceration: Protrusion of viscera through the incision.
• Fistula formation: Abnormal passageway from an internal organ to the skin or another internal organ.

Nursing Management

• Assessment: Appearance, approximation of wound edges, colour, drains/tubes/staples/sutures, signs of dehiscence or evisceration. Healthy wounds appear clean, approximated, with a crust along edges. Initially edges may be reddened, swollen but normal within a week. If infection is present, wound will be swollen, deep red, hot, with increased purulent drainage, foul odour. Dehiscence or separation of edges is imminent.
• Drainage: Inflammatory response leads to exudate formation. Exudate contains fluid and cells escaping blood vessels and deposited on tissue. Exudates are serous, sanguineous, or purulent (if infected). Drains may be inserted to promote drainage and healing. Evaluate amount, colour, odour, and consistency.
• Pain: Pain from the wound may be constant, especially with increase/purulent drainage (indicates delayed healing or infection). Incisional pain is usually most severe for the first 2-3 days then progressively diminishes.

Patient Education

• Keep wound dry and clean if soiled, notify caregiver.
• Report signs of infection (redness, swelling, increased warmth, pus, foul odor).
• Elevate affected body part.
• If pain or soreness apply a cold pack or analgesics.
• Eat plenty of protein and Vitamin C rich foods.