Wound Care - University of Babylon



Wound Care

Contents:

• Wound Care Introduction

• Wound Care Signs and Symptoms

• Home Care

• When to Call the Doctor

• When to Go to the Hospital

• Physician Diagnosis

• Wound Care Treatment

• Prognosis

• Prevention

• Glossary

Wound Care Introduction

A wound is a break in the skin (the outer layer of skin is called the epidermis). Wounds are usually caused by cuts or scrapes. Different kinds of wounds may be treated differently from one another, depending upon how they happened and how serious they are.

Healing is a response to the injury that sets into motion a sequence of events. With the exception of bone, all tissues heal with some scarring. The object of proper care is to minimize the possibility of infection and scarring.

There are basically 4 phases to the healing process:

• Inflammatory phase: The inflammatory phase begins with the injury itself. Here you have bleeding, immediate narrowing of the blood vessels, clot formation, and release of various chemical substances into the wound that will begin the healing process. Specialized cells clear the wound of debris over the course of several days.

• Proliferative phase: Next is the proliferative phase in which a matrix or latticework of cells forms. On this matrix, new skin cells and blood vessels will form. It is the new small blood vessels (known as capillaries) that give a healing wound its pink or purple-red appearance. These new blood vessels will supply the rebuilding cells with oxygen and nutrients to sustain the growth of the new cells and support the production of proteins (primarily collagen). The collagen acts as the framework upon which the new tissues build. Collagen is the dominant substance in the final scar.

• Remodeling phase: This begins after 2-3 weeks. The framework (collagen) becomes more organized making the tissue stronger. The blood vessel density becomes less, and the wound begins to lose its pinkish color. Over the course of 6 months, the area increases in strength, eventually reaching 70% of the strength of uninjured skin.

• Epithelialization: This is the process of laying down new skin, or epithelial, cells. The skin forms a protective barrier between the outer environment and the body. Its primary purpose is to protect against excessive water loss and bacteria. Reconstruction of this layer begins within a few hours of the injury and is complete within 24-48 hours in a clean, sutured (stitched) wound. Open wounds may take 7-10 days because the inflammatory process is prolonged, which contributes to scarring. Scarring occurs when the injury extends beyond the deep layer of the skin (into the dermis).

Wound Care Signs and Symptoms

• Scrapes and abrasions are superficial (on the surface). The deeper skin layers are intact, and bleeding is more of a slow ooze. They are usually caused by friction or rubbing against an abrasive surface.

• Lacerations (cuts) go through all layers of the skin and into the fat or deeper tissues. Bleeding may be more brisk or severe. Severe blows by a blunt object, falls against a hard surface, or contact with a sharp object are the most common causes of lacerations.

• Puncture wounds are generally caused by a sharp pointed object entering the skin. Most common examples are stepping on a nail, getting stuck with a needle or a tack, or being stabbed with a knife. Bleeding is usually minimal, and the wound may be barely noticeable.

• Human bites and animal bites can be puncture wounds, lacerations, or a combination of both. These wounds are always contaminated by saliva and require extra care.

Home Care

Scrapes and abrasions often do not require any more care than washing the area 4 times daily for the first 48 hours and keeping the area covered with a sterile bandage. Deeper wounds and bites will require medical attention.

• Stop the bleeding: If bleeding will not stop, apply a clean bandage to the area and press down on it for 10 minutes.

• Clean the wound: Water under pressure is the best way to clean a wound. Either a briskly running faucet or a hand-held shower nozzle is the best way to wash a wound. The wound should be washed for 10-15 minutes. Make sure you remove all dirt and debris. Do not scrub deep wounds or bites, just wash them out.

• Check when you last had a tetanus shot.

When to Call the Doctor

• All bites and any cut or laceration greater than 1/2-inch long in which you can see fat or deeper tissues (muscle or bone) will require medical attention.

• If bleeding is brisk or blood spurts with your heartbeat or does not stop after 10 minutes, your doctor should be called.

• If there is still dirt and debris in an abrasion after your best attempt at cleaning the area, you should notify your doctor.

• Any redness extending from the wound after 2 days or yellow drainage from the area should warrant medical attention.

• You should find out from your doctor when you last had a tetanus shot. If the wound was dirty, you should have one if it has been more than 5 years since your last tetanus immunization. You should have this done within 48 hours of the injury.

When to Go to the Hospital

Most doctors will not stitch a cut or laceration that is more than 8-12 hours old. This is because there is a greater chance of infection after that time. In fact, after 3 hours, the incidence of infection begins to increase. Therefore, do not wait to have the injury repaired. If you are in doubt, call your doctor or go to the nearest hospital's emergency department. An open wound takes longer to heal and leaves a bigger scar.

Reasons to go to the hospital if you have a wound:

• Obvious life-threatening wounds (Call 911 for emergency services.)

• Any laceration greater than 1/2-inch long that is through all layers of the skin exposing the underlying fat.

• If you cannot stop the bleeding

• If the blood continues to "spurt" from the wound (Apply pressure and go to the hospital’s emergency department.)

• If you think that there may be something in the wound such as glass, wood, or rust, for example

• If you cannot move your finger or toe in the area of the laceration, or you have lost sensation in the area beyond the laceration

• For any bite wound (human or animal)

• If your physician cannot see you that day

Physician Diagnosis

The doctor will want to know how the injury occurred, what home care you did for the injury yourself before coming in, if you feel as if there is anything in the wound, and when your last tetanus shot may have been.

You will be asked about your general health, present medications, and any allergies to medications. Conditions such as diabetes, cancer, AIDS, immunosuppression, sickle cell disease, and clotting abnormalities affect wound healing. Steroids and chemotherapy drugs also interfere with wound healing.

• If a hand or finger is involved, the doctor will want to see that you are able to move the extremity or finger through its full range of motion. There is a difference between not being able to bend or extend a finger or not being able to do so simply because it is uncomfortable. Sensation and circulation to the area will be tested carefully as well.

• If there is some suspicion of a foreign body in the wound or an underlying bone break, an x-ray may be ordered.

Wound Care Treatment

• After careful examination and evaluation, the wound will once again be cleaned.

• The area will then be numbed with a local anesthetic. This will allow a deeper examination of the wound as well as repair without any further discomfort. You may feel pressure, but no pain.

• If the wound requires stitches, it will be cleansed with an antiseptic solution, and sterile towels or drapes placed over the area.

o The doctor will wear sterile gloves and put in the stitches to bring the wound edges together.

o Once this has been accomplished, the area will be washed off once again and a sterile bandage applied.

• You will be given further instructions regarding care of the wound.

o Generally the bandage is kept on for 2 days. You should keep it clean and dry, elevating it whenever possible to minimize swelling and pain.

o Over-the-counter pain relievers such as acetaminophen (Tylenol) or ibuprofen (Motrin) are usually sufficient for any pain.

o You will be told when the stitches need to be removed. Once they are removed, small tapes may be applied over the wound to lessen the stress on the healing wound and to lower the amount of scarring, especially if on the face.

o Use a sunblock (not a sunscreen) on the area for 6 months to avoid discoloration from sun exposure.

• Bites may not be sutured unless a large area is involved or the bite involves the face. Many of these become infected, so most doctors prefer to leave them open for daily wound care. You usually will be given antibiotics for bite wounds.

• Abrasions will be washed and scrubbed, if needed. It is important that all the dirt and debris be removed because tattooing (permanent skin discoloration) may result if this debris is left in the wound.

• Puncture wounds will require careful examination. If there is any dirt or debris in the wound, the doctor may remove this small area so that an infection does not occur.

Prognosis

Most wounds heal just fine if given proper care.

• Overall, the infection rate is 6.5%. Redness around the wound, a red line extending toward the body from the wound, or yellowish drainage from the wound are signs of infection and require immediate re-evaluation by a doctor.

• Keeping the sutures clean and avoiding the formation of a scab over them aid in a good cosmetic result. A dilute peroxide solution or plain water may be used. It is all right to wash a sutured wound after 48 hours, but it should not be soaked.

• Antibiotics are not necessary in most cases.

Prevention

• Take care when using sharp objects such as knives, scissors, saws, and trimmers.

• Wear shoes or boots on your feet.

• Use helmets when riding a bicycle.

• Use helmets, kneepads, wrist protectors, and elbow pads when using in-line skates.

• Avoid picking up broken pieces of glass and handling razor blades.

Glossary

Abrasion: An abrasion or "excoriation" is a wearing away of the upper layer of skin as a result of applied friction force. In dentistry an "abrasion" is the wearing away of the tooth substance.

Acetaminophen: A pain reliever and fever reducer. Brand name: Tylenol. The exact mechanism of action of acetaminophen is not known. Acetaminophen relieves pain by elevating the pain threshold (that is, by requiring a greater amount of pain to develop before it is felt by a person). Acetaminophen reduces fever through its action on the heat-regulating center (the "thermostat") of the brain. Generic is available.

Anesthetic: A substance that causes lack of feeling or awareness. A local anesthetic causes loss of feeling in a part of the body. A general anesthetic puts the person to sleep .

Antiseptic: Something that discourages the growth microorganisms. By contrast, aseptic refers to the absence of microorganisms.

Bacteria: Single-celled microorganisms which can exist either as independent (free-living) organisms or as parasites (dependent upon another organism for life).

Blood: The familiar red fluid in the body that contains white and red blood cells , platelets , proteins , and other elements. The blood is transported throughout the body by the circulatory system . Blood functions in two directions: arterial and venous. Arterial blood is the means by which oxygen and nutrients are transported to tissues while venous blood is the means by which carbon dioxide and metabolic by-products are transported to the lungs and kidneys, respectively, for removal from the body.

Bone: Bone is the substance that forms the skeleton of the body. It is composed chiefly of calcium phosphate and calcium carbonate . It also serves as a storage area for calcium, playing a large role in calcium balance in the blood.

Cancer: An abnormal growth of cells which tend to proliferate in an uncontrolled way and, in some cases, to metastasize (spread).

Capillaries: Capillaries are the smallest of blood vessels. They serve to distribute oxygenated blood from arteries to the tissues of the body and to feed deoxygenated blood from the tissues back into the veins. The capillaries are thus a central component in the circulatory system, essentially between the arteries and the veins. When pink areas of skin are compressed, this causes blanching because blood is pressed out of the capillaries. The blood is the fluid in the body that contains, among other elements, the red blood cells (erythrocytes) that carry the oxygen and give the blood its red color.

Cell: The basic structural and functional unit in people and all living things. Each cell is a small container of chemicals and water wrapped in a membrane .

Chemotherapy : 1. In the original sense, a chemical that binds to and specifically kills microbes or tumor cells. The term chemotherapy was coined in this regard by Paul Ehrlich (1854-1915).

2. In oncology, drug therapy for cancer. Also called "chemo" for short.

Circulation: The movement of fluid in a regular or circuitous course. Although the noun "circulation" does not necessarily refer to the circulation of the blood, for all practical purposes today it does. Heart failure is an example of a problem with the circulation.

Collagen: Collagen is the principal protein of the skin, tendons, cartilage, bone and connective tissue.

Cuts: Severed skin. Washing a cut or scrape with soap and water and keeping it clean and dry is all that is required to care for most wounds. Putting alcohol hydrogen peroxide, and iodine into a wound can delay healing and should be avoided. Seek medical care early if you think that you might need stitches. Any delay can increase the rate of wound infection. Any puncture wound through tennis shoes has a high risk of infection and should be seen by your healthcare professional. Any redness, swelling, increased pain, or pus draining from the wound may indicate an infection that requires professional care.

Dermis: The lower or inner layer of the two main layers of cells that make up the skin.The dermis contains blood vessels, lymph vessels, hair follicles, and glands that produce sweat , which helps regulate body temperature, and sebum , an oily substance that helps keep the skin from drying out. Sweat and sebum reach the skin's surface through tiny openings in the skin that act as pores.

Diabetes: Refers to diabetes mellitus or, less often, to diabetes insipidus . Diabetes mellitus and diabetes insipidus share the name "diabetes" because they are both conditions characterized by excessive urination (polyuria).

Diagnosis: 1 The nature of a disease ; the identification of an illness. 2 A conclusion or decision reached by diagnosis. The diagnosis is rabies . 3 The identification of any problem. The diagnosis was a plugged IV.

Dominant: A genetic trait is considered dominant if it is expressed in a person who has only one copy of that gene. (In genetic terms, a dominant trait is one that is phenotypically expressed in heterozygotes).

Elbow: The juncture of the long bones in the middle portion of the arm. The bone of the upper arm (humerus) meets both the ulna (the inner bone of the forearm) and radius (the outer bone of the forearm) to form a hinge joint at the elbow. The radius and ulna also meet one another in the elbow to permit a small amount of rotation of the forearm. The elbow therefore functions to move the arm like a hinge (forward and backward) and in rotation (outward and inward). The biceps muscle is the major muscle that flexes the elbow hinge, and the triceps muscle is the major muscle that extends it. The primary stability of the elbow is provided by the ulnar collateral ligament, located on the medial (inner) side of the elbow. The outer bony prominence of the elbow is the lateral epicondyle, a part of the humerus bone. Tendons attached to this area can be injured, causing inflammation or tendonitis (lateral epicondylitis, or tennis elbow). The inner portion of the elbow is a bony prominence called the medial epicondyle of the humerus. Additional tendons from muscles attach here and can be injured, likewise causing inflammation or tendonitis (medial epicondylitis, or golfer's elbow). See also: Elbow bursitis ; Elbow pain ; Nursemaid's elbow.

Emergency department: The department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care. Emergency department personnel may also respond to certain situations within the hospital such cardiac arrests.

Environment: The sum of the total of the elements, factors and conditions in the surroundings which may have an impact on the development , action or survival of an organism or group of organisms.

The epidermis is mostly made up of flat, scale-like cells called squamous cells . Under the squamous cells are round cells called basal cells. The deepest part of the epidermis also contains melanocytes. These cells produce melanin , which gives the skin its color.

Epithelial: Relating to the epithelium, the outside layer of cells that covers all the free, open surfaces of the body including the skin, and mucous membranes that communicate with the outside of the body.

Extremity: The extremities in medical language are not freezing cold or scorching heat but rather the uttermost parts of the body. The extremities are simply the hands and feet.

Fat: 1 Along with proteins and carbohydrates, one of the three nutrients used as energy sources by the body. The energy produced by fats is 9 calories per gram. Proteins and carbohydrates each provide 4 calories per gram. 2 Total fat; the sum of saturated, monounsaturated and polyunsaturated fats. Intake of monounsaturated and polyunsaturated fats can help reduce blood cholesterol when substituted for saturated fats in the diet. 3 A slang term for obese or adipose. 4 In chemistry, a compound formed from chemicals called fatty acids. These fats are greasy, solid materials found in animal tissues and in some plants. Fats are the major component of the flabby material of a body, commonly known as blubber.

Feet: The plural of foot, both an anatomic structure and a unit of measure.

Hospital: It may seem unnecessary to define a "hospital" since everyone knows the nature of a hospital. A hospital began as a charitable institution for the needy, aged, infirm, or young.

Ibuprofen: A non-steroidal anti-inflammatory drug (NSAID) commonly used to treat pain, swelling, and fever . Common brand names for Ibuprofen include Advil, Motrin, and Nuprin.

Immunization: Vaccination. Immunizations work by stimulating the immune system, the natural disease-fighting system of the body. The healthy immune system is able to recognize invading bacteria and viruses and produce substances (antibodies) to destroy or disable them. Immunizations prepare the immune system to ward off a disease. To immunize against viral diseases, the virus used in the vaccine has been weakened or killed. To immunize against bacterial diseases, it is generally possible to use only a small portion of the dead bacteria to stimulate the formation of antibodies against the whole bacteria. In addition to the initial immunization process, it has been found that the effectiveness of immunizations can be improved by periodic repeat injections or "boosters." Also see Immunizations (in the plural) and Immunization of a specific type (such Immunization, Polio).

Immunosuppression: Suppression of the immune system . Immunosuppression may result from certain diseases such as AIDS or lymphoma or from certain drugs such as some of those used to treat cancer . Immunosuppression may also be deliberately induced with drugs, as in preparation for bone marrow or other organ transplantation to prevent the rejection of the transplant .

Incidence: The frequency with which something, such as a disease, appears in a particular population or area. In disease epidemiology, the incidence is the number of newly diagnosed cases during a specific time period. The incidence is distinct from the prevalence which refers to the number of cases alive on a certain date.

Infection: The growth of a parasitic organism within the body. (A parasitic organism is one that lives on or in another organism and draws its nourishment therefrom.) A person with an infection has another organism (a "germ") growing within him, drawing its nourishment from the person.

Injury: Harm or hurt. The term "injury" may be applied in medicine to damage inflicted upon oneself as in a hamstring injury or by an external agent on as in a cold injury . The injury may be accidental or deliberate, as with a needlestick injury . The term "injury" may be synonymous (depending on the context) with a wound or with trauma .

Laceration: A cut.

Muscle: Muscle is the tissue of the body which primarily functions as a source of power. There are three types of muscle in the body. Muscle which is responsible for moving extremities and external areas of the body is called "skeletal muscle." Heart muscle is called "cardiac muscle." Muscle that is in the walls of arteries and bowel is called "smooth muscle."

Nail: In medicine, there are two types of nails. One is just a plain old metal nail used to hold 2 or more pieces of bone together, for example, after a fracture. The other type of nail is the horny plate on the end of the finger or toe. Each nail anatomically has a body, lateral nail folds (on the sides), a lunula (the little moon-shaped feature at the base), and a proximal skin fold (at the base).

Open wound: An injury that is exposed due to broken skin. An open wound is at high risk for infection.

Oxygen: A colorless, odorless and tasteless gas that makes up about 20% of the air we breathe (and at least half the weight of the entire solid crust of the earth) and which combines with most of the other elements to form oxides. Oxygen is essential to human, animal and plant life.

Pain: An unpleasant sensation that can range from mild, localized discomfort to agony. Pain has both physical and emotional components. The physical part of pain results from nerve stimulation. Pain may be contained to a discrete area, as in an injury, or it can be more diffuse, as in disorders like fibromyalgia . Pain is mediated by specific nerve fibers that carry the pain impulses to the brain where their conscious appreciation may be modified by many factors.

Pharmacy: A location where prescription drugs are sold. A pharmacy is, by law, constantly supervised by a licensed pharmacist.

Primary: First or foremost in time or development. The primary teeth (the baby teeth) are those that come first. Primary may also refer to symptoms or a disease to which others are secondary.

Prognosis: 1. The expected course of a disease .

2. The patient's chance of recovery.

The prognosis predicts the outcome of a disease and therefore the future for the patient . His prognosis is grim, for example, while hers is good.

Proliferative: Growing and increasing in number rapidly.

Proteins: Large molecules composed of one or more chains of amino acids in a specific order determined by the base sequence of nucleotides in the DNA coding for the protein.

Range of motion: The range through which a joint can be moved, usually its range of flexion and extension. Due to an injury, the knee may for example lack 10 degrees of full extension.

Scrub: 1. As a verb, to wash the hands and forearms very thoroughly, as before engaging in surgery. To scrub implies the use of a brush (and often an implement to clean under the nails). To scrub, to scrub in (on a surgical procedure), and to scrub up are synonymous.

2. As a noun, a person who scrubs, as for surgery.

3. As an adjective, pertaining to scrubbing in for surgery, as a scrub nurse or a scrub tech.

Sensation: In medicine and physiology , sensation refers to the registration of an incoming ( afferent ) nerve impulse in that part of the brain called the sensorium , which is capable of such perception. Therefore, the awareness of a stimulus as a result of its perception by sensory receptors. (Sensory is here synonymous with sensation.)

Sickle cell disease: A genetic blood disease due to the presence of an abnormal form of hemoglobin, namely hemoglobin S . Hemoglobin is the molecule in red blood cells that transports oxygen from the lungs to the farthest reaches of the body.

Skin: The skin is the body's outer covering. It protects us against heat and light, injury, and infection. It regulates body temperature and stores water, fat, and vitamin D. Weighing about 6 pounds, the skin is the body's largest organ. It is made up of two main layers; the outer epidermis and the inner dermis.

Stress: Forces from the outside world impinging on the individual. Stress is a normal part of life that can help us learn and grow. Conversely, stress can cause us significant problems.

Substance:

• 1- Material with particular features, as a pressor substance .

• 2- The material that makes up an organ or structure. Also known in medicine as the substantia.

3- A psychoactive drug as, for example, in substance abuse .

Sunscreen: A substance that blocks the effect of the sun's harmful rays. Using lotions that contain sunscreens can reduce the risk of skin cancer , including melanoma .

Superficial: In anatomy, on the surface or shallow. As opposed to deep. The skin is superficial to the muscles. The cornea is on the superficial surface of the eye.

Tetanus : An often fatal infectious disease caused by the bacteria Clostridium tetani (C. tetani) which usually enters the body through a puncture, cut, or open wound. Tetanus is characterized by profoundly painful spasms of muscles, including "locking" of the jaw so that the mouth cannot open (lockjaw). C. tetani releases a toxin that affects the motor nerves, (the nerves which stimulate the muscles).

Tissue: A tissue in medicine is not like a piece of tissue paper. It is a broad term that is applied to any group of cells that perform specific functions. A tissue in medicine need not form a layer. Thus,

• The bone marrow is a tissue;

• Connective tissue consists of cells that make up fibers in the framework supporting other body tissues; and

• Lymphoid tissue is the part of the body's immune system that helps protect it from bacteria and other foreign entities.

Tylenol: See: Acetaminophen .

Vessel: A tube in the body that carries fluids: blood vessels or lymph vessels.

Wrist: The proximal segment (the near part) of the hand consisting of the carpal bones and the associated soft parts.

X-ray: 1. High-energy radiation with waves shorter than those of visible light. X-rays possess the properties of penetrating most substances (to varying extents), of acting on a photographic film or plate (permitting radiography), and of causing a fluorescent screen to give off light (permitting fluoroscopy). In low doses X-rays are used for making images that help to diagnose disease, and in high doses to treat cancer . Formerly called a Roentgen ray. 2. An image obtained by means of X-rays.

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