Wounds - Emergency Nursing

Wounds

Wounds involving injury to soft tissues can vary from minor tears to severe crushing injuries. The types of wounds that may occur are defined in Chart 71-6. The primary goal is to restore the phys-ical integrity and function of the injured tissue, with minimal scarring and without infection. Proper documentation of the wound, using precise descriptions and correct terminology, is essential. Such information may be needed in the future for forensic evidence. Photographs are helpful because they provide an accurate, visible description of the wound.

Determining when and how the wound occurred is important, because a treatment delay exceeding 3 hours increases infection risk. Using aseptic technique, the clinician inspects the wound to determine the extent of damage to underlying structures. Sen-sory, motor, and vascular function are evaluated for changes that might indicate complications.

Management

WOUND CLEANSING

Hair around the wound may be clipped or shaved (only as di-rected) if it is anticipated that the hairs will interfere with wound closure. Typically, the area around the wound is cleaned with normal saline solution or a polymer agent (eg, SureClens). Anti-bacterial agents, such as povidone-iodine (Betadine) or hydrogen peroxide, should not be allowed to get deep into the wound with-out thorough rinsing. These agents are used only for the initial cleansing because they injure exposed and healthy tissue, resulting in further cell injury.

If indicated, the area is infiltrated with a local intradermal anes-thetic through the wound margins or by regional block. Patients with soft tissue injuries usually have localized pain at the site of injury. The nurse then assists the physician, nurse practitioner, or physician’s assistant in cleaning and débriding the wound.

The wound is irrigated gently and copiously with sterile iso-tonic saline solution to remove surface dirt. Devitalized tissue and foreign matter are removed because they impede healing and may encourage infection. Any small bleeding vessels are clamped or tied. Alternatively, hemostasis may be achieved with cauteri-zation. After wound treatment, a nonadherent dressing is com-monly applied to protect the wound. The dressing may serve as a splint and also as a reminder to the patient that the area is injured.

PRIMARY CLOSURE

The decision to suture a wound depends on the nature of the wound, the time since the injury was sustained, the degree of con-tamination, and the vascularity of tissues. If primary closure is in-dicated, the wound is sutured, usually by the physician, with the patient receiving a form of anesthesia known as moderate sedation. Wound closure begins when subcutaneous fat is brought together loosely with a few sutures to close off the dead space. The sub-cuticular layer is then closed, and finally the epidermis is closed. Sutures are placed near the wound edge, with the skin edges leveled carefully to promote optimal healing. Instead of sutures, sterile strips of reinforced microporous tape or a bonding agent (skin glue) may be used to close clean, superficial wounds.

DELAYED PRIMARY CLOSURE

Delayed primary closure may be indicated if tissue has been lost or there is a high potential for infection.

A thin layer of gauze (to ensure drainage and prevent pooling of exudate), covered by an occlusive dressing, may be used. Other options include split-thickness cadaver or porcine xenografts to simulate the function of epithelium. The wound is splinted in a functional position to prevent motion and decrease the possibility of contracture.

If there are no signs of suppuration, the wound may be su-tured (with the patient receiving a local anesthetic). Use of anti-biotics to prevent infection depends on factors such as how the injury occurred, the age of the wound, and the risk for contami-nation. The site is immobilized and elevated to limit accumula-tion of fluid in the interstitial spaces of the wound.

Tetanus prophylaxis is administered as prescribed, based on the condition of the wound and the patient’s immunization status. The patient is instructed about signs and symptoms of in-fection and is told to contact the health care provider or clinic if there is sudden or persistent pain, fever or chills, bleeding, rapid swelling, foul odor, drainage, or redness surrounding the wound.