WOUND MANAGEMENT – DRESSING AND TREATMENT
Wound management is an ongoing treatment of a wound, by providing an appropriate environment for healing, by both direct and indirect methods, together with the prevention of skin breakdown. Proper wound management is determined by the wound’s size, depth, severity, and location over the care period. This management is changing rapidly due to the advancement in technologies which is shedding more light onto the etiology of the wound and its healing process.
Wound management contributes to the healing process by protecting the wound’s fluids, preventing and managing infection, controlling mechanical influences, and influencing the collagen maturation process. The ultimate aim of wound management is to promote healing without microbial infection.
Wound management has traditionally involved controlling the underlying cause and allowing the body to heal the wound naturally, or utilizing skin grafts to replace lost tissue.
It is an injury to the body (as from violence, accident, or surgery) that typically involves laceration or breaking of a membrane (such as the skin) and usually damage to underlying tissues.
WHAT ARE THE DIFFERENT TYPES OF OPEN WOUNDS?
There are four types of open wounds, which are classified depending on their cause.
An abrasion occurs when your skin rubs or scratch against a rough or hard surface. Road rash is an example of an abrasion. There’s usually not a lot of bleeding, but the wound needs to be scrubbed and cleaned to avoid infection.
A laceration is a deep cut or tearing of your skin. Accidents with knives, tools, and machinery are frequent causes of lacerations. In the case of deep lacerations, bleeding can be rapid and extensive.
A puncture is a small hole caused by a long, pointy object, such as a nail or needle. Sometimes, a bullet can cause a puncture wound. Punctures may not bleed much, but these wounds can be deep enough to damage internal organs. If you have even a small puncture wound, visit your doctor to get a tetanus shot, and prevent infection.
An avulsion is a partial or complete tearing away of skin and the tissue beneath. Avulsions usually occur during violent accidents, such as body-crushing accidents, explosions, and gunshots. They bleed heavily and rapidly.
The basic principles for the management of a wound or laceration are:
- Cleaning the wound
- Skin closure
- Dressing and follow-up advice
These principles can be applied to any simple wound, yet always involve your senior colleagues for advice and input as necessary. Always remember your own personal protection when assessing a wound, including gloves, apron or gown, and goggles/visors.
Hemostasis is the process that causes bleeding to stop. In most wounds, hemostasis will be spontaneous.
In cases of significant injury or laceration of vessels certainly, steps may need to be taken to reduce bleeding and aid hemostasis. These include pressure, elevation, tourniquet, or suturing.
CLEANING THE WOUND
Wound cleaning is important for reducing infection and promoting healing. There are five aspects of wound cleaning:
- Disinfect the skin around the wound with antiseptic
- Avoid getting alcohol or detergents inside the wound
- Decontaminate the wound by manually removing any foreign bodies
- Cleanse any devitalized tissue where possible
- Irrigate the wound with saline
- If there is no obvious contamination present, low-pressure irrigation is sufficient* (pouring normal saline from a sterile container carefully into the wound)
- Antibiotics for high-risk wounds or signs of infection.
Risk factors for wound infection include foreign body present or heavily soiled wounds, bites (including human), puncture wounds, and open fractures.
Analgesia will allow for a tolerant and easier closure of the wound. Infiltration with a local anesthetic is the most common form of analgesia used, with regular systemic analgesia (such as paracetamol) used as an adjunct.
The aid wound healing; the edges of the wound can be manually opposed. There are four main methods of doing so:
- Skin adhesive strips are suitable if no risk factors for infection are present.
- Tissue adhesive glue can be used for small lacerations with easily opposable edges.
- Sutures are typically used for any laceration greater than 5cm, deep dermal wounds, or in locations that are prone to flexion, tension, or wetting.
- Staples can be used for some scalp wounds.
DRESSING THE WOUND AND FOLLOW-UP
Correct dressing of the wound will reduce infection and contamination.
When applying a wound dressing to a non-infected laceration, the first layer should be non-adherent (such as saline-soaked gauze), followed by an absorbent material to attract any wound exudate, and finally, soft gauze tape to secure the dressing in place.
HOME CARE FOR MINOR WOUNDS
- Wash your hands thoroughly with soap and clean water, if possible.
- Avoid touching the wound with your fingers while treating it (if possible, use disposable gloves).
- Remove obstructive jewelry and clothing from the injured body part.
- Apply direct pressure to any bleeding wound to control bleeding.
- Clean the wound after bleeding has stopped.
- Examine wounds for dirt and foreign objects.
- Gently flood the wound with bottled water or clean running water (if available, saline solution is preferred).
- Gently clean around the wound with soap and clean water.
- Pat dry and apply an adhesive bandage or dry clean cloth.
- Leave unclean wounds, bites, and punctures open. Wounds that are not cleaned correctly can trap bacteria and result in infection.
- Provide pain relievers when possible.
- Review the wound every 24 hours.
- You’ll need to keep the wound clean and dry for five days. You should also make sure you get plenty of rest.
WHEN TO SEE A DOCTOR
Although you can treat some wounds at home, you should see a doctor if:
- an open wound is deeper than 1/2 inch
- bleeding doesn’t stop with direct pressure and bleeding lasts longer than 20 minutes
- bleeding is the result of a serious accident
WHY ISN’T MY WOUND HEALING FASTER?
Sometimes bacteria (germs) are the problem. When you have an open wound, it’s easy for common bacteria from your skin to get inside. Bacteria in your wound are called contamination. Not all contamination is bad, though.
- If bacteria are in your wound, but are not reproducing and not causing a problem, this is called colonization.
- Infection means the bacteria are reproducing, so there are a lot more of them. They are invading the soft tissue and preventing healing.
Other factors that slow wound healing include:
- Poor nutrition
- Certain diseases, such as diabetes or diseases of the liver, kidney, or lungs
- Certain treatments, such as chemotherapy or radiation
WHAT IS A WOUND CARE DRESSING?
A dressing is used by a doctor, caregiver, and/or patient to help a wound heal and prevent further issues like infection or complications. Dressings are designed to be in direct contact with the wound, which is different from a bandage that holds the dressing in place.
Dressings serve a variety of purposes depending on the type, severity, and position of the wound. Aside from the major function of reducing the risk of infection, dressings are also important to help:
- Stop bleeding and start clotting so the wound can heal
- absorb any excess blood, plasma, or other fluids
- Wound debridement
- Begin the healing process.
WHAT TYPE OF WOUND CARE DRESSING IS RIGHT FOR MY WOUND?
Hydrocolloid dressings are used on burns, light to moderately draining wounds, necrotic wounds, under compression wraps, pressure ulcers, and venous ulcers.
This type of dressing is for wounds with little to no excess fluid, painful wounds, necrotic wounds, pressure ulcers, donor sites, second degree or higher burns, and infected wounds.
Alginate dressings are used for moderate to high amounts of wound drainage, venous ulcers, packing wounds, and pressure ulcers in stage III or IV.
A collagen dressing can be used for chronic or stalled wounds, ulcers, bedsores, transplant sites, surgical wounds, second degree or higher burns, and wounds with large surface areas.
HOW TO CHANGE WOUND DRESSING
Hopefully, you’ll never need to know how to dress a wound. But if you do ever have to change a wound dressing, whether it’s for a simple cut or if something more serious, this handy step-by-step guide of wound management can help. It’s a simple process, but one that’s important to do correctly to avoid infection. Even if you’ve never changed a dressing before, these steps for dressing a wound will guide you to perform effectively.
Get the right wound-care supplies. Gather the following items before you start your wound-dressing change, and place them on a sterile surface mat to keep them clean:
PREPARE FOR YOUR DRESSING CHANGE
- Sterile disposable gloves
- Saline water
- Antibiotic ointment
- Dressing – open the package and lay the dressing with the area to touch the wound facing up
- Gauze pads or rolled gauze
- Non-stick pad
- Plastic bag for trash (not paper, so there is no leakage)
- Tape (use paper tape for skin that is very fragile or has an allergy to tape)
- Hand Washing Supplies
- Make sure you have a bag next to you to put your old dressing and gloves and (fasten a bag with tape to a table if possible).
- On a clear, flat surface, set up an area to do the dressing change with the new dressing (still in its packet), your disposable gloves (you will need 2-3 pairs), hand sanitizers, gauze, and other items you may need.
CHANGE THE DRESSING
- Wash your hands with soap and water thoroughly for 20 seconds especially between fingers and palms of hands.
- Important: Dry your hands with a clean cloth or something clean.
- Put on disposable gloves or use hand sanitizer.
REMOVE OLD DRESSING
- Remove the old wound dressing. Carefully loosen the old dressing, and then remove it. Use lukewarm water or a little saline water to loosen any sticky parts. Be careful not to remove any tape the surgeon used to close the wound.
- Once you remove the dressing place it together with the gloves and dispose of it in the bag.
CLEAN THE WOUND
- Change gloves if soiled by the old dressing.
- Clean the wound. Remove a gauze pad or sponge from its wrapping to begin the wound cleaning (don’t do this ahead of time, only do it once you’ve removed the old dressing to keep the pad or sponge sterile). Wet the gauze with lukewarm water or saline water and carefully clean any visible blood or other fluids from the wound.
- Clean the wound from inside to out using a circular motion. Change pad or applicator frequently, putting the dirty ones in the impermeable bag.
- Let the wound dry. While you’re waiting, check the wound for any signs of infection.
APPLY THE NEW DRESSING
- Wash your hands and put on new gloves or use the hand sanitizer.
- Apply antibiotic ointment to the wound, then apply a new nonstick pad to the wound, plus any extra gauze it may need for cushioning.
- Secure the new wound-care dressing. Do this with tape or with a wrap, depending on where the wound is located.
- If you’re using tape, apply it to two or more edges of the pad so it’s secure.
- If you’re using a wrap, wrap it around the bandage so that it’s firm but comfortable.
- Double bag all garbage.
- Wash hands.
HOW OFTEN SHOULD I CHANGE MY DRESSING?
- Leave your dressing in place for as long as possible or as long as your nurse recommends. The dressing is changed normally between 1 or 3 times a week.
It will be necessary to change your dressing immediately in this situation:
- If fluids start to leak out of the edge of the dressing
- If the dressing peels off
ARE THERE ANY COMPLICATIONS FROM HAVING AN OPEN WOUND?
The main complication of an open wound is the risk of infection. Common symptoms of wound infection include:
- Redness or excessive swelling of the wound area
- Throbbing pain or tenderness in the wound area
- Red streaks in the area around the wound
- Pus or watery discharge collecting beneath the skin of the wound
- Foul odor from the wound
Other signs of infection include:
- a fever of over 100.4°F (38°C) for more than four hours
- a tender lump in your groin or armpit
- a wound that isn’t healing
EATING TO HELP YOU HEAL
Having a wound puts extra demands on your body. To heal, you need more calories and more nutrients. Wounds heal faster if you get enough of the right foods — and if you don’t, they heal more slowly. Follow the guidelines below to promote healing.
Protein. Protein provides the building material for muscle and skin repair. It also helps boost immunity. Eat 3 to 4 servings per day. (One serving is 3 to 4 ounces.) Good sources of protein include:
- Lean animal meat, such as beef, pork, chicken, or fish
- Dried beans, peas, lentils, or tofu
- Nuts, peanut butter, or seeds
- Cheese, yogurt, or eggs
Carbohydrates. Carbohydrates supply the energy your body needs to heal. Good choices include:
- Whole-grain bread and cereals
- Potatoes, rice, or pasta
- A variety of fruits and vegetables
- Foods with vitamin A, such as bright orange fruits and vegetables, and dark green leafy vegetables
- Foods with vitamin C, such as citrus fruits, peppers, tomatoes, strawberries, cantaloupe, and broccoli
Milk and dairy products. These are good sources of both carbohydrates and protein. Unless your doctor says not to eat dairy, be sure to include at least 3 servings per day. One serving of milk or yogurt is one cup. Soymilk can be substituted for regular milk.
Water. Water replaces fluid lost with draining wounds. Make sure you drink about 6 to 8 cups of liquids each day unless your doctor tells you otherwise.
If you have diabetes, carefully follow the diet and medication recommendations for your diabetes. If your wounds are not healing, follow up with your dietitian or another healthcare provider.
Be sure to get enough healthy foods
Some people have trouble eating enough at meals to promote wound healing. These ideas that may help:
Eat smaller meals more often. It may be easier to eat 6 small meals per day rather than 3 larger meals.
Eat healthy snacks. You can get more of the nutrition you need by snacking between meals on healthy foods such as:
- Cheese and crackers
- Cottage cheese and fruit
- Half a sandwich and a small piece of fruit
- Peanut butter or nuts and sliced apples
- Granola bars and fresh fruit
Vitamins and minerals. You can get most of the vitamins and minerals you need from eating a well-balanced diet, as described above. Be sure to eat at least one serving per day of red meats, fortified cereals, or dark green leafy vegetables.
If you’re not eating at least 5 servings a day of fruits and vegetables, your doctor or dietitian may recommend a daily multi-vitamin or an extra vitamin D supplement if your levels are low. Only take other vitamins or minerals recommended by a healthcare provider.
The care of wounds and proper management is an important component of the overall care of patients, regardless of the type of surgical practice you are currently working in. when a patient’s skin is compromised, be it by surgical incision, laser, chemicals, or any means, the appropriate of the resulting wound is paramount to a positive outcome.
Education of patients, families, caregivers, and healthcare providers is the key to a proactive program of prevention and timely, appropriate interventions. Wound management involves a comprehensive care plan with consideration of all factors contributing to and affecting the wound and the patient. No single discipline can meet all the needs of a patient with a wound.