Wounds

Definition

A wound occurs when the integrity of skin is compromised (e.g., skin breaks, burns, or bone fractures ). A wound may be caused by an act, such as a gunshot, fall, or surgical procedure; by an infectious disease; or by an underlying condition.

Description

Types and causes of wounds are wide ranging. They may be chronic, as are pressure ulcers (which are common in persons with diabetes as a result of skin breakdown)—or they may be acute, as in gunshot wounds or an animal bites. Wounds may also be referred to as open, in which the skin has been compromised and underlying tissues are exposed. Alternatively, they may be closed. Here, the skin has not been compromised, but trauma to underlying tissue has occurred (e.g., a bruised rib or cerebral contusion). Emergency personnel generally place acute wounds in one of eight categories:

• Abrasions. Also called scrapes, they occur when the skin is rubbed away by friction against a rough surface (e.g., rope burns and skinned knees).
• Avulsions. Occur when an entire structure or part of it is forcibly pulled away, such as in the loss of a permanent tooth or an ear lobe. Explosions, gunshots, and animal bites may cause avulsions.
• Contusions. Also called bruises, these are the result of a forceful trauma that injures an internal structure without breaking the skin. Blows to the chest, abdomen, or head with a blunt instrument (e.g., a football or a fist) can cause contusions.
• Crush wounds. Occur when a heavy object falls onto a person, splitting the skin and shattering or tearing underlying structures.
• Cuts. These are slicing wounds made with a sharp instrument, leaving even edges, or those made with a dull cutting instrument, which leaves uneven edges. Cuts may be as minimal as those caused by paper (i.e., paper cuts), or as significant as a surgical incisions.
• Lacerations. Also called tears, these are separating wounds that produce ragged edges. They are produced by a tremendous force against the body, either from an internal source, as in childbirth, or from an external source, like a punch.
• Missile wounds. Also called velocity wounds, they are caused by an object entering the body at a high speed, typically a bullet.
• Punctures. Deep, narrow wounds produced by sharp objects such as nails, knives, and broken glass.

Causes and symptoms

Acute wounds have a wide range of causes. Often, they are the unintentional results of motor vehicle accidents, falls, mishandling of sharp objects, or sports-related injuries. Wounds may also be the intentional results of violence involving assault with weapons, including fists, knives, and guns.

The general symptoms of a wound are localized pain and bleeding. Descriptions of the appearance of different kinds of wounds are as follows:

• An abrasion usually appears as lines of scraped skin with tiny spots of bleeding.
• An avulsion has heavy, rapid bleeding and a noticeable absence of tissue.
• A contusion may appear as a bruise beneath the skin or may appear only on imaging tests; an internal wound may also generate symptoms such as weakness, perspiration, and pain.
• A crush wound may have irregular margins like a laceration; however, the wound will be deeper, and trauma to muscle and bone may be apparent.
• A cut may have little or profuse bleeding depending on its depth, length, and anatomical site. Its even edges readily line up.
• A laceration, too, may have little or profuse bleeding; the tissue damage is generally greater, and the wound's ragged edges do not readily line up.
• A missile entry wound may be accompanied by an exit wound, and bleeding may be profuse, depending on the nature of the injury.
• A puncture wound will be greater in its length; therefore, there is usually little bleeding around the outside of the wound and more bleeding inside, causing discoloration.

Diagnosis

A diagnosis is made by visual examination and may be confirmed by a report of the causal events. Health care personnel will also assess the extent of the wound and what effect it has had on the patient's wellbeing (e.g., profound blood loss, damage to the nervous system or skeletal system ).

Treatment

Treatment of wounds involves stopping any bleeding, then cleaning and dressing the wound to prevent infection. Additional medical attention may be required if the effects of the wound have compromised the body's ability to function effectively.

Stopping the bleeding

Most bleeding may be stopped by direct pressure. Direct pressure is applied by placing a clean cloth or dressing over the wound and pressing the palm of the hand over the entire area. This limits local bleeding without disrupting a significant portion of the circulation. The cloth absorbs blood and allows clot formation. The clot should not be disturbed. Therefore, if blood soaks through the original cloth, another one should be placed directly on top of it. The new cloth should not replace the original one.

If the wound is on an arm or a leg that does not appear to have a broken bone, the injured limb should be elevated to a height above the person's heart, while direct pressure is applied. Elevating the wound allows gravity to slow the flow of blood to that area.

If severe bleeding cannot be stopped by direct pressure or with elevation, the next step is to apply pressure to the major artery supplying blood to the area of the wound. In the arm, pressure would be applied to the brachial artery by pressing the inside of the upper arm against the bone. In the leg, pressure would be applied to the femoral artery by pressing on the inner crease of the groin, against the pelvic bone.

If the bleeding from an arm or leg is so extreme as to be life threatening, and if it cannot be stopped by any other means, a tourniquet may be required. However, in the process of limiting further blood loss, the tourniquet also drastically deprives the limb tissues of oxygen. As a result, the patient may live, but the limb may die.

Dressing the wound

Once the bleeding has been stopped, cleaning and dressing the wound is important for preventing infection. Although the flowing blood flushes debris from the wound, running water should also be used to rinse away dirt. Embedded particles, such as wood slivers and glass splinters—if not too deep—may be removed with a needle or pair of tweezers that has been sterilized in rubbing alcohol or in the heat of a flame. Once the wound has been cleared of foreign material and washed, it should be blotted dry gently, with care not to disturb the blood clot. An antibiotic ointment may be applied. The wound should then be covered with a clean dressing and a bandage to hold the dressing in place. Depending on the wound type, dressings can be designed to retain (or absorb) moisture, or to rehydrate desiccated wounds. Dressing materials may include polyurethane films or foams, hydrogels, hydrofibre, calcium alginates, and hydrocolloids.

Getting medical assistance

A person who has become impaled on a fixed object, such as a fence post or a stake in the ground, should only be moved by emergency medical personnel. Foreign objects embedded in the eye should only be removed by a physician. Larger penetrating objects, such as a fishhook or an arrow, should only be removed by a doctor, who can prevent further damage as the object is extracted.

In several instances, additional medical attention will be necessary. Wounds that penetrate the muscle beneath the skin should be cleaned and treated by a doctor, and may require stitches to stay closed during healing. Some deep wounds that do not extend to the underlying muscle may only require butterfly bandages. Wounds to the face and neck, even small ones, should always be examined by a physician so that scarring can be minimized and sensory function can be preserved. Deep wounds to the hands and wrists should be examined for nerve and tendon damage. Puncture wounds may require a tetanus shot to prevent serious infection. Animal bites should always be examined and the possibility of rabies infection considered.

Infection

Wounds that develop signs of infection should also be brought to a doctor's attention. Signs of infection are swelling, redness, tenderness, throbbing pain, localized warmth, fever, swollen lymph glands, the presence of pus either in the wound or draining from it, and red streaks spreading away from the wound.

Emergency treatment

With as little as one quart of blood lost, a person may lose consciousness and go into traumatic shock. If the person stops breathing, artificial respiration should be administered. In the absence of a pulse, cardiopulmonary resuscitation (CPR) must be performed. Once the person is breathing unassisted, one can attend to the bleeding.

In cases of severe blood loss, treatment may include the intravenous replacement of body fluids. This may be infusion with saline or plasma, or with a whole-blood transfusion.

Some alternative therapies may help to support the injured person. Homeopathic remedies include: Ledum (Ledum palustre) taken internally for puncture wounds, calendula (Calendula officinalis) or tea tree oil (Melaleuca spp.) used topically as an antiseptic, aloe (Aloe barbadensis) applied topically to soothe skin during healing, and St. John's wort (Hypericum perforatum) used internally or topically when wounds affect the nerves, especially in the arms and legs. Acupuncture is thought to support the healing process by restoring energy flow in the meridians affected by the wound. In some cases, vitamin E, taken orally or applied topically, may speed healing and prevent scarring.

Prognosis

Without the complication of infection, most wounds heal well with time. Depending on the depth and size of the wound, it may or may not leave a visible scar.

Health care team roles

Nurses are extensively involved in the assessment and treatment of wounds. Typical responsibilities include daily cleaning of the wound with disinfectant soap, removal of crusting and loose, non-viable tissue, dressing the wound, and ensuring that a physician is notified of any changes in the wound, especially signs of infection. Other issues to be addressed by nursing staff may include pain management, appropriate nutrition to promote healing, psychosocial effects of serious or disfiguring wounds, and administration of tetanus toxoid to prevent a systemic infection. It can be very important to determine the cause of wounds, especially those that are chronic—such as leg ulcers.

Prevention

Most actions that result in wounds are preventable. Injuries from motor vehicle accidents may be reduced by advising patients to wear seatbelts and to place children in size-appropriate car seats in the back seat. Sharp, jagged, or pointed objects or machinery parts should be used according to the manufacturer's instructions and only for their intended purpose. Firearms and explosives should be used only by adults with explicit training; they should also be kept locked and away from children. Persons engaging in sports, games, and recreational activities should wear all proper protective equipment and follow safety rules.

KEY TERMS

Abrasion— Also called a scrape. The rubbing away of the skin surface by friction against another rough surface.

Avulsion— The forcible separation of a piece from the entire structure.

Butterfly bandage— A narrow strip of adhesive with wider flaring ends (shaped like butterfly wings) used to hold the edges of a wound together while it heals.

Cut— Separation of skin or other tissue made by a sharp edge, producing regular edges.

Laceration— Also called a tear. Separation of skin or other tissue by a tremendous force, producing irregular edges.

Plasma— The straw-colored fluid component of blood, without the other blood cells.

Puncture— An injury caused by a sharp, narrow object deeply penetrating the skin.

Tourniquet— A device used to control bleeding, consisting of a constricting band applied tightly around a limb above the wound. It should only be used if the bleeding is life-threatening and cannot be controlled by other means.

Traumatic shock— A condition of depressed body functions as a reaction to injury with loss of body fluids or lack of oxygen. Signs of traumatic shock include weak and rapid pulse, shallow and rapid breathing, and pale, cool, clammy skin.

Whole blood— Blood that contains red blood cells, white blood cells, and platelets in plasma.

Resources

PERIODICALS

Jull, Andrew. "Decision-Support For Moist Wound Dressings." New Zealand Nursing Review (December 2000).

ORGANIZATIONS

American Red Cross. P.O. Box 37243, Washington, D.C. 20013. 〈http://www.redcross.org〉.

OTHER

"Principles of Wound Management." Critical Care—London Health Sciences Centre. 2000. 〈http://critcare.lhsc.on.ca/icu/cctc/procprot/nursing/procedures/wound_mgmt.html〉 (March 29, 2001).