WOUNDS

Definition

A wound is a type of injury which happens relatively quickly in which skin is torn, cut, or
punctured (an open wound), or where blunt force trauma causes a contusion (a closed wound). It
specifically refers to a sharp injury which damages the dermis of the skin. An injury is damage to
your body. It is a general term that refers to harm caused by accidents, falls, hits, weapons, and
more.

Pathophysiology

To heal a wound, the body undertakes a series of actions collectively known as the wound
healing process.

1. Hemostatic or inflammatory phase - starts immediately and lasts 2-5 days

a. Hemostatic (restricts the flow of blood within the vessels) – initial injury to approximately
3 hours post injury
i. Vasoconstriction
- Is the blood vessels’ first response to injury
- Collagen is exposed which attracts the platelets to adhere to the injury site
- Platelets release cytoplasmic granules which contain serotonin, ADP and
thromboxane A2, all of which, increase the effect of vasoconstriction
- Serotonin is a vasoconstrictor
- Adenosine diphosphate (ADP) attracts more platelets to the affected area
- Thromboxane A2 assists in platelet aggregation, vasoconstriction and degranulation
- As more cytoplasmic granules are released, more platelets stick and release their
chemicals, creating a platelet plug
ii. Platelet plug formation
- Platelet adhesion: Von Willebrand factors assist and help bind platelets to the
injured site, platelets bind easily to the exposed collagen
- Platelet release reaction: Platelets release more cytoplasmic granules which can
signals more platelets to bind in the site
- Platelet aggregation: Is the clumping together of platelets
- Platelet plug formation: a platelet plug is formed
- Note: healthy cells doesn’t form a platelet plug because it releases nitrous oxide and
prostaglandins which prevents platelets to adhere to the healthy cells or non-injured
area
iii. Blood Coagulation
- Enhances and strengthens the plug formed by the platelets by creating a fibrin mesh
- Clotting factors: This involves two pathways(intrinsic and extrinsic pathway) which
releases a substance called prothrombinase (prothrombin activator)
- The extrinsic pathway is activated by the release of thromboplastin from the tissue.
As the result of a series of reactions, prothrombin is converted to thrombin, which
in turn catalyzes the conversion of fibrinogen to fibrin. Clotting by the intrinsic
pathway is activated when the collagen that lines blood vessels is exposed
- Thrombin formation: prothrombinase and Ca2+ catalyzes prothrombin into thrombin
- Fibrin formation: Thrombin and Ca2+ acts as an enzyme convert fibrinogen into
fibrin
- Fibrin acts as a glue for the sticky platelets
 - As the fibrin mesh begins to form, the blood is also transformed from a liquid to a
gel like substance that forms a clot in the area
- This forces blood cells and platelets to stay trapped in the wounded area and stop
the bleeding
b. Inflammatory (destroying bacteria and cleansing the wound)
- Serotonin is released, which, together with histamine (released by mast cells),
induces a reversible opening of the junctions between the endothelial cells, allowing
the passage of neutrophils and monocytes (which become macrophages) to the site
of injury.
- Monocytes and neutrophils are attracted to the site of injury
- Neutrophils trap and kill bacteria immediately
- Monocytes become activated macrophages, scavenge nonviable tissue and bacteria
- The migration of neutrophils and monocytes is made possible by dilation and
increase permeability of the capillaries which allows plasma to leak into the tissue
surrounding the wounded area
- The dilated capillaries caused the inflammation of the wound
- The plasma that leaked into the tissue caused the swelling of the wound
- The increase surface area of the dilated vessels result in greater visibility of the red
color capillaries giving the skin around the wound more reddish appearance
2. Proliferative phase
- lasts from 2 days to 3 weeks
- Begins as the cells that migrate to the site of injury, such as fibroblasts, epithelial
cells, and vascular endothelial cells, start to proliferate and the cellularity of the
wound increases.
- Macrophages do not only destroy wound debris but also releases cytokines and
other growth factors and dissolves the platelet plug for granulation
- Granulation: The cytokines involved in this phase include FGFs (fibroblast growth
factors) which stimulates angiogenesis and epithelial cell and fibroblast
proliferation
- Angiogenesis is the physiological process through which new blood vessels form
from pre-existing vessels
- The fibroblast, newly formed capillaries and epithelial cells form the granulation
tissues which appear like a red, beefy, shiny tissue
- As the granulation tissue proliferates, fibroblast stimulates the production of
collagen which gives tissue strength and structure, it holds the tissue together
- Capillaries carries oxygens and nutrients to the granulation tissue and helps absorb
and carry away waste product from the tissue that would help the process of wound
healing
- Oxygen is incorporated by 2 amino acids, proline and lysine, which are both
required for collagen chain synthesis
- Contraction: As wound site fills with a granulation tissue, its margins contract or
pull together decreasing the size of the wound
- Epithelialization: Cells migrate to the wound margins and ultimately touch one
another sealing the wound when there is an adequate oxygen to help the healing
process
3. Maturation and Remodeling Phase
- lasts from 3 weeks to 2 years
- An organized form of collagen gradually replaces the immature, soft, gelatinous
collagen
 - The effect is to increase the tensile strength of the healed wound, but it is less than
80% as strong as the original tissue

Types of wound healing

1. First intention, also termed primary healing, is the healing that occurs when a clean laceration
or a surgical incision is closed primarily with sutures, Steri-Strips, or skin adhesive.
2. Second intention, also termed secondary healing, is the healing that occurs when a wound is
left open to heal by granulation, contraction, and epithelialization.
3. Delayed primary closure is a combination of the aforementioned types of wound healing. It is
often intentionally applied to lacerations that are not considered clean enough for immediate
primary closure. The wound is left open for 5-10 days; then, it is sutured closed to decrease
the risk of wound infection.

Causes and Types of Wounds

Wounds occur when the skin is broken or damaged because of injury. Causes of injury
may be the result of mechanical, chemical, electrical, thermal, or nuclear sources. The skin can
be damaged in a variety of ways depending upon the mechanism of injury.

 Incisions or incised wounds - caused by a clean, sharp-edged object such as a knife,

razor, or glass splinter.
 Lacerations - irregular tear-like wounds caused by some blunt trauma. Blunt traumas are
physical trauma to a body part, either by impact, injury or physical attack
 Abrasions (grazes) - superficial wounds in which the topmost layer of the skin (the
epidermis) is scraped off. Abrasions are often caused by a sliding fall onto a rough
surface.
 Avulsions - injuries in which a body structure is forcibly detached from its normal point
of insertion. A type of amputation where the extremity is pulled off rather than cut off.
 Puncture wounds - caused by an object puncturing the skin, such as a splinter, nail or
needle.
 Penetration wounds - caused by an object such as a knife entering and coming out from
the skin.
 Gunshot wounds - caused by a bullet or similar projectile driving into or through the
body. There may be two wounds, one at the site of entry and one at the site of exit,
generally referred to as a "through-and-through.

Wound Signs and Symptoms

The most common symptoms of a wound are pain, swelling, and bleeding. The amount of
pain, swelling, and bleeding of a wound depends upon the location of the injury and the
mechanism of injury.

Some large lacerations may not hurt very much if they are located in an area that has few
nerve endings, while abrasions of fingertips (which have a greater number of nerves) can be very
painful.

Some lacerations may bleed more if the area involved has a greater number of blood vessels,
for example, the scalp and face.
Wound Care Diagnosis

The following tests may be useful to identify factors associated with wound development or
those that can slow wound healing:

 CBC count to assess for leukocytosis, anemia, and/or thrombocytopenia

 Analysis of the patient's basic metabolic profile to look for renal insufficiency and
electrolyte abnormalities
 Determination of serum protein, albumin, prealbumin, and transferrin levels to assess the
patient's nutritional status
 Coagulation studies to evaluate for abnormalities, especially if deep wound excision is
required
 Tissue cultures of wound to determine appropriate antibiotic therapy
 X-rays may be taken to look for broken bones (fractures). X-rays may also be helpful in
looking for foreign objects that may have been embedded in the laceration.
 Fluoroscopy done at the bedside may help find foreign bodies that are deeply buried
 Ultrasound may also be used to assist in diagnosis of foreign bodies in the wound

Wound Home Remedies

 Most wounds may be cared for at home. Superficial abrasions and lacerations can be
cleaned, an antibacterial ointment applied, and then covered with a band-aid or light
bandage.
 Bleeding can often be controlled with direct pressure to the wound, and if possible,
elevating the bleeding site above the level of the heart. This allows gravity to help
decrease blood flow to the injury. Most bleeding will stop within 10 minutes, at which
point, a dressing can be placed over the wound.
 If bleeding is not a problem, the wound can be cleaned using tap water to wash out any
debris to decrease the risk of infection. River and lake water can contain many types of
bacteria that can cause significant infection. It is not recommended to clean wounds with
contaminated water.
 Deeper wounds are painful and scrubbing is not necessarily advised.

Medical Management

Treatment of recent lacerations involves examining, cleaning, and closing the wound.

Minor wounds, like bruises, will heal on their own, with skin discoloration usually disappearing
in 1–2 weeks.

Abrasions, which are wounds with intact skin (non-penetration through dermis to subcutaneous
fat), usually require no active treatment except keeping the area clean, initially with soap and
water.

Puncture wounds may be prone to infection depending on the depth of penetration. The entry of
puncture wound is left open to allow for bacteria or debris to be removed from inside.

Cleaning

1. Stop the bleeding

2. Irrigate the wound with warm flowing water for 1 minute
3. Apply antibiotic topical ointment and let it dry
4. Bandage the wound
Closure

These include bandages, a cyanoacrylate glue, staples, and sutures.

Bandages for minor cuts or scrapes

Sutures- a stitch or row of stitches holding together the edges of a wound

cyanoacrylate glue - Studies confirm that cyanoacrylate is safer and more functional for wound
closure than traditional suturing (stitches). The adhesive is superior in time required to close
wounds, incidence of infection, and final cosmetic appearance.

Staples- in place of sutures to close skin wounds

Dressings

Alginate Hydrofiber Debriding agent Foam Hydrocolloid Hydrogel Low-adherence dressing

Transparent film

What type of wound care dressing is right for my wound?

Hydrocolloid:

Hydrocolloid dressings are used on burns, light to moderately draining wounds, necrotic wounds,
under compression wraps, pressure ulcers and venous ulcers.

Hydrogel:

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:

Alginate dressings are used for moderate to high amounts of wound drainage, venous ulcers,
packing wounds and pressure ulcers in stage III or IV.

Surgical Treamtment

Skin grafting- type of graft surgery involving the transplantation of skin

Cadaveric allografting

A cadaveric skin allograft is a useful covering for relatively deep wounds after surgical excision
when the wound bed does not appear appropriate for application of an autologous skin graft. The
allograft is only a temporary solution

Nursing Management

Assess the entire patient

Successful treatment of difficult wounds requires assessment of the entire patient and not just the
wound. Systemic problems often impair wound healing; conversely, nonhealing wounds may
herald systemic pathology.
Consider the negative effects of endocrine diseases (eg, diabetes, hypothyroidism), hematologic
conditions (eg, anemia, polycythemia, myeloproliferative disorders), cardiopulmonary problems
(eg, chronic obstructive pulmonary disease, congestive heart failure), GI problems that cause
malnutrition and vitamin deficiencies, obesity, and peripheral vascular pathology (eg,
atherosclerotic disease, chronic venous insufficiency, lymphedema).

Characterize the wound

Assess the following: (1) size and depth of involvement and the extent of undermining, (2) the
appearance of the wound surface—is it necrotic or viable, (3) amount and characteristic(s) of
wound exudate

Ensure adequate oxygenation

The usual reason for inadequate tissue oxygenation is local vasoconstriction as a result of
sympathetic overactivity. This may occur because of blood volume deficit, unrelieved pain, or
hypothermia, especially involving the distal extent of the extremities.

Ensure adequate nutrition

Adequate nutrition is an often-overlooked requirement for normal wound healing.[25] Address

protein-calorie malnutrition and deficiencies of vitamins and minerals.

Inadequate protein-calorie nutrition, even after just a few days of starvation, can impair normal
wound-healing mechanisms. For healthy adults, daily nutritional requirements are approximately
1.25-1.5 g of protein per kilogram of body weight and 25-30 calories/kg. These requirements can
increase, however, for patients with sizeable wounds.

Vitamin and mineral deficiencies also require correction. Vitamin A deficiency reduces
fibronectin on the wound surface, reducing cell adhesion, and tissue repair. Vitamin E inhibits
prostaglandin synthesis by interfering with phospholipase-A2 activity and is therefore anti-
inflammatory. Vitamin E supplementation may decrease scar formation.

Zinc is a component of approximately 200 enzymes in the human body, including DNA
polymerase, which is required for cell proliferation.

Consider compression therapy

Consider the advisability of compression therapy. Compression is appropriate for ulcers caused
or exacerbated by extremity edema. to gently apply pressure to the ankles and legs by wearing
specifically designed stockings. These dressings then work to slowly stretch out vein walls and
improve overall circulation, which in turn helps eliminate swelling.

Manage pain

Manage wound pain by moistening dressings before removal. Consider using 2% topical
lidocaine gel during wound care.

Preventive Measures

Accidents happen and most people will sustain a wound regardless of how careful they
might be.

It is important to remember that when using tools at home or at work, to make certain
they are being used in the appropriate manner and the appropriate precautions are taken. Often
accidents occur because the person was in a rush, took a shortcut, or was using a tool in a way it
wasn't designed.
 Protective gear is always appropriate. Wearing proper shoes or boots, wearing a bike
helmet, or eye protection regardless of the situation will prevent an injury.

Complication

Bacterial infection of wound can impede the healing process and lead to life-threatening
complications.

Workup

Wounds that are not healing should be investigated to find the causes; many microbiological
agents may be responsible. The basic workup includes evaluating the wound, its extent and
severity. Cultures are usually obtained both from the wound site and blood. X-rays are obtained
and a tetanus shot may be administered if there is any doubt about prior vaccination.[19]

Many of these lower extremity amputations can be prevented through an interdisciplinary

approach to treatment involving a variety of advanced therapies and techniques, such as dressing
selection, special shoes, and patient education. When wounds persist, a specialized approach is
required for healing.

Updates

Future and Controversies

The aging of the population and advances in biotechnology continue to drive the wound
care industry, estimated at $10 billion globally. Besides the always-improving synthetic dressing
materials, newer technologies in wound treatment include the xenogeneic tissue scaffold,
bilayered human dermal substitutes, recombinant growth factors, endoscopic subfascial
ligation of venous perforators, and endovascular arterial repair techniques. The use of
hyperbaric oxygen therapy and electrical stimulation remain controversial.

Recent systematic reviews, although not conclusive, suggest that different debridement
methods, whether they be chemical, surgical or autolytic, all result in similar results.[64] Other
reviews suggest that there may be a role for negative-pressure wound therapy and hyperbaric
oxygen in the management of chronic wounds and that there probably is no role for
electromagnetic therapy or low-frequency ultrasound therapy based on current best evidence.