Definition
A.Wounds are breaks in the external surface of the body.
Pathogenesis
A.Wounds can be caused by any one of innumerable objects that breach the skin. Lacerations and abrasions typically heal by a four-stage process of clotting, inflammation, skin cell proliferation, and remodeling. The most common pathogens of wound infections are Staphylococcus aureus and beta hemolytic streptococcus.
Predisposing Factors
A.Exposure to accidental or intentional injury.
B.Accident prevention failure.
C.High-risk behaviors.
D.Conditions that predispose to poor wound healing:
1.Diabetes.
2.Corticosteroid therapy.
3.Immunodeficiency.
4.Advanced age.
5.Undernourishment.
6.Comorbidities.
Common Complaints
A.Bleeding.
B.Pain.
C.Cut
in the skin integrity.
D.Drainage.
Other Signs and Symptoms
A.Signs and symptoms of infection: Deep wounds and dirty wounds have increased risk for infection.
B.Soft-tissue damage: Wounds with tissue necrosis have increased risk for infection.
Subjective Data
A.Elicit the patient’s description of how the wound occurred, including where and when the injury was sustained.
B.Ascertain how much time elapsed until treatment. If 6 hours have elapsed, bacterial multiplication is likely.
C.Ask if the patient is currently immunized for tetanus.
D.Complete a drug history; include any allergies to medications, anesthetics, or dressings.
E.Ask if the patient is taking any medications, especially steroids or anticoagulants.
F.Assess iodine and sulfa drug allergies before starting treatment.
G.Review with the patient whether anything significant in the past medical history may interfere with the healing process (e.g., immunodeficiency).
Physical Examination
A.Check temperature, pulse, respirations, and blood pressure.
B.Inspect:
1.Inspect wound.
2.Measure wound for length × width × depth. Wounds with untidy edges may heal more slowly and with disfigurement.
3.Assess underlying bony structures.
4.Inspect for foreign objects.
C.Palpate:
1.Palpate extremities for neurovascular function and sensation.
2.Palpate tissue distal to wound.
3.Palpate lymph nodes surrounding injured area.
D.Neurologic exam: Assess motor function distal to wound.
Diagnostic Tests
A.Culture wound site if suspicious of infection.
B.Take x-ray films for deep or crushing wounds.
Differential Diagnoses
A.Wound, minor.
B.Accidental self-inflicted injury.
C.Self-inflicted injury.
D.Domestic violence.
E.Bite.
Plan
A.General interventions:
1.Wounds that require open-wound management:
a.Abrasions and superficial lacerations.
b.Wounds with great amount of tissue damage.
c.Wounds more than 6 hours old.
d.Contaminated wounds.
e.Large area of superficial skin denudation.
f.Puncture wounds.
2.For wounds that do not require sutures:
a.Cleanse wound well with warm water and soap; remove all dirt and foreign bodies.
b.Forceful irrigation may be needed; use finepore sponge (Optipore) with a surfactant, such as poloxamer 188 (Skin Clens). If wound edges are easily approximate, apply Steri-Strips.
c.Dry, sterile dressings (Telfa, and tape or gauze wrap) may be used.
3.If inflammation is present, soak and wash for 15 to 20 minutes three to four times per day. Cover with clean, dry dressing. Do not use Steri-Strips.
4.For wounds that require sutures:
a.Clean with warm water and soap. Irrigate with sterile saline solution.
b.Anesthetize with 1% to 2% lidocaine (xylocaine). Do not use solution with epinephrine at fingertips, nose, or ears. Probe wound for any remaining foreign bodies. Approximate wound edges.
c.Suture the following with technique appropriate to site:
i.Skin sutures: Nonabsorbable material (e.g., nylon, Prolene, silk).
ii.Subcutaneous and mucosal sutures: Absorbable material (e.g., Dexon, Vicryl, or plain or chromic gut).
iii.Extremities: 4 to 0 nylon.
iv.Soles of feet: 2 to 0 nylon.
d.Cover with clean, dry dressing; change after first 24 hours.
e.Suture removal is based on location:
i.Head and trunk: 5 to 7 days.
ii.Extremities: 7 to 10 days.
iii.Soles and palms: 7 to 10 days.
f.Tetanus prophylaxis.
B. 
See Section III: Patient Teaching Guide Wound Care: Pressure Ulcers.
C.Pharmaceutical therapy:
1.Control pain with acetaminophen (Tylenol) or ibuprofen, as needed.
2.Topical antibiotic ointments: Bacitracin and neomycin.
3.Patients with severe wound contamination, involvement of structures, immunocompromise, or vascular insufficiency would be given oral antibiotics for prophylaxis:
a.Amoxicillin, clavulanate acid (Augmentin) 875 mg orally twice a day for 7 to 10 days.
b.With penicillin allergy, use erythromycin; 500 mg orally twice a day for 7 to 10 days.
4.Other alternatives: Cephalexin (Keflex), cefadroxil (Duricef ), ciprofloxacin.
5.Tetanus toxoid 0.5 mL by intramuscular (IM) injection in deltoid, if no booster has been administered in the past 5 years.
6.Wounds diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) should be treated with the following oral antibiotics:
a.Trimethoprim sulfamethoxazole (Bactrim).
b.Minocycline or doxycycline.
c.Clindamycin rifampin (should be used in combination with one of the previous antibiotics).
d.Linezolid.
7.Antibiotics not recommended because of high resistance include the following:
a.Beta lactams.
b.Fluoroquinolones.
c.Dicloxacillin.
d.Cephalexin.
8.Treating the nares with Bactroban ointment twice a day and having the patient use hibiclens soap when showering will help to prevent recurrent infections.
9.For severe cases of infection, the patient requires hospitalization for aggressive antibiotic treatment.
Follow-Up
A.Have the patient return for evaluation and dressing change in 24 to 48 hours.
Consultation/Referral
Refer the patient to a physician for the following wounds:
A.Facial wounds.
B.Subcutaneous tissue penetration.
C.Functional disturbance of tendons, ligaments, vessels, or nerves.
D.Grossly contaminated wounds.
E.Wounds requiring hospitalization or aggressive antimicrobial therapy for evidence of pyogenic abscess, cellulitis, and ascending lymphangitis.
Individual Considerations
A.Adults:
1.Adults with compromised immune systems and chronic conditions are at greater risk for developing a secondary bacterial infection.
B.Geriatrics:
1.Avoid use of nonsteroidal anti-inflammatory drugs (NSAIDs) in patients that have chronic kidney disease Stage IV or less (creatinine clearance <30 mL/min).
2.Medications commonly used in the elderly population are associated with poor wound healing: cytotoxic antineoplastic agents, corticosteroids, aspirin, NSAIDs, anti-coagulants, bisphosphonates, and pain medications that contain morphine.