Wound Care and Laceration Repair for Nurse Practitioners in Emergency Care

Abstract The purpose of this article is to outline the phases and categories of wound healing and to discuss factors that affect wound healing. This article also describes an approach for systematic wound management so as to decrease the risk for infection of nonsurgical wounds. Patient assessment, special circumstances involving underlying structures, and foreign bodies are also discussed herein. Patient preparation, including wound cleansing, irrigation, scrubbing, and debridement are also covered along with anesthetic and analgesic tips and techniques for the advanced practice nurses in emergency care.

WOUND HEALING PHASES OF WOUND HEALING Phase II: PROLIFERATIVE (5 days - 3 weeks) Granulation: o Fibroblasts lay down a bed of collagen. o Defect filled in. o New capillaries at site of injury. Contraction: o Wound edges come together, reducing defect. Epithelialization: o Crosses moist surface. o Cells move outward from site.

Phase I: INFLAMMATORY (2 - 5 days) Hemostasis: o Vasoconstriction. o Platelet aggregation. o Thromboplastin makes clot. Inflammation: o Vasodilation. o Phagocytosis.

Phase III: REMODELING (3 weeks - 2 years) New collagen forms increases tensile strength. Scar tissue forms (only 80% as strong as original tissue).

Primary intention Closure of clean laceration/surgical incision. Closed with sutures, steri-strips, adhesives). Functional and aesthetic purposes: o Eliminates dead space by approximating the subcutaneous tissues. o Minimizes scar formation by careful epidermal alignment. o Avoids a depressed scar by precise eversion of skin edges.

CATEGORIES OF WOUND HEALING Secondary intention Delayed primary closure Spontaneous healingwound Combination of the other two left opento heal. types of wound healing. Closure by secondary Intentionally applied to intention is an adequate lacerations not considered alternative to other woundclean enough for primary closure techniques (e.g., closure Wounds that are at head and neck). high risk of infection (e.g., Spares patient more complex bites, wounds with delayed procedures (e.g., flap, skin presentation). grafts). Useful in superficial or deep defects resulting from dermatological surgery. Appropriate in conjunction with other reconstructive techniques.

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FACTORS AFFECTING WOUND HEALING Diabetes: The long-term effects of diabetes impair wound healing by diminishing sensation and arterial inflow. In addition, even acute loss of diabetic control can affect wound healing by causing diminished cardiac output, poor peripheral perfusion, and impaired polymorphonuclear leukocyte phagocytosis. Infection: Infection potentiates collagen lysis. Bacterial contamination is a necessary condition but is not sufficient for wound infection. A susceptible host and wound environment are also required. Foreign bodies (including sutures) potentiate wound infection. Drugs: Steroids and antimetabolites impede proliferation of fibroblasts and collagen synthesis. Nutritional problems: Protein-calorie malnutrition and deficiencies of vitamins A, C, and zinc impair normal wound-healing mechanisms. Tissue necrosis: Resulting from local or systemic ischemia or radiation injury, impairs wound healing. Wounds in characteristically well-perfused areas, such the face and neck, may heal surprisingly well despite unfavorable circumstances. Conversely, even a minor wound involving the foot, which has a borderline blood supply, may mark the onset of a long-term, nonhealing ulcer. Hypoxia and excessive tension on the wound edges also interfere with wound healing because of local oxygen deficits. See, for example, the pressure ulcers shown in the image below. Hypoxia: Inadequate tissue oxygenation due to local vasoconstriction resulting from sympathetic overactivity may occur because of blood volume deficit, unrelieved pain, or hypothermia, especially involving the distal extent of the extremities. Excessive tension on wound edges: This leads to local tissue ischemia and necrosis. Another wound: Competition between several healing areas for the substrates required for wound healing impairs wound healing at all sites. Low temperature: The relatively low tissue temperature in the distal aspects of the upper and lower extremities (a reduction of 1C1.5C [2F 3F] from normal core body temperature) is responsible for slower healing of wounds at these sites.