Wound Care
TERMINAL LEARNING OBJECTIVE
Given a standard fully stocked Combat Medic Vest System (CMVS) or fully stocked M5 Bag, you encounter a casualty with an open wound who is breathing. The casualty has been initially assessed and injury(ies) prioritized.
As a soldier medic, you may likely encounter a soldier needing wound care. You need to understand the wound healing process and wound care to enable you to identify abnormal healing processes, wound contamination, and provide proper treatment of common wounds. Good wound management includes assessing nutritional status, nutrient intake and appropriate intervention as needed.
(1) Integument System - Serves to shield the body from its environment, protect it from bacterial invasion, control temperature and retain or release fluids. It is the largest organ of the body
(2) Epidermis - The superficial or outer layer of skin. This layer does not contain blood vessels or nerves. Protects dermis from infection and drying
(3) Dermis - The second layer of skin, contains structures that affect cooling, sensation, and circulation of nutrients
(4) Subcutaneous layer - Third layer of skin; insulates and adds shape to the body and stores energy. Varies in thickness IAW its location in the body
(5) Infection - The invasion and multiplication of infective agents in body tissues with a resultant reaction to their presence and their toxins
(1) Contusion - Hematoma beneath unbroken skin because of small vessel ruptures
(2) Crush injuries - Overlying skin may remain intact, injury to multiple tissues, muscle or bone injury
(1) Abrasions - Partial thickness skin loss
(2) Lacerations - Break in skin of varying depth
(3) Avulsion - Full thickness skin loss, degloving or flap injuries are avulsions
(4) Amputations - A part of the body is partially or completely severed or torn from the body
(5) Punctures/ penetrations - Caused by a foreign object that enters the body, underlying damage can be extensive
(6) Bite - Breakage of the skin caused by animal or human teeth, all bites are considered contaminated
(1) Primary intention (primary union)
(a) Wounds that are closed surgically
(b) Little tissue loss
(c) Skin edges are close together and minimal scarring
(d) Healing begins during the inflammatory phase
(2) Secondary intention (granulation)
(a) Healing occurs when skin edges are not close together (approximated) or when pus has formed
(b) If wound is producing or containing pus (purulent) a drainage system is established or the wound is packed with gauze
(c) Slowly the necrotized tissue decomposes and escapes
(d) The cavity begins to fill with soft, pink, fleshy projections consisting of capillaries surrounded by fibrous collagen (granulation tissue)
(e) The amount of granulation tissue required depends on the size of the wound
(f) Scarring is greater in a large wound
(3) Tertiary (third) intention
(a) Delayed primary closer
(b) Two layers of granulation tissue are sutured together
(c) Occurs when:
(1) Contaminated wound is left open and sutured closed after the infection is controlled
(2) Delayed suturing of a wound
(3) Primary wound becomes infected, is opened, is allowed to granulate, and is then sutured
(d) Results in a larger and deeper scar than primary or secondary intention
(1) Adequate oxygenation
(2) Adequate rest or local immobilization
(3) Sufficient blood supply
(4) Proper nutrition
(a) Nutrients are needed for wound repair and prevention of infection
(b) Adequate wound healing is dependent upon the availability of essential nutrients
(1) Age - causes slower regeneration of tissue
(a) Physiological Effects
(1) Alters all phases of wound healing
(2) Vascular changes impair circulation to wound site
(3) Reduced liver function alters synthesis of clotting factors
(4) Formation of antibodies and lymphocytes is reduced
(5) Collagen tissue is less pliable
(6) Scar tissue is less elastic
(b) Interventions
(1) Instruct patient on safety precautions to avoid injuries
(2) Be prepared to provide wound care for longer period
(3) Teach home caregivers wound care techniques
(a) Physiological Effects
(1) All phases of wound healing are impaired
(2) Stress from burns or severe trauma increases nutritional requirements
(b) Interventions - Provide balanced diet rich in protein, carbohydrates, lipids, vitamins A and C, and minerals
(a) Physiological Effects - Fatty tissue lacks adequate blood supply to resist bacterial infection and deliver nutrients and cellular elements
(b) Interventions - Observe obese patient for signs of wound infection, dehiscence, and evisceration
(a) Physiological Effects
(1) Low arterial oxygen tension alters synthesis of collagen and formation of epithelial cells
(2) If local circulating blood flow is poor, tissues fail to receive needed oxygen
(3) Decreased hemoglobin (anemia) reduces arterial oxygen levels in capillaries and interferes with tissue repair
(b) Interventions
(1) Diet adequate in iron
(2) Monitor patients’ hemotocrit and hemoglobin levels
(a) Physiological Effects
(1) Reduces the amount of functional hemoglobin in blood, thus decreasing tissue oxygenation
(2) May increase platelet aggregation and cause hypercoagulability
(3) Interferes with normal cellular mechanisms that promote release of oxygen to tissue
(b) Interventions - Discourage patient from smoking by explaining its effects on wound healing
(a) Physiological Effects
(1) Steroids reduce inflammatory response
(2) Anti-inflammatory drugs suppress protein synthesis, wound contraction, epithelialization, and inflammation
(3) Prolonged antibiotic use may increase risk of superinfection
(4) Chemotherapeutic drugs can depress bone marrow function, number of leukocytes, and inflammatory response
(b) Interventions - Carefully observe patient; signs of inflammation may not be obvious
(8) Diabetes mellitus
(a) Physiological Effects
(1) Causes small blood vessel disease that impairs tissue perfusion
(2) Causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues
(3) Alters ability of leukocytes to perform phagocytosis and also supports overgrowth of fungal and yeast infection
(b) Interventions
(1) Instruct patient to take preventive measures to avoid cuts or breaks in skin
(2) Provide preventive foot care
(3) Control blood sugar to reduce the physiological changes associated with diabetes
(1) How did the wound occur?
(2) What type of object caused the injury?
(3) When did the wound occur?
(4) Color
(a) Pink - usually indicates healthy tissue
(b) Black - indicates poor tissue perfusion, necrosis
(c) Red - indicates infection
(5) Odor - a foul smell indicates presence of bacteria
(6) Wound size –
(a) Measure wound from side to side at largest point
(b) Take second measurement perpendicular to first
(c) Document both measurement (i.e., "1" by "3"), or by using commonly-known object, such as "dime-sized" wound
(7) Wound boundaries - edges of wound smooth or irregular
(8) Drainage
(a) Color
(b) Quantity
(c) Consistency (watery, thick, etc.)
(d) Odor
Neurovascular status of the affected extremity MUST be assessed prior to wound treatment
(1) Pulse quality, location, rate
(2) Capillary refill, unreliable indicator in adults
(3) Skin color/temperature
(4) Sensation/Motor function
(1) Contusion
(a) Assess for depth of hematoma
(b) Identify damage to underlying vessels, nerves and bony structures
(c) Assess peripheral pulses
(d) Assess sensation
(e) Assess motor function and strength
(f) Assess for pain control
(g) Assess need for tetanus prophylaxis
(2) Crush injury
(a) Assess for wound depth and blood loss
(b) Assess for neurovascular status:
(1) Pulse quality, location, rate
(2) Capillary refill, may be unreliable in adults
(3) Skin color
(4) Level of consciousness
(c) Assess for pain control
(d) Assess need for tetanus prophylaxis
(3) Abrasion
(a) Assess for amount of fluid loss in large wounds
(b) Assess functional capabilities
(c) Assess for pain control
(d) Assess need for tetanus prophylaxis
(4) Laceration
(a) Assess age and depth
(b) Assess degree and/or type of contamination
(c) Assess for associated injuries
(d) Assess neurovascular status of affected extremity as appropriate:
(1) Pulse quality, location, rate
(2) Capillary refill
(3) Skin color/temperature
(4) Sensation/motor function
(e) Assess for pain control
(f) Assess need for tetanus prophylaxis
(5) Avulsion
(a) Assess amount of tissue and functional loss
(b) Assess depth of injury
(c) Assess for pain control
(d) Assess need for tetanus prophylaxis
(6) Amputations
(a) Assess for blood loss and bleeding source
(b) Assess neurovascular status:
(1) Pulse quality, location, rate
(2) Capillary refill, may be unreliable indicator in adults
(3) Skin color/temperature
(4) Sensation/motor function
(c) Assess for pain control
(d) Assess need for tetanus prophylaxis
(7) Punctures/ penetrations
(a) Assess for presence of foreign bodies/materials and impaled objects
(b) Assess depth of penetration for underlying structural damage
(c) Assess type/degree of contamination
(d) Assess for pain control
(e) Assess need for tetanus prophylaxis
(1) Life-threatening injuries are managed prior to isolated wounds: Assess for and treat any existing critical injuries
(a) Airway
(b) Breathing
(c) Circulation
(2) Wound categories
(a) Penetrating chest wounds
(b) Impaled or open abdominal wounds
(c) Amputations
(d) Avulsions
(e) Crush injury
(3) Expose area
(4) Stop the bleeding
(5) Maintain intravenous access and fluids for significant blood loss or severe underlying structure damage: Treat for shock as necessary
(6) Assess for neurovascular status:
(a) Pulse quality, location, rate
(b) Capillary refill, may be unreliable indicator in adults
(c) Skin color/temperature
(d) Sensation/motor function
(7) Emergency treatment of specific wounds
(a) Cleanse wound to decrease contamination
(b) Prevent dehydration of wound by covering wound with sterile dressing
(8) Assess and apply appropriate type of dressing and splints
(9) Assess activity restrictions
(10) Provide pain relief management
(a) Apply ice packs
(b) Administer medication
(1) Contusion
(a) Elevate contused area or extremity
(b) Apply ice pack within first 24 hrs
(2) Crush injury
(a) Control bleeding
(1) Direct pressure
(2) Pressure dressing
(b) Apply dry, sterile dressing
(c) Elevate extremity, if possible
(d) Administer antibiotics as directed
(e) Tetanus prophylaxis if needed.
(3) Abrasion
(a) Cleanse wounds thoroughly by scrubbing with normal saline
(b) Remove debris and foreign bodies with soaked sponge or irrigation
(c) Apply antibiotic ointment
(d) Leave wound covered with a nonadherent dressing
(4) Laceration
(a) Control bleeding with direct pressure
(b) Cleanse and irrigate thoroughly
(c) Wound closure by skin sutures, staples or steri-strips
(1) Sutures - thread, wire or other materials used to sew body tissues together
* Placed within tissue layers in deep wounds and superficially as the final means for wound closure
* Deeper sutures are usually made of material that will be absorbed by the body in several days
* Types: Interrupted or separate, continuous, blanket, retention suture covered with rubber tubing to provide greater strength
(2) Staples
* Provides quick closure
* Usually less costly
* Limited to areas of less cosmetic importance such as scalp or trunk
* Removal of staples requires a sterile staple extractor and maintenance of aseptic technique
(d) Tetanus prophylaxis if needed
(5) Avulsion
(a) Control bleeding by direct pressure
(b) Cleanse thoroughly
(c) Cover wound with ointment, sterile dressing, and splints
(d) Tetanus prophylaxis if needed
(6) Amputations
(a) Control bleeding with direct pressure, pressure points and elevation - Apply tourniquet if above measures are not successful
(b) Apply moist, sterile dressing over amputation stump
(c) Wrap amputated body part in moist, sterile dressing; place in plastic bag and place over ice
(d) Tetanus prophylaxis if needed
(7) Punctures/ penetrations
(a) Secure any impaled objects
(b) Soak the wound in Betadine/normal saline solution for several minutes
(c) Provide care of drains, if present
(d) Administer antibiotics as directed
(e) Tetanus prophylaxis If needed
(1) Dry gauze dressing - Permit air to reach the wound
(2) Wet gauze dressing –retains moisture while it removes drainage from the wound
(3) Transparent dressing
(a) Chief advantage is they facilitate wound assessment without removing the dressing.
(b) Less bulky than gauze
(c) Does not require tape
(d) Non Absorbent
(4) Hydrocolloid dressing
(a) Self adhesive
(b) Air and water occlusive dressing
(c) Can be left in place up to one week
(1) Dressings are changed per doctor's orders, when the wound requires assessment or care, and when they become loose or saturated with drainage
(2) Supplies and equipment needed
(a) Gather supplies and wash hands
(b) Waterproof bed pads
(c) Sterile dressings
(d) Plastic bag or basin
(e) Sterile saline or water
(f) Irrigation pack and solution
(g) Eye shield or face guard
(h) Sterile and clean gloves
(i) Tape or Montgomery straps
(3) Explain procedure to patient
(a) Position the patient and expose the area to be redressed
(b) Place waterproof pad under patient and prepare plastic bag as receptacle
(c) Put on clean non-sterile exam gloves
(d) Gently loosen tape toward the wound while supporting the skin around the wound or untie Montgomery straps
(e) Remove the dressing, being careful not to tear the wound or dislodge any drains. Use sterile saline to moisten dressing if it is sticking to the wound, to prevent discomfort to the patient and/or to maintain integrity of sutures.
(f) Assess amount, color, odor, and consistency of drainage
(g) Remove gloves and dispose in plastic bag
(h) Establish a sterile field. Open all sterile equipment and supplies and place within the sterile field. Uncap sterile saline or other solution as ordered
(i) Put on sterile gloves
(1) Linear wound
(a) First stroke - cleanse the area directly over the wound by wiping from the top to bottom. Discard the gauze.
(b) Second stroke - cleanse the skin area on one side next to the wound, wiping from top to bottom. Discard the gauze.
(c) Third stroke - cleanse the skin on other side of wound, wiping from top to bottom. Discard the gauze.
(d) Continue this procedure alternating sides of the wound, working away from the wound until clean.
(2) Circular wound
(a) First stroke - starting at the center of the wound, wipe the wound area with an outward spiral motion. Do not use the same swab/gauze to clean the entire wound
(b) Continue this procedure, working outward until wound is clean. Do not cross back to the center of wound.
(1) Put on sterile gloves and eye shield or face guard, if available
(2) To prevent contamination and to clean the bottle rim, pour a small amount of the liquid into waste receptacle. If the seal of the bottle has not been broken, this step is not necessary
(3) Pour irrigating solution into basin with the label facing the palm
(4) Fill the syringe with solution from the sterile basin
CAUTION: If Betadine (iodine) is being used, check to ensure patient does not have allergies to the iodine. An alternate, non-iodine-based solution may be used (Hibiclens, phisohex, hydrogen peroxide). Betadine not generally used in irrigation unless severly contaminated.
(5) Hold the tip of the syringe just above top end of wound and force fluid into the wound slowly and continuously. Use enough force to flush out debris but do not squirt or splash fluid
(6) Irrigate all portions of the wound. DO NOT force solution into wound pockets. Continue irrigating until solution draining from bottom end of wound is clear
(7) Using sterile gauze, gently pat dry the edges of the wound. Work from cleanest to most contaminated areas
(1) Lay inner dressing over wound ensuring the dressing extends past the edge of the wound
(2) All other dressings will overlap each other and cover entire wound
(3) Cover all inner dressings with a large out dressing
CAUTION: Some wounds must be kept moist, and will require the use of "wet to dry" dressings. The inner dressings that touch the wound directly will be dampened with a solution (usually normal saline) before application. The outer dressings are applied dry. Example: abdominal evisceration.
WARNING: During combat conditions, the medic will NOT remove an existing dressing but will only reinforce with additional dressings. Label the dressing "REINFORCED." Write date, time and your initials.
(4) Remove gloves and place in disposal bag
(5) Tape the dressing or tie Montgomery straps
CAUTION: Tape should not form a constricting band around the wound or extremity.
(6) Reposition and cover patient
(7) Close and dispose of plastic bag with used supplies IAW local policy
(8) Wash hands
(9) Document wound care and all assessments on the appropriate form
(a) Enter the date and time of the procedure
(b) Enter a description of the wound's color, odor, consistency, and amount of drainage
(1) Exudate –fluid, cells or other substances that have slowly exuded or discharged from cells or blood vessels through small pores or breaks in cell membrane
(2) Drainage – the removal of fluids from a body cavity, wound, or other source of discharge by one or more methods
(3) Types
(a) Serous
(1) Clear, watery fluid that has been separated from its solid elements (e.g., the exudate from a blister)
(2) Serous fluid has characteristics of serum
(3) Serum is clear, thin, sticky fluid portion of blood that remains after coagulation
(b) Sanguineous - Fluid contains blood
(c) Serosanguineous - Thin and red, described as pink
(4) Exudate/drainage greater than 300 ml in the first 24 hours should be treated as abnormal
(5) When patients first ambulate, a slight increase may occur
(6) If sanguineous drainage continues, small blood vessels may be oozing
(7) Not all surgical wounds drain, the following characteristics are important to note and chart:
(a) Color
(b) Amount
(c) Consistency (thick/thin)
(d) Odor
Wound drainage systems
(1) Open drainage
(a) Drainage that passes through an open-ended tube into a receptacle or out onto the dressing
(b) Penrose drain is a soft tube that may be „advanced“ or pulled out in stages as the wound heals from the inside out
(2) Closed / Suction drainage
(a) Self-contained suction units that connects to drainage tubes within the wound
(b) Removes fluid in an airtight circuit
(c) Prevents environmental contaminates from entering the wound or cavity
(d) Two types of drainage devices that are portable and provide constant low-pressure suction to remove and collect drainage without wall suction
(1) Jackson-Pratt drain – used when small amounts (100 –200 ml) of drainage is anticipated
(2) Hemovac drainage system used for larger amounts (up to 500 ml) of drainage
Assist with on-going casualty management
(1) Checked after:
(a) Each dressing change
(b) Application of heat and cold therapies
(c) Wound irrigation
(d) Stress to the wound site
(2) Evaluation measures
(a) Assess condition of the wound
(b) Ask whether patient notes any discomfort during procedure
(c) Inspect condition of dressings at least every shift
(3) Documentation: minimal characteristics in every wound evaluation
(a) Location
(b) Size
(c) Drainage color
(d) Amount
(e) Consistency (thick/thin)
(f) Odor
(g) Neurovascular (NV) Status
(1) Monitor vital signs
(2) Monitor distal peripheral pulses
(3) Monitor skin color, sensation and temperature
(4) Monitor motor function
(5) Monitor IV fluids
(6) Provide pain control
(7) Monitor for compartment syndrome
(a) Pain
(b) Firmness of muscle compartment
(c) Paresthesia
(8) Evacuate to next echelon of care for further medical treatment as indicated
(1) Impaired wound healing
(2) Terms associated with wound complications
(a) Abscess – Cavity containing pus and surrounded by inflamed tissue, formed as a result of suppuration in a localized infection
(b) Adhesion – Band of scar tissue that binds together two anatomical surface normally separated; most commonly found in the abdomen
(c) Cellulitis – Infection of the skin characterized by heat, pain, erythema, and edema
(d) Dehiscence – Separation of a surgical incision or rupture of a wound closure
(e) Eviseration – Protrusion of an internal organ through a wound or surgical incision
(f) Extravasaion – Passage or escape into the tissues; usually of blood, serum, or lymph
(g) Hematoma – Collection of extravasated blood trapped in the tissues or in an organ resulting from incomplete hemostasis after surgery
(3) Wound bleeding may indicate a slipped suture, dislodged clot, coagulation problem, or trauma placed on blood vessels or tissues
(4) Inspection of the wound and dressing aids in detecting increase drainage and color changes
(5) If bleeding occurs internally
(a) Dressing may remain dry while the abdominal cavity collects blood
(b) Patient will have increase thirst, restlessness, rapid, thready pulse, decreased blood pressure, decreased urinary output, and cool, clammy skin
(c) Abdomen will become rigid and distended
(d) If not detected, hypovolmic shock can cause circulatory system to collapse, causing death
(6) Dehiscence – wound layers have separated
(a) Patient may say that something has ‘given way’
(b) May result after periods of sneezing, coughing, or vomiting
(c) Evidence of new or increased serosanguineous drainage on the dressing is an important sign to assess
(d) Management:
(1) Patient should remain in bed
(2) Kept NPO
(3) Told not to cough
(4) Always reassure patient
(5) Place sterile dressing over area until physician evaluates the site
(7) Evisceration – abdominal organs protrude through opened incision
(a) Patient is to remain in bed
(b) Wound and contents should be covered up with warm, sterile saline dressings
(c) Surgeon is notified immediately – this is a medical emergency
(8) Wound infection, or wound sepsis – results when the surgical wound becomes contaminated
(a) CDC labels a wound infected when it contains purulents (pus) drainage
(b) Patient with an infected wound displays a fever, tenderness and pain at the wound, edema, and an elevated WBC
(c) Purulent drainage has an odor and is brown, yellow or green, depending on the pathogen
SUMMARY
You will care for all types of wounds throughout your time in the Army. You may scrub a wound in the ER, irrigate a wound on a hospital ward or change a dressing in a Battalion Aid Station. A soldier medic must be knowledgeable about wounds and wound care to prevent infection and facilitate wound healing. These practices will minimize the time that a soldier must be away from his unit due to illness or injury. This is one of the best ways "to conserve fighting strength!"