A wound is an injury that disrupts the epithelial lining of the skin and mucosa (moist inner lining of some body cavities and internal organs). A wound typically breaks the skin barrier and can affect surrounding body tissue. Wounds can be open or closed, as well as acute or chronic. Wounds can be severe like the loss of a limb, or minor like simple cuts and scrapes. Regardless of the extent and location of the wound injury, proper wound care is essential for fast and uncomplicated wound healing since even minor wounds can become more serious with improper wound management.
An acute wound is a result of an accident or surgery and typically heals within 8-12 weeks depending on the extent of damage, size, and depth.
Choric wounds are non-healing wounds that do not adhere to the normal process of healing such as leg ulcers and burns. Chronic wounds do not heal as expected. This sometimes happens in many medical conditions including repeated trauma, advanced age, diabetes, circulation problems, smoking, obesity, heart disease, cancer, unhealthy diet, certain medications, and weakened immune system.
Open Wounds include bites and stings, puncture wounds, surgical wounds/incisions, gunshot wounds, electrical burns, chemical burns, thermal burns, skin tears, lacerations, and abrasions.
Closed wounds include seroma (fluid-filled area under the skin/tissue), hematoma (a blood-filled area under the skin/tissue), crash injuries, contusions (blunt force trauma), and blisters.
Apart from chronic, acute, open, and closed wounds, some other types of wounds include:
- Ulcers – another type of wound that often needs wound care and management. There are four types of ulcers - pressure ulcer (injuries from prolonged pressure to the skin); arterial ulcer (due to insufficient flow of blood to the arteries); venous ulcer (due to insufficient flow of blood to the veins); and, neuropathic ulcer (loss of sensation that can result in an inability to sense injuries which can lead to ulcers especially in diabetic patients, thereby increasing the risk of infection).
- Surgical wounds – these are incisions and cuts made on the skin during surgery. Most times these cuts are sutured, but sometimes they are left open as part of the healing process. Typically, surgical wounds are monitored for signs of infection including redness, increased pain, delayed healing, pus, and a bad smell. Certain medical conditions like obesity and diabetes can predispose a patient to surgical site complications.
Symptoms of a Wound
The symptoms associated with a wound depend on the severity and location of the wound. Most common symptoms of having a wound include pain, bleeding, and swelling. If the wound is infected, other symptoms that may be present include pus, warmth, fever, oozing around the wound, soreness, and difficulty moving the affected area of the body. Since wounds do not occur in isolation, other factors also affect wound development, wound healing, and wound management. Early intervention and proper wound care with the right products can prevent infections, speed up healing, and improve outcome especially in severe wounds that require more skilled medical attention.
Steps in Wound Healing
Wound healing is a complex process that involves tissue regeneration and growth progress It naturally goes through four overlapping stages:
- Hemostasis and coagulation – hemostasis is the process of bleeding stopping at the site of injury and coagulation is when the material in the blood forms an insoluble gel to plug leaks in the blood vessels to stop bleeding. This is typically the first step in healing and occurs after the injury.
- Inflammatory phase – this is characterized by swelling that occurs shortly after the injury occurs. The body elicits this response as a way to protect itself and start the healing process.
- Proliferation phase – this final phase is where new blood cells and tissue form to continue healing the wound.
- Maturation phase – this last state of healing involves the process of remodeling the new tissue.
These phases overlap in a natural order over the length of the healing process. The duration of each step is largely dependent on the type of wound, type of wound dressing, nutrition, and other medical conditions. Selecting appropriate wound dressings and other wound care products is an extremely crucial part of the healing process.
Characteristics of a Wound
No two wounds are the same and no two wound care plans are the same. Before determining how to proceed with caring and managing a wound, clinicians and caregivers should consider some of the following characteristics of a wound to determine the best approach to wound management: tissue appearance and color; moisture level (dry or wet wound); pain associated with the wound; infection (signs can include warmth, odor, swelling, fever, redness); length, depth, and width of wound; location of wound; drainage (color, odor, quantity, texture); burrowing under skin; and, condition of the periwound (tissue surrounding the wound).
Wounds that Need Medical Care
Simple wounds like cuts and bruises may not need specialized wound care; however, some wounds do, including wounds that require stitches to close, wounds that cannot be cleaned easily, wounds that bleed despite management, injuries that result from force and trauma, and wounds that are caused by animal bites.
Factors that can Affect Wound Healing
How well and how fast a wound heals depends on the interactions among multiple components including the blood, growth factors, and body components. These interactions prevent dehydration, increase inflammation, form tissues, and form the membranes. Wound healing is also affected by other factors like pain, temperature, tissue oxygenation, and infection. The overall health of the patient, vitamin/mineral levels, and age also plays a role in wound healing.
Nutrition and hydration are also extremely important in wound care and wound healing. Up to 50% of hospitalized patients are malnourished, and for wound care patients, not getting sufficient protein and micronutrients can slow wound healing and complicate wound care. A good nutritional plan that takes into consideration a patient’s overall health is essential for overall success of wound care.
Types of Wounds
- Abrasion – this is a scrape on the skin with little or no bleeding. It is an open wound typically caused by skin rubbing against something harsh or rough. They can range from mild to severe. With abrasions, the first layer of the skin may be rubbed off, and even though this can be minor, they still require proper wound care and treatment to prevent infection and promote quicker healing.
- Puncture – this is a deep wound that creates a hole in the skin and can cause damage to internal organs. It happens when something sharp and pointed pierces the skin, like a nail. Even though the opening on the skin may be minimal, and depending on the severity of the puncture, bleeding can be negligible, this sort of wound should still be treated appropriately to improve healing, especially if it is a deep wound. If untreated, a puncture wound can lead to infection which can spread to the bone and skin.
- Laceration – this is a deep cut or wound in the skin resulting from the tearing of the soft body tissue by a sharp object. Lacerations can also result from impact injury from a blunt object or by blunt force. Unlike an abrasion, the skin is normally intact but can look jagged and irregular. Lacertations can look like a cut, tear, or gash. It may bleed and swell. It is often contaminated with the pathogens from the object that caused the wound. Minor lacerations at home may not require specialized care, but deep lacerations can cause damage to the muscles, ligaments, and tendons, and as such, should be treated promptly.
- Avulsion – this type of wound involves the sudden and accidental tearing away of the skin and detachment of tissue beneath the skin including fat, ligaments, tendons, bone, and cartilage. An avulsion can be partial or complete, often accompanied by heavy and rapid bleeding. Unlike lacerations that look like cuts with a jagged edge, lacerations will typically have a flap. The torn skin may be lost during the injury, or just too damaged to be repaired. An avulsion typically occurs in gunshots, explosions, and major vehicle accidents. They can range from minor skin flaps to severe amputation of limbs or extremities.
What Are Some Goals of Wound Care?
- Decreasing the risk of further injury to an existing wound
- Minimizing pressure around the wound
- Speeding up healing
- Ensuring adequate blood flow to other parts of the body
- Protecting the skin especially in skin tears
- Controlling swelling, especially in the lower extremities, by using compression dressings
- Educating patient/caregivers about what they can do to assist wound healing
- Managing diabetes in patients with a history of this health condition since uncontrolled diabetes can lead to wound development and poor wound healing
- Preventing and managing infection
- Preventing loss of limb(s)
- Improving quality of life of the patient
- Managing chronic non-healing wounds
- Avoiding wound complications like osteomyelitis and cellulitis
- Treating infected wounds to avoid sepsis which can lead to more severe injuries
- Preserving appearance and function of injury area
How to Choose the Best Wound Care Dressing
The dressing material used for wound care is dependent on the type of wound. Regardless of how minor or severe a wound might be, using the proper sterile, non-toxic, and hypoallergenic wound dressing is important to ensure a better outcome. A wound dressing is designed to be in close contact with a wound and the dressing should be selected based on the ability to:
- Provide protection against pathogens that cause infections
- Maintain the right tissue temperature
- Allow gas exchange between the wound and the environment
- Promote tissue synthesis
- Be easily removed (non-adherent to the wound)
- Provide and retain a moist environment suitable for healing
- Enhance epidermal skin migration to enhance repair
- Support debridement which is the removal of dead or infected skin tissue as well as foreign materials from the wound site
Types of Wound Dressing Products
There are currently over 3000 types of wound dressings that are used to promote a suitable healing condition for a wound. These dressings target different types of wounds and different stages in the healing process. Wound dressings can be classified largely into traditional wound dressing and modern wound dressing.
- Traditional Wound Dressing
Traditional wound dressing includes products like gauze, plasters, bandages, lint, and cotton wool. They are typically dry and used as primary or secondary dressing to protect wounds from contamination. They also promote wound healing.
Traditional dressing like sterile gauze made from fibers of cotton, rayon, and polyesters can be used to absorb drainage from an open wound. However, these dressings, when used for moist wounds, require frequent changes due to excessive drainage. They also tend to adhere to the wound thus making them painful and irritating to remove. To make them more user-friendly, these dressings could be moistened to prevent adhesion and aggravation to the wound. Traditional dressings are usually covered by a secondary dressing and have to be changed at least once a day.
Bandages are usually used for light minor wounds and dressings; however, high compression bandages can provide support with ulcers and other wounds. Most traditional wound dressings are best for dry and clean wounds. They are also used as secondary dressings since they do not often provide a moist environment for optimal wound healing.
- Modern or Advanced Wound Dressing
Modern wound dressing do more than just cover a wound – they also act as a barrier to prevent penetration of the wound environment by pathogens, and they promote healing. These dressing are made from synthetic polymers and promote the right environment for healing. Most modern dressings are designed to prevent wound dehydration. Modern dressings can be classified as bioactive, interactive, and passive products. Bioactive dressings are made from biomaterials, mostly derived from natural and artificial sources. Interactive dressings are occlusive (air and water-tight) or semi-occlusive (breathable) and are available as hydrocolloids, hydrogel, foam, and film. Passive products like gauze and tulle dressings are non-occlusive and function as a cover for the wound to restore its functions.
Types of Modern Dressing
- Semi-permeable film dressing/transparent films
These dressings are flexible and highly elastic and conform to any shape without any additional reinforcement. They are made of transparent and adherent polyurethane which allows the movement of air around the wound. A semi-permeable film dressing protects the wound against bacteria and provides debridement. Since the dressing is transparent, a caregiver or clinician can inspect the wound without removing or changing the dressing. This dressing, like the Fixapro Advaced Transparent Dressing, is recommended for shallow wounds, superficial wounds, and wounds with little exudate (fluid made of cells, solid material, and protein that leak from blood vessels or nearby tissue in wounds). Film dressings differ based on their size, flexibility, adhesiveness, and permeability.
- Semi-permeable foam dressings
Foams are absorptive, often have adhesive borders, and can be used as a primary dressing or under compression dressings. Typically, secondary dressing is not required when using a foam dressing due to their high absorbency. Foam dressigns are made of hydrophilic and hydrophobic foams. This allows an exchange of gas and water vapor essential for wound healing. Silicon-based rubber foam dressings can be used for almost all types of wounds including skin tears as it is nonadherent yet conforms to the shape of the wound. Foam dressings can be adhesive or non-adhesive dressings. Foam dressings are useful for healing environments that require moisture since it can absorb a varying amount of wound drainage. It is, however, not frequently used in dry wounds, dry scars, and wounds with low drainage.
- Alginate Dressing
Made of calcium and sodium salts, alginate dressings are highly absorptive, yet they do not adhere to wounds. They are useful as primary dressing in exuding wounds and are typically covered with a secondary dressing since alginate can cause wound dehydration and delay the process of healing. These dressings are also derived from seaweed and are absorbent and biodegradable. Once they are applied to a wound, the ions in the alginate form a protective layer (gel), and the alginates initiate inflammatory processes necessary for wound healing. Their high absorption property is largely due to the hydrophilic gel formation. This gel reduces bacterial contamination, limits wound drainage, and keeps the wound moist. Alginate dressings are useful in wounds with moderate-to-heavy drainage and should be avoided in dry wounds, wounds that expose the bones, and third-degree burns. Alginate dressings are typically changed every 24 to 48 hours.
- Hydrogel dressing
Hydrogel wound dressings are soothing and cooling, especially with painful wounds. They are insoluble hydrophilic materials with a high-water content that help the skin in moist environments. These dressings encourage the critical formation of microscopic blood vessels and new connective tissue on the surface of the wound. This tissue, known as granulation tissue, grows from the base of the wound to fill the wound over time, regardless of the size. Hydrogels are effective in every stage of wound healing. They are non-reactive and non-irritation, effective in treating burn wounds, pressure ulcers, and dry chronic wounds. Hydrogels help to create a moist environment for wound healing and are easily applied and removed without further injury to the wound. The major setback for hydrogel dressings is their tendency to absorb excess drainage which can promote the growth of bacteria; however, they can be useful in wound care for challenging wounds like chronic leg ulcers.
- Hydrocolloids Dressing
Hydrocolloids dressings consist of two layers – an outer, water-impermeable layer and an inner colloidal layer. The dressing itself is made of a combination of different types of gel-forming agents including pectin and gelatin. Hydrocolloids protect the wound against bacteria, can absorb wound drainage, and have debridement (wound cleaning) properties. They are permeable to water vapor which is useful for promoting a moist environment for wound healing. Hydrocolloids should be avoided in the presence of existing wound infections or highly draining wounds, so they are mostly used as secondary dressing. Hydrocolloids, especially the thicker ones, absorb wound drainage while promoting wound healing. When hydrocolloids come in contact with wound exudate (drainage), they form gels and create a moist environment which protects cells and tissues that are in the process of repair. Hydrocolloids dressings are best used in light-to-moderate draining wounds such as minor burns and pressure sores, and they should be changed every 3 to 5 days.
Essential Steps to Take for Better Wound Care
The ultimate goal of wound care or wound management is to develop the most effective treatment plan that promotes fast and complete healing. Wound care involves this process:
- Assess and determine the plan of treatment – assessing a wound is the foundation of wound care. During this initial step, the caregiver or clinician managing the wound will evaluate and inspect the injury to identify any issues that might delay or impact healing, and then create a plan of treatment.
- Cleanse the wound – after assessing the wound, it is important to create the best healing environment for wound healing. This second step of wound healing typically involves cleansing and irrigating the wound without irritating the wound. Sometimes, the wound is swabbed with gauze and irrigated if needed.
- Protect the areas around the wound – one of the most missed steps in wound care is to protect the skin surrounding the wound to avoid any future injuries like the skin stripping. Cleansing with normal saline and applying a non-alcohol-based solution can help to protect and keep the wound from expanding.
- Pack and fill the wound – to prevent pockets of potentially serious abscess from forming at the wound site and ultimately delaying healing, fill the wound based on the initial wound assessment and depth of the wound. If the wound is infected or has a potential to be infected, consider using an anti-microbial agent. Commonly used material for filling and packing a wound include gels, alginates, foams, and fibers.
- Cover the wound – once the wound is filled, the next step is to cover the wound with a protective wound dressing to decrease the risk of infection, especially while the wound is still fresh and undergoing the initial healing process. Wound dressings are based on the type of wound as well as where the wound is located, if there is any drainage, and if it is infected.
- Secure the wound – securing the wound with a protective dressing and secondary dressing when indicated helps to ensure that the wound dressing stays secured and in place. Keeping this protective dressing in place prevents more damage to the wound and areas surrounding the wound. It also promotes healing and secures any medical device that might be in place.
- Evaluate – the last step in wound management is to determine if the treatment plan is effective and what modification, if any, needs to be made. During every dressing change, the wound is evaluated for continued healing.
Red Flags in Wound Care
- Increased wound drainage
- Fever above 101.0°F or shaking/chills
- Odor emanating from wound
- Changes in wound tissue color to white, black, or yellow
- Redness around the wound
- Increased size of the wound