Wounds Emergencies CEN Study Guide

The CEN Study Guide are designed to reflect the types of scenarios and patient situations encountered in real-world nursing practice.

Wounds Emergencies CEN Study Guide

Wound Assessment and Management

1. Skin is composed of 3 layers.

• The epidermis is the outermost layer of the skin. This waterproof layer contains no blood vessels and acts mainly to protect the body.
• Under the epidermis lies the dermis, which consists of dense connective tissue that allows skin to stretch and flex. The dermis is home to blood vessels, glands, and hair follicles.
• The hypodermis is a layer of fat below the dermis that stores energy (in the form of fat) and acts as a cushion for the body. The hypodermis is sometimes called the subcutaneous layer.

Figure 15.1. Anatomy of the Skin

General guidelines for wound care are outlined below.

• History and physical examination of wound:

1. Should be done after patient is stable.
2. Get vaccination history: Tetanus vaccination (DTaP, DT, Tdap, or Td) is required if patient has not been vaccinated within the last 5 years. Tetanus immunoglobulin (Tig) is required for unvaccinated patients with a high risk of wound infection.
3. Include neurovascular assessment and examination of anatomy of a wound.
4. X-rays as needed.

• Local anesthesia:

1. Local anesthesia (injected or topical) should be administered before the wound is cleaned and closed.
2. Common anesthetics include lidocaine (duration 1-2 hours), bupivacaine (duration 4-8 hours), and procaine (duration 15 - 45 minutes).
3. Epinephrine may be added to anesthetic agents to increase the duration of effect.

• Wound cleaning:

1. Irrigate with sterile water or normal saline to flush debris from wound.
2. Remove foreign bodies.
3. Debride nonviable tissue.

• Wound closure:

Methods of primary closure include sutures, staples, wound tape, and glue.

1. Glue should not be used in high-tension areas (e.g., joints) or on mucous membranes.
2. Staples should only be used in areas where scars will not be visible.
3. Wound tape may be used for superficial wounds but may fall off when exposed to moisture.

Topical antibiotics may be applied after wound closure for wounds at high risk for infection.

• Wound dressing:

1. gauze and non-adherent pads: used for dry, closed wounds
2. wet-to-dry dressings: The innermost layer is wet and keeps wound bed moist
3. transparent film: securement for IVs, moisture-retentive
4. calcium alginate dressing: absorbs wound exudate
5. hydrogel: promotes moisture within wound bed
6. foam dressing: provides cushioning over bony prominences

TABLE 15.1. Types Of Wound Closure

Type	Description
Primary	closure within 4 to 8 hours of wound occurrence used with minimal risk, clean or clean-contaminated wounds tissue integrity is maintained, and there is no tension created with closure
Secondary	wound is left to heal on its own used when wounds are contaminated, have edges that cannot be approximated, have penetration to an organ, or have a high risk for infection may take longer to heal, and healing may become halted at the full-thickness stage
Tertiary	wound is left intentionally open to allow for improved healing used when infection or edema is present

Specific Wounds

TABLE 15.2. Diagnosis and Management of Trauma Wounds

Wound	Management
Avulsion full thickness injury in which skin is separated from the body by an external force tearing or pulling the tissue; exposed ligaments, tendons, muscle fibers, and bone may be visible Degloving injury an avulsion where the skin is completely separated from the underlying structures	control bleeding local or topical anesthetic debride wound (remove detached tissues as needed) irrigate wound with saline solution (avoid application of soap, hydrogen peroxide, or alcohol directly on wound) cover wound with an absorbent, non-adhering bandage or dressing ice, analgesics, and antibiotics as needed
Laceration a tear of the soft tissue; external lacerations that involve full thickness of the skin layers into the subcutaneous tissue are at high risk for infection due to bacteria or debris from the object causing the injury Injection injury injection of substances (e.g., paint, grease, industrial chemicals) through an almost unseen point of entry via high-pressure equipment; can result in tissue necrosis, compart¬ ment syndrome, or infection	control bleeding local anesthetic irrigate with normal saline prepare for closure (suturing, stapling, Dermabond adhesive, or Steri Strips as appropriate) dress wound ice, analgesics, and antibiotics as needed degloving injury: realign tissue and cover with sterile dressing debride, irrigate, and dress wound prophylactic antibiotics surgical consult ASAP monitor for compartment syndrome
Missile injury damage from a projectile (e.g., bullet); injury is dependent on the type, trajectory, and velocity of the bullet and on the character of the tissue or organs involved	remove clothing primary survey for entry/exit wounds; secondary survey to diagnose all injuries imaging: CT angiogram, eFAST, X-ray, or MRI IV fluids or blood products as needed pressure/tourniquet to bleeding injuries analgesics surgical consult
Puncture wounds caused by an object entering through soft tissue, resulting in hemorrhage and damage to the skin and underlying tissues; the a penetrating object also deposits organisms or foreign bodies into the deeper tissue, increasing the risk for infection	irrigate wound with saline solution topical anesthetic or ice cover using clean, moist dressing or nonstick/non-adherent dressing antibiotics

Wound Infections

Pathophysiology

Trauma wounds are at high risk for infection because they are contaminated by debris and microorganisms. Surgical site infections may also require emergency care, particularly if the patient had a preexisting infection or there was spillage from the GI tract during surgery. If not treated properly wound infections prevent proper healing and may lead to complications including cellulitis, endocarditis, septicemia, and osteomyelitis.

Physical Examination

• fever
• pain, erythema, and edema around the wound
• purulent exudate from a wound

Diagnostic Tests
CBC with differential and cultures to identify an infectious organism

Management

• wound care, including drainage, debridement, and appropriate dressings
• incision and drainage of abscesses
• topical antibiotics for non-purulent, local infections
• oral antibiotics for purulent local infections
• IV antibiotics for systemic infections or high-risk patients