Question

laceration. which of the following action should the nurse plan to take?

Answer 1

Lacerations are a pattern of injury in which skin and the underlying tissues are cut or torn. Healthcare providers encounter lacerations regularly. It was reported in 2005 the nearly 12% of all ER visits or 13.8 million visits occurred for laceration care.Lacerations can be managed in the outpatient setting as well depending on the location and severity of the injury.

The clinical presentation of lacerations can be highly variable based on location, depth, width, and length. Due to this highly variable presentation, the healthcare team must have a strong understanding of the critical history and physical exam items each laceration requires

Guidelines for laceritis/ wound management:

1. Promote a multidisciplinary approach to care.
2. Initial patient and wound assessment is important and whenever there is a change in condition.
3. Consider the psychological implications of a wound- especially relevant in the paediatric setting in relation to developmental understanding and pain associated with the wound and dressing changes.
4. Determine the goal of care and expected outcomes.
5. Respect the fragile wound environment.
6. Maintain bacterial balance- use aseptic technique when performing wound procedures.
7. Maintain a moist wound environment
8. Maintain a stable wound temperature. Avoid cold solutions or wound exposure.
9. Maintain an acidic or neutral pH.
10. Allow a heavily draining wound to drain freely.
11. Eliminate dead space but don’t pack a wound tightly.
12. Select appropriate dressings and techniques based on assessment and scientific evidence.
13. Instigate appropriate adjunctive wound therapies- e.g. compression, splinting and pressure redistribution equipment, off-loading orthotics.
14. Follow the principles for managing acute and chronic wounds.

Acute Wound Management

Wound cleansing

The goal of wound cleansing is to:

• Remove visible debris and devitalised tissue
• Remove dressing residue
• Remove excessive or dry crusting exudates
• Reduce contamination

Principles of wound cleansing:

• Use Aseptic Technique procedure- a non-touch technique is used to protect key parts and key sites. If a key part or key site is to be touched directly then sterile gloves must be worn. Note: when using a disinfectant on a key site (e.g. skin) or key part (e.g. injection port) it must be allowed to dry.
• Cleansing should be performed in a way that minimises trauma to the wound as new epithelial cells and vessels are fragile.
• Irrigation is the preferred method for cleansing open wounds. This may be carried out utilising a syringe in order to produce gentle pressure and loosen debris. Gauze swabs and cotton wool should be used with caution.
• Wounds are best cleansed with sterile isotonic saline or water, warmed to body temperature.

Choice of dressing

A wound will require different management and treatment at various stages of healing. No dressing is suitable for all wounds; therefore frequent assessment of the wound is required.

Wound healing progresses most rapidly in an environment that is clean, moist (but not wet), protected from heat loss, trauma and bacterial invasion.

• Much research has demonstrated that moisture control is a critical aspect of wound care.
• The appropriate dressing can have a significant effect on the rate and quality of healing.
• The appropriate dressing will help to minimize bacterial contamination and pain associated with wound care.

There are a multitude of dressings available to select from. Effective dressing selection requires both accurate wound assessment and current knowledge of available dressings (Ayello, Elizabeth A)

Wounds healing by Primary Intention

These wounds require little intervention other than protection and observation for complications.
Recommended dressings include:

• Dry non-adherants
• Island dressings
• Semi-permeable films
• Hydrocolloids
• Foams

Wounds healing by delayed primary intention

Occurs when the wound is contaminated or infection is suspected. These traumatic or surgical wounds require intensive cleaning before healing can occur. Debridement using irrigation may be required.
Recommended dressings include:

• Normal saline compresses
• Amphorous hydrogels or hydrogel impregnated gauzes to assist with debridement
• Calcium alginate ropes or ribbons
• Hyrofibre ropes or ribbons
• Drainable wound/ostomy appliances when large amounts of exudate is present
• Foams

Absorbent or protective secondary dressings will be required for most wounds- it is important to ensure that the surrounding skin is protected from maceration. A skin barrier wipe can be used.

Wounds healing by secondary intention

Acute surgical or traumatic wounds may be allowed to heal by secondary intention- for example a sinus, drained abscess, wound dehiscence, skin tear or superficial laceration.
Dressing selection should be based on specific wound characteristics. Referral to Stomal Therapy should be considered to promote optimal wound healing.

RCH Dressing Selection Resources

• Wound Dressing Product Reference Guide
• Dressing and Wound Management Poster
• Dressing Supplies Ordering

Chronic wound management

Determine the aetiology for inhibition of wound healing. Address or control the factors identified for example: presence of infection, poor nutritional status, appropriate dressing selection, moist wound environment.

Dressing selection should be based on the specific wound characteristics and referral to Stomal Therapy should be initiated to promote optimal wound healing. Advanced wound therapies may be required to be utilitised e.g surgical debridement, application of a negative pressure dressing, hyperbaric therapy.