What is an open wound?
An open wound is any cut or opening which goes through the skin, particularly one where the edges of the skin cannot be brought together or don’t stay together, exposing the deeper layers of the skin or tissues beneath.
Types of Open Wound
Most wounds can fall into one of four broad categories:
This is any ‘cutting’ or ‘slicing’ type wound; it can be as a result of an accident, or it could be a surgical wound. Usually, with a straight cut where there isn’t any loss of tissue inside the wound, the wound edges will close together and heal with no or only minimal scarring and complication.
A puncture wound is caused by a sharp, pointed object. Puncture wounds may have only minimal skin loss or impact on the outer layers of the skin but can go very deep and damage internal structures such as organs. Puncture wounds tend to be prone to infections as bacteria is introduced deep into the body, but the natural processes of cleaning and draining are inhibited by the depth and narrowness of the wound.
Usually a more superficial wound, an abrasion can be caused by skidding, grazing, or scraping. Although they’re usually shallow, a loss of a large area of skin means that it can be vulnerable to infections and may be quite painful.
This is a serious traumatic wound where skin and subcutaneous tissue are torn away or apart. They are usually a result of violent trauma.
Fun fact: A wound is usually acute in nature and is caused by an external force. In contrast, an ulcer is usually chronic in nature and caused by an internal problem. Examples of ulcers include pressure ulcers (also known as bedsores) and diabetic ulcers.
Stages of Wound Healing
When we damage our skin and the deeper tissues of the body, our body needs to stabilise the wound then begin a natural healing process. Healing generally goes through four main phases:
- Haemostasis: When we get hurt or cut, our body’s most urgent natural response is to try to stop any bleeding. The blood vessels around the damaged area constrict to reduce blood flow and the body begins a clotting cascade; sticky, flat blood cells called platelets rush to the injured place to stop the bleeding, and a network of fibres builds up as a flat area of clotted blood. This also helps to protect against any bacteria or particles entering the wound and provide a stable frame under which healing can begin. This clot hardens and dries to form a scab, which should eventually slough off when the skin underneath is well-healed.
- Inflammation: This describes the phase where a wound becomes swollen. This is partly due to the leakage of fluids within damaged tissues, and partly due to the healing processes – having extra white blood cells, fluids and nutrients is all part of the healing.
- Proliferation or granulation: This is the point where new tissue starts to grow. Collagen and epithelial cells cover the surface of the wound (this may be underneath a scab if the wound is dry), and the area begins to regain its stability and strength.
- Maturation or remodelling: The patchy proliferative stage gives way to tighter, more normal-looking layers of skin. This is the stage at which it begins to be clear whether the wound will leave a scar when it has healed, although scars can continue to reduce for months after the wound has healed.
The phases don’t all happen at the same time all over the wound – different parts of the wound can be in different phases of healing. A large wound may appear well-healed around the edges even when the centre of the wound is still raw.
We also describe the way a wound is healing in three ways:
- Primary intention: This is where a wound can be completely closed, whether it naturally comes together, needs only ‘paper stitches’, or needs to be surgically drawn together, stitched, stapled, or glued. If the tissues of a wound are healing in the right positions relative to each part of the wound, then it is closed by primary intention. Wounds that heal by primary intention usually have minimal scarring and a low rate of complications.
- Secondary intention: For wounds where there has been a significant amount of tissue loss, such as large abscesses, pressure sores or leg ulcers. The skin cannot be drawn together and the healing process takes place across a larger open space. The tissues can still heal and re-epithelialise, but if there has been full-thickness skin loss then that skin will never fully regrow over a large open wound. Wounds that are healing by secondary intention can take a long time to heal and are more prone to infections and extensive scarring.
- Tertiary intention: Some wounds are intentionally or surgically left open. Some large and complex surgical or traumatic wounds, or wounds with lots of exudate, infection and circulatory problems can cause problems; keeping them open prevents them from healing superficially at skin level, trapping large areas of infected or heavily draining matter within the body. Wounds that heal by tertiary intention often show significant scarring and need close and careful management.
Types of Wound Dressing
There are lots of types of dressing for wounds, with hundreds of brands offering a range of products – some highly similar to each other. The most basic requirements for a dressing are that it protects against further damage or infection and that it promotes a good healing environment. A good healing environment is one with the right amount of moisture – dry wounds don’t heal as well as moist wounds, but wounds that are too wet can cause skin breakdown around the wound and prevent healing. The absorbency of the dressing, therefore, needs to be chosen based on the assessment of each individual wound.
- For dry wounds, a primary dressing should be something that creates a moist environment, such as paraffin-soaked gauze. An adhesive dressing over the gauze keeps everything in place. Hydrogels
- For wetter wounds, a contact dressing which maintains a moist healing environment while allowing excess fluid to drain away into an absorbent pad is necessary. Alginate dressings – made from seaweed – are absorbent but remain moist, and can be covered with dressing pads and adhesive dressings.
- For infected wounds or those at high risk of infection, special dressings have to be used. Some dressings are designed to have specific antiseptic properties – some contain silver or iodine, both of which prevent or reduce microbial growth. Honey-based creams and ointments are also commonly used for difficult wounds.
How to Change Wound Dressings
People with particularly fragile and delicate skin may find that even gently adhesive dressings tear their skin when removed. Soaking the dressing before removing it may help, but sometimes it may be necessary to avoid any adhesive against skin altogether. On limbs, dressings can be held in place with wool and crepe bandages, which avoids having anything stuck to the skin. Tube bandages are also available and come in different sizes for arms, legs, fingers and toes.
Different types of dressing can be left in place for different lengths of time, sometimes up to a week if they don’t become wet or show significant strikethrough. Removing a dressing that’s stuck to healing skin can cause trauma, so it’s generally recommended that dressings be left in place for as long as the manufacturer recommends. If they get too wet, it may be possible to change outer dressings while leaving the wound contact layer intact to prevent damage to new cells. Wounds which become infected may need to be changed more frequently, especially if there is a lot of pus or slough coming from the wound.
Dressing changes should be done with an aseptic, no touch technique. Dressings should be changed in the cleanest possible environment, with clean hands and disposable gloves. Wounds should be gently cleaned and any slough that comes away easily should be removed. Anything material that does not come away easily should not be pulled at, in case it causes more damage.
Most dressings, particularly those intended for contact with the wound’s surface, come in sterile packaging. This packaging should be opened carefully to avoid touching and contaminating the dressing.
Basics of Wound Treatment
In the past, it was thought that keeping wounds dry and exposed to the air was the best way to heal them. However, extensive research has found that the best way to heal wounds and minimise scarring is through maintaining a moist, clean environment. Choosing the right dressings can create the best environment for healing.
Wounds need to be kept clean and monitored for signs of infection. Swelling and redness around a wound when it is healing is natural, but it’s important to watch out for signs of infection. Seek medical help should the wound and/or its surrounding areas become:
- Excessively swollen
- Hot to the touch
- Wetter, particularly if it is exuding pus
- Exceptionally red, especially if it is spreading – marking the edges of a reddened patch of skin with a pen can help show whether it is getting more widespread over time
An infected wound can make someone unwell and severe infections can lead to sepsis. It’s important to watch out for fever or other signs. If a wound is causing concerns, it should be assessed by a professional who can give advice and prescribe antibiotics if necessary.
Large wounds which are wet can leak a lot of fluid and need to be managed with dressings and absorbent pads. This fluid loss can also contribute to dehydration, loss of electrolytes and protein, so it’s also important to remember to stay hydrated and follow a healthy diet to help your body heal itself.
Wound Care at Home
Minor wounds can be managed at home with simple dressings, and medication for pain if necessary. More serious, deep or dirty wounds should be assessed by a professional. This can be done at home or at a clinic. Chronic wounds – those that take a long time to heal – may need to be dressed regularly by nurses or trained caregivers.
Severe infections and infections which become widespread may require strong intravenous antibiotics or specialist treatment. Hospital admission may be necessary as well. Large or deep traumatic wounds and wounds that won’t stop bleeding should be treated as a medical emergency. People who take blood thinners such as warfarin are more prone to bleeding problems.
Wounds that become infected may need antibiotics. Sometimes topical ointments, antiseptic creams, or emollients may be appropriate, and sometimes it might be recommended to soak a wound in water, possibly with an emollient soap substitute to keep the skin around the wound healthy.
Medical Treatment for Wounds
Some wounds may require more specialised treatment. Some of these treatments include:
Surgical Debridement (Sharp Debridement)
When a wound has lots of dead (necrotic) tissue that don’t slough away naturally, a nurse or doctor with special training in debriding wounds can remove the dead matter, leaving only healthy tissues ready to heal.
An abscess may develop when a wound heals over an area of infection, encapsulating pus and exudate within the body. This may need to be surgically punctured and drained – do not try to drain a wound at home.
Vacuum (Suction) or VAC Dressings
Some wounds benefit from a vacuum dressing. This is a layer of sponge-like foam that is first applied over the wound, then waterproof, airtight adhesive dressings are applied over it to make a tight seal. A small tube attached to a vacuum machine applies constant negative pressure. VAC dressings improve blood flow to wounds, drain excess fluid and can help pull wound margins together.
Spending time in a 100% oxygen environment in a high-pressure chamber has been shown to have good results for problematic chronic wounds.
Potential Complications from an Open Wound
With good management and nursing care, complications can be minimised but it can’t always be prevented. Complications from an open wound include:
Infections can occur within the wound bed and/or in the skin surrounding the wound. Infections that spread widely throughout layers of the skin are called cellulitis. Untreated infections can affect deeper tissues and processes of the body, causing infections in the muscles and bones (osteomyelitis).
Chronic Non-Healing Wounds
Wounds with poor blood flow, particularly in people with vascular diseases or diabetic ulcers, can take a long time to heal, sometimes months or even years.
The larger a wound and the more complications that occur during the healing process, the higher likelihood that a wound will leave a scar.
Any trauma or damage to the skin can be painful. Nerve damage may occur around severe or chronic wounds, making them less painful but usually more serious.
This means that there are areas of dead tissue. Sometimes a dry necrotic cap on a wound can be protective, but large areas of worsening necrosis often require surgical debridement or even amputation.
Prevention is better than cure. Some wounds can be avoided – pressure sores can often be prevented by proper nursing care, people who are prone to falling may need to have someone present with them throughout the day, and good management of diabetes and cardiovascular disease can prevent ulcers and non-healing wounds. However, there are also some wounds that cannot be predicted or prevented and need to be carefully managed with medical and nursing care. People who cannot attend clinics can have trained caregivers and nurses deliver effective wound care at home.
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