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Traumatic wounds: nursing assessment and management

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VOL: 97, ISSUE: 24, PAGE NO: 52

Christine Dearden is A&E consultant at the Royal Hospitals and Dental Hospital Health and Social ServicesTrust, Belfast, Northern Ireland

Janice Donnell, RGN, RSCN, is a staff nurse, Martina Dunlop, RGN, BSc, is an emergency nurse practitioner at the Royal Hospitals and Dental Hospital Health and Social ServicesTrust, Belfast, Northern Ireland

It has been calculated that traumatic wounds account for 25-30% of total A&E department work. The hands and face are the areas most often affected, and the commonest type of wound is a laceration caused by blunt trauma (Wardrope and Smith, 1992).

Given the potential adverse effects of mismanagement, for example septicaemia or poor cosmetic outcome, it is imperative that nurses, particularly those working in A&E departments, minor injury units or the practice room, are skilled in the assessment and management of traumatic injuries of the skin. These wounds will include mechanical injuries - such as abrasions and lacerations - thermal injuries - such as burns - and chemical injuries.

Initial management

While it may be tempting to focus solely on the injury itself, it is very important to assess the health of the whole person. For practical reasons this assessment must begin with a primary survey - that is, airway, breathing, circulatory volume and level of consciousness. If this survey is overlooked, a potentially life-threatening injury may be missed.

A patient with a bleeding laceration should have gentle pressure applied with a sterile dressing to control the haemorrhage, and the affected area should be elevated. If the patient feels or looks faint they should be asked to lie down. Analgesia should be given as appropriate.

The removal of a large foreign body, such as a knife, should only be undertaken in theatre. This reduces the risk of uncontrolled bleeding and allows any serious underlying damage to be treated immediately.

The practice of clamping is not recommended, as previously undamaged structures, such as nerves or tendons, may be inadvertently crushed and irreversibly damaged (American Society for Surgery of the Hand, 1990).

The inflammatory phase of wound-healing is a vital part of traumatic wound-healing. Swelling, pain, redness and heat are the normal visible signs of this process. For this reason, anti-inflammatory drugs are not recommended as the analgesia of choice. However, they may be of benefit if excessive swelling occurs, as this will prevent the injured part from functioning.

History-taking

Once the patient has been stabilised, a more detailed history should be taken.

How did the injury occur?

The mechanism of the injury is vital to the assessment and care of the patient, as it provides clues to the type and amount of tissue damage. In order to establish the mechanism of the injury, it is important to try to get as detailed a history as possible from the patient, witnesses or ambulance personnel of how the injury occurred. This may include the type, size and weight of any instrument or machinery involved, whether it was blunt or sharp, the angle and speed of penetration or impact or, where appropriate, the type of chemical involved, whether it was acid or alkaline, for example.

In relation to the examples shown, it is important to note the following:

- A sharp implement such as a metal spike, knife or a piece of broken glass may have damaged deeper structures, such as tendons, nerves and organs. Remember that the wound tract may be longer than the length of the blade due to the elasticity of the tissues.

- Even though a crushing injury may reveal little surface damage, underlying structures, such as soft tissues and bone, may be extensively damaged.

- A human or animal bite increases the risk of bacterial infection.

If the history indicates that the wound may contain a foreign body, such as glass or metal, an X-ray should be taken to exclude this possibility. However, it is important to remember that some foreign bodies, such as wood, are not radio-opaque.

Where was the wound sustained?

It is important to establish the environment in which the injury happened for many reasons. For example, wounds sustained in an unclean environment are at a very high risk of contamination with bacteria, fungi and spores - for example, Clostridium tetani.

When did the wound occur?

Research indicates that the greater the time between wounding and good wound care, the greater the chance of infection (Templeton, 1988). If the interval is greater than six hours it should be assumed that bacterial multiplication will be great enough to cause a significant risk of infection if the wound is closed. The timing of the injury should be reflected in the urgency of triage (Manchester Triage Group, 1997).

Why did the wound occur?

The reason why the wound occurred should be established, as it may be an outward manifestation of abuse or an underlying medical disorder. For example, although a laceration may result from a fall, the ‘fall’ may have occurred as a result of tripping, an assault or, alternatively, any condition which leads to loss of consciousness, such as epilepsy. The nurse should also note if the accident could have been prevented through the use of safety equipment, such as hard hats or safety gates on stairs. If this is the case, information on accident prevention must be incorporated into the overall treatment plan.

Once the history of the presenting injury has been considered, the nurse should determine all other factors that may have a bearing on treatment. These factors will relate to coexisting medical conditions as well as the patient’s lifestyle, work and social circumstances.

Practice point

Check if the history of the injury is consistent with clinical findings. For example, a laceration over the metacarpophalangeal joint of the dominant hand should alert you to the possibility of a punch against an opponent’s teeth. However, patients may be too embarrassed to report their involvement in a fight. They need to be encouraged to disclose the full details of the injury, as human bite lacerations, for example, carry a very high risk of infection.

Current health status

It is important to be fully aware of coexisting medical conditions, as certain illnesses, such as peripheral vascular disease or diabetes mellitus, can predispose to poor healing or infection. The patient’s medication should be recorded, as drugs such as steroids and anticoagulants may adversely affect wound-healing. The practitioner should also consider any known allergies to drugs or dressings. This should include tetanus as well as general and local anaesthetics.

Lifestyle, work and social circumstances

It is important to remember that a seemingly trivial wound has the potential to seriously affect patients’ social and psychological well-being. This will largely depend on the type of the patient’s employment, hobbies, age and psychological make-up.

For example, a wound to the hand will often mean that many tasks at work or home are not possible. There may be difficulty driving a car, and an elderly patient with a pre-tibial laceration may lose mobility and will require help with the tasks of daily life.

Tetanus immune status

All patients with wounds (including burns) should be asked about their tetanus immunisation status.

Depending on where you live in the UK, a primary/basic course of tetanus toxoid usually consists of three doses of 0.5ml of tetanus toxoid given to babies at two, three and four months old. A booster dose is given before entry to nursery school or primary school and between the ages of 13 and 18.

An adult who has received these five doses is likely to have life-long immunity; a booster dose on injury should only be required if more than 10 years have elapsed.

It is important to remember that immigrants, foreign nationals, patients with a history of vaccine refusal and the over-65 age group may not have received a basic tetanus course (patients who served in the armed forces can be assumed to have had a course of tetanus toxoid at that time).

Non-immunised individuals, or those whose immunisation status is not known, should be given a full course of the vaccine. Patients with impaired immunity, such as transplant patients, may not respond to tetanus toxoid. They will require tetanus immunoglobulin.

Tetanus-prone wounds include the following:

- The penetrating type - for example, a rusty nail in the foot;

- Those containing a significant amount of devitalised tissue;

- Those which have been in contact with soil or manure;

- Clinically infected wounds;

- Those which are six or more hours old (before thorough surgical toilet).

Individuals who are at particular risk of a tetanus-prone wound include agricultural workers, gardeners and vets.

The management of tetanus-prone wounds is as for clean wounds, with the addition of a dose of tetanus immunoglobulin. This is purified immunoglobulin from the sera of donors with high levels of tetanus antitoxin. It provides an immediate protective level that lasts for approximately four weeks.

Nurses must follow local treatment guidelines, as these may vary according to the drug and the time elapsed since injury.

In summary, it essential that one should take an AMPLE history:

A: Allergies

M: Medication

P: Past medical history

L: Last ate and drank (in case a general anaesthetic is required)

E: Events - the mechanism of injury (Guly, 1996).

Wound assessment

The most important part of the initial wound assessment is to determine if important structures that lie deep to the wound have been damaged - for example, tendons, bones or nerves (McNicholl et al, 1992). This is achieved through gentle, systematic examination of the limb or digit distal to the injury (Guly, 1996). This should only be carried out by an appropriately qualified practitioner. If there is any suspicion of damage the patient must be referred to an appropriate specialist, such as a plastic surgeon.

Wound site, direction, size and shape

The site of the wound may indicate wound-healing potential. For instance, a wound on the head will probably heal quickly because the scalp has an excellent blood supply, whereas a wound on the lower leg may be compromised due to the presence of peripheral vascular disease.

The position and direction of the wound can be recorded by citing its relationship to the midline of the body, that is transverse, longitudinal or oblique. The size of the wound, haematoma, flap or skin loss should be measured and recorded, preferably in metric measurement. The shape of the wound may be drawn, photographed or described.

The depth of a wound may be difficult to assess, especially when a sharp piercing instrument has been inserted. Also, in some situations - for instance, burns - the depth of tissue damage is essentially an impression based on an interpretation of the clinical picture. For this reason, Guly (1996) suggests that practitioners should simply document what they see - for instance, ‘2cm x 2cm burn on the dorsum of the left hand; tissue involved looks brown, dry and leathery, typical of a full-thickness burn’.

Although wounds need to be fully explored, great care needs to be taken to prevent further tissue damage. For example, abdominal wounds should only be examined by a surgeon to see if the abdominal cavity has been penetrated.

Practice point

Large wounds may require grafting, as healing may be prolonged and the resulting cosmetic effect as well as function may be poor.

Wound exudate

Initially, the amount and type of bleeding should be noted, as the patient may be at risk of hypovolaemic shock. Major or minor haemorrhage can be controlled by pressure over the bleeding point and elevation of the part, if possible. Subsequently, the amount of exudate will influence dressing choice: for example, a wet wound will require a dressing that can absorb excess fluid, while a dry wound may require hydration. Exudate can be described by its colour - serous (straw-like), sanguinous (bloody), serosanguinous (straw-like fluid streaked with blood) and purulent.

Wound bed

The type of tissue on the wound bed will provide the rationale for treatment. A wound that contains healthy living tissue will require protection, while a wound that contains debris or dead tissue will require some form of debridement.

In general, black tissue is dead tissue, yellow tissue is subcutaneous fat, tendon or dead tissue, and red tissue is living tissue.

Wound edge

A clean incised wound edge usually indicates that the injury has been inflicted using a sharp implement, while a ragged edge indicates blunt trauma. If a flap of tissue is present, practitioners should check if the attached edge is viable. This is largely determined by colour - for example, a dusky blue flap edge is unlikely to be viable.

Surrounding skin

Note the general condition of the skin. Look for and record any other evidence of tissue trauma (old and new) - for example, bruising, grazing, blistering, scarring, erythema. If the wound is on the leg, examine for signs of venous or arterial disease, such as varicose veins, no pulses, cold, white or mottled skin. Coexisting disease may need to be treated in order to improve a patient’s wound-healing potential.

Practice point

Carefully document all your findings - negative as well as positive. Good documentation aids communication and is therefore integral to nursing care. In addition, given the violent causes of many of these wounds, your assessment may later be required as evidence.

Conclusion

The history and examination of a traumatic wound is vital in deciding the most appropriate treatment regime for the wound and the patient. It will also alert you to the possibility of complications, such as delayed healing or infection. Although the treatment plan will be individualised, the general principles of management must be adhered to. These will be discussed in the next article in this series.

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