Wound Care: Treat or Refer?

Patients with varying degrees of self-care abilities seek attention in retail health clinics for many different wound types, such as acute abrasions, lacerations, contusion, punctures, avulsions (wounds in which tissue has been forcibly removed), burns, or ulcers.

Patients often sustain wounds by accident at home or at work, but other times, the wound is deliberate due to “bathroom surgery” when patients try to repair ingrown toenails, manage a painful pimple, or remove a wart.

Quick discharge from the hospital often leaves patients unprepared to manage surgical wounds. Occasionally, patients with psychological or cognitive syndromes self-inflict or neglect their wounds.

Initial Intervention

When patients arrive with acute wounds, clinicians should first assess the wound and take a history. These initial steps can help you assess whether you can handle the wound in the retail settling.

Make sure to estimate the wound’s depth and extent of contamination, and also look for internal tissue injuries. Obviously, patients with extensive wounds or who need the ABCs (airway, breathing, and circulation) supported need to go to the emergency room.

Clincians should be sure to refer patients with other wounds that need more specialized care than is available in retail care to a different provider. These specialized care wounds include:

· Wounds that are extensively contaminated with enmeshed, difficult to remove foreign matter or particles

· Bites (either human or animal)

· Necrotic wounds, like those seen in diabetics

· Wounds that tend to develop into chronic wounds

· Wounds with nerve, tendon, bone, muscle, duct, or organ damage

· Wounds that need stitches (unless your state allows you to perform this procedure)

In addition, clinicians should refer patients who self-inflict injury to the appropriate mental health provider, and report elders whose self-neglect creates danger to local elder abuse authorities.

Stop the Bleeding and Cleanse the Wound

If you’ve determined that you can treat the wound, and if the wound is bleeding, apply direct pressure for about 5 minutes to curtail bleeding.

In many cases, wounds need to be anesthetized to minimize pain during cleansing and care. Use antiseptic solution (eg, hydrogen peroxide, povodine iodine, or a commercial product) and normal saline to cleanse the wound from the center outward.

Avoid aggravating the trauma to the skin. Clip hair that obstructs and wash the entire area surrounding the wound. Use tweezers to remove visible debris.

Importantly, clinicians should know their limits. Refer to your health care facility's protocols and state law, and respect your own skills and abilities.

Close the Wound

Many wounds won’t need closure and can be covered with a Band-Aid. However, if the wound does require closure, retail clinicians can use 3 methods to close it, depending on your state’s laws, the facilities’ policies, and your specific abilities. The appropriate method should be determined based on the amount of protection the wound needs, the wound’s size, and the infection risk.

Primary wound closure:For clean, uncomplicated wounds, a suture, staple, glue, or tape will suffice. For example, using tape strips or “butterflies” in parallel, like railroad ties, across the wound qualifies as primary closure.

Secondary wound closure(or open wound management): For dirty wounds. This method lets contaminated wounds contract and re-epithelialize on their own while reducing infection risk. Using this option, clinicians can pack the wound with sterile fine-mesh gauze dampened with sterile 0.9% saline, and then cover it with dry, thick absorbent sterile pads. If the wound is very wet, use an absorbent dressing (foam, alginate, carbon impregnated, or composite) dressing to collect excess exudate. If the goal is to keep the wound hydrated, use a hydrocolloid or transparent film dressing to maintain moisture, and amorphous hydrogels or hydrogel sheets to boost moisture.

Delayed primary closure: This method is best for wounds that will need closure, but aren’t ready. Using this method, leave the wound alone for up to 5 days before suturing, stapling, gluing, or taping, which allows time for repeated debridement or antibiotic treatment before closure.

Home Care

After dressing the wound, clinicians should address home care with the patient. In the past, health care providers have advised patients to use bacitracin or Neosporin on wounds. More recent evidence has found that these products can (and often do) cause allergic reactions and increase antibacterial resistance.

Therefore, suggest clear petrolatum as an alternative. Patients who have deep, extensive, or dirty wounds will need prophylactic oral antibiotics.

Determine how often the dressing will need to be changed, and whether the patient can do self-care or needs to return for assessment. If the patient is performing self-care, describe the type of bandage to be used and the duration of treatment. Also, advise patients to avoid disturbing the wound.

Finally, this is a good time for clinicians to ask whether the patient has had a tetanus shot, and give one if he or she isn’t up to date.