A Complete Guide to Open Wound Care & Management

Medically Reviewed by Dr Chua Zi Wei.

What is a wound?

A wound is damage to the integrity of biological tissue, including skin, mucous membranes, and organ tissues. 

Types of Wound

Wounds can be divided into four broad categories:

Timing: Acute/ Chronic 

An acute wound– is any surgical wound that heals by primary intention or any traumatic or surgical wound that heals by secondary intention. An acute wound is expected to progress through the phases of normal healing, resulting in the closure of the wound.  

A chronic wound– is a wound that fails to progress healing or respond to treatment over the normally expected healing time frame

Causes

Traumatic 

• Laceration: Usually caused by the application of blunt or crushing force. Wound edges are usually irregular and jagged.

• Incision/ Surgical: This is caused by sharp objects, for example, blades, glass or even surgical blades. The wound edge is usually sharp and clean.  

• Puncture Wound: 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 are prone to infections as microorganisms are introduced deep into the tissue, but the natural processes of cleaning and draining are inhibited by the depth and narrowness of the wound.

• Abrasion: This is usually a more superficial wound that can be caused by skidding, grazing, or scraping. 

• Avulsion: This is a serious traumatic wound where skin and subcutaneous tissue are torn away or apart. May cause excessive bleeding. 

Burn

Injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals

Pressure injury/ ulcers

Caused by prolonged pressure on the skin. They can happen to anyone, but usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time.

Diabetic foot ulcers

A common complication affecting patients with long-standing diabetes mellitus? Usually affects the lower extremities (eg foot). 

Venous ulcers

Also known as stasis ulcer. It is caused by problems with blood flow (circulation) in your leg veins. 

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 which 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 which heal by tertiary intention often show significant scarring and need close and careful management.

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
• Smelly
• 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 Management 

Wound assessment 

It enables the evaluation of wound bed, wound edge as well as periwound skin. Optimal wound assessment by professionals are essential to develop a holistic care plan for patients. Monitoring the viability of the tissue, exudate type and level, and presence of infection are all part of the wound bed assessment. Assessment of wound edge can provide valuable information on wound progression and the effectiveness of the current management plan. Periwound skin is the skin surrounding the wound. Periwound skin damage can lead to prolonged healing time, pain and discomfort for patients. Infected wounds may require intravenous antibiotics. Hence, a comprehensive wound assessment by wound care specialist is essential for optimal wound healing. 

Wound cleansing 

Serves the purpose of removing the visible debris, residual dressing materials as well as contaminants which may serve as a source of infection for patients. Choice of wound cleansing solution will be determined based on the wound assessment. Examples of wound cleansing solutions in the market would be normal saline, Dermaycn, Hydrocyn solutions etc. Some contaminated or deep wounds would require irrigation or scrubbing methods as well. 

Wound debridement 

A procedure of removing devitalized, necrotic or infected tissue in the wound which cant be removed during wound cleansing. There are many debridement methods, such as surgical (sharp) debridement, enzymatic debridement, autolytic debridement, biological debridement, hydrosurgical debridement etc. Wound debridement should be performed by trained nurses or doctors. 

Wound dressings

Play an important major role in wound healing. An optimal wound dressing should be able to reduce pain, protect the wound and surrounding tissue, control and prevent bleeding and last but not least provide a moist environment for wound healing. Some advanced dressings are able to perform autolytic debridement.

• For dry wounds, a primary dressing should be something that provides a moist environment for optimal wound healing. Hydrogel or hydrocolloid dressings are common dressing solutions for dry wounds. 
• For wet (exudative) wounds, a contact dressing which maintains a moist healing environment while allowing excess fluid to drain away is necessary. Alginate or Hydrofiber dressings are good absorbent dressings that help in exudative wounds. Foam dressings can also be used as secondary dressing in these cases. 
• 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 dressings are also commonly used for difficult wounds.
• Vacuum dressings (VAC) are one of the advanced dressings that involve the application of a controlled negative pressure on the wound to stimulate granulation tissue formation and wound healing, which is beneficial for chronic wounds. 
• Adjunct hyperbaric oxygen therapy is also applied to stimulate healing in chronic non-healing ulcers. 

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 which 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.

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 that 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.

Potential Complication of Wound

With good management and nursing care, complications can be minimised but it can’t always be prevented. Complications include:

Infection

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.

Scarring

The larger a wound and the more complications that occur during the healing process, the higher likelihood that a wound will leave a scar.

Pain

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.

Necrosis

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.

If you or your loved one need nursing support with wound care at home, our qualified Homage nurses can help. Reach out to our Care Advisors at 016 299 2188 to find out more or fill out the form below: