Lacerations: Evidence-based Practices in Nursing Care

00:01 Let's look at evidence based practice and treating a laceration.

00:04 Now these guidelines are consistent with recommendations from organizations such as the American College of Emergency Physicians, the Wound Ostomy Incontinence Nurses Society, and current Wound Care literature.

00:15 The wound is irrigated with normal saline at about 5 to 8 psi of pressure, because you want to remove that debris without causing additional tissue damage.

00:24 Make sure that you avoid any antiseptics that may damage tissue like hydrogen peroxide or povidone iodine. Those antiseptics can damage healthy tissue and impair or slow down the healing.

00:36 Now, there is evidence against the routine use of high pressure irrigation in uncomplicated wounds.

00:42 When we say high pressure, you mean greater than 15 psi.

00:45 So for uncomplicated wounds greater than 15 psi can cause tissue damage without any additional benefit. So the timing of the closure, the evidence supports that in patients that don't have risk factors for poor wound outcome.

01:00 Most simple lacerations that are small remember less than five centimeters in length, do not have gross contamination and are not located on the lower extremities.

01:09 These can be closed up to 12 to 18 hours later with little risk of infection.

01:14 The larger wounds that are longer than five centimeters, or wounds that are contaminated, or a laceration in an individual who has risk factors for poor outcomes.

01:24 Closures beyond 12 hours after injury should be avoided.

01:28 So when it comes to timing, simple wounds that are small and don't have the risk factors, those can be closed up to 12 to 18 hours later.

01:36 Large wounds or contaminated wounds or have specific risk factors.

01:40 You shouldn't really close those beyond 12 hours after injury.

01:44 Now, wounds of the head and neck can be closed up to 24 hours after injury because your scalp and head have a really rich vascular supply and we're using antibiotics.

01:54 Prophylactic antibiotics are usually not recommended for just a clean, simple laceration. But you do use prophylactic antibiotics for bite wounds, particularly hands. Grossly contaminated wounds.

02:06 Wounds that are in patients who are immunocompromised, and certain high risk locations like hands, feet, and genitalia. Now, tetanus prophylaxis is based on wound characteristics and immunization status, so tetanus prone wounds require Tdap.

02:20 If greater than five years since the last dose that they've had that immunization.

02:25 Tetanus immunoglobulin or TIG.

02:27 For tetanus prone wounds and patients is also used if they have unknown or incomplete immunization status. When it comes to addressing, you want to make sure that you keep the wound clean and covered for the first 24 to 48 hours.

02:41 Now, here's why we set that time frame.

02:44 The first 24 to 48 hours after wound closure are critical for initial healing, because during this period, remember what's going on in the wound. It's beginning to form a fibrin clot, and the epithelial cells are starting to migrate across the wound surface.

02:58 That's why you want to keep them protected, clean, and covered by a dressing for those first two days.

03:04 So it keeps that wound from external contamination and bacteria stops it from drying out.

03:10 Also minimizes the risk of physically disrupting the newly formed clot.

03:15 Also help absorb any drainage or exudate in this phase of healing, and it'll just help you overall reduce the risk of infection during this really vulnerable period.

03:25 So but evidence tells us that early showering is okay.

03:29 Now historically, patients were told that they had to keep their wounds completely dry for several days. But now evidence supports early showering after 12 to 24 hours for uncomplicated wounds is perfectly safe. So the more recent research shows that clean, sutured wounds can tolerate a brief exposure to clean shower water after the first 12 to 24 hours without increasing infection rates.

03:53 Now you can imagine what this feels like to a patient.

03:57 There's nothing like having a shower to feel better.

04:00 So this is a significant quality of life improvement for our patients.

04:05 Now, things that you want to keep in mind when you're educating the patient.

04:08 The shower should be brief.

04:10 They don't want to prolong soaking showering.

04:12 They're just get in, get clean and get out.

04:15 Make sure they use clean and running water and that they have access to clean running water.

04:20 Do just a gentle pat afterwards.

04:22 You don't want them to do significant rubbing.

04:24 Then they just reapply a clean dressing after showering.

04:27 Now this is only recommended for uncomplicated well approximated wounds, right? They're closed well. This is still contraindicated for heavily contaminated wounds or patients who are immunocompromised. So there are several studies that support this practice.

04:44 And they show no increased infection rate with early showering.

04:48 So the evolution of wound care has kind of moved toward maintaining this moist, healing environment, rather than the older practice of exposing wounds to air to dry out, which we now know can impair healing and increase scarring.

05:02 So there's some special dressing practices I want to talk about that are proven by evidence.

05:07 Occlusive dressings help maintain that moist, wound healing environment that we now know is best. So this principle is based on the understanding that wounds heal best in a moist but not wet environment. That's important.

05:21 So these occlusive dressings, they help create this barrier.

05:24 And that's what stops the wound from drying out, which will allow those epithelial cells to migrate more easily across the wound surface.

05:31 So this promotes that self debridement right.

05:34 The body's natural cleaning process called autolytic debridement.

05:39 And that's a good thing. This also will help reduce pain by keeping those nerve endings moist.

05:45 So when all this is going on in the moist environment, this can also reduce scarring compared to wounds that form hard, dry scabs. So these occlusive dressings protect the wound from external contaminants, things that might get in there and cause all kinds of havoc.

06:00 And it may also reduce the need for dressing changes, which will cause less disruption to the healing tissue.

06:06 You might be asking, so what is an occlusive dressing? Well. Types of occlusive dressings include things like semipermeable films like Tegaderm or Hydrocolloid dressings or foam dressings, and there's even some dressings that have antibiotics impregnated right in them.

06:23 So keeping in mind the evidence shows when a wound is healing, it's important to emphasize that you want the wound to be moist and you don't want it to be wet.

06:32 Excessive moisture or maceration is really detrimental to healing.

06:37 So us picking the proper dressing, the patient changing it frequently.

06:42 These are important considerations based on what's going on with this specific wound.

06:47 Also, keep in mind when you're discharging a patient, you want to make sure they have access to the most effective dressing for their wound.

06:55 Now, when it comes to sutures on the face, they'll take them out after 3 to 5 days on the scalp, 7 to 10 days. The trunk and upper extremities are also 7 to 10 days, and the lower extremities are over joints will be 10 to 14 days.