124: Wound Closure

Published on 06/03/2015 by admin

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Last modified 06/03/2015

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PROCEDURE 124

imageWound Closure

PURPOSE: 

Wound closure is the process of holding body tissues together to promote wound healing. It is used to achieve hemostasis, approximate tissues separated by surgery or trauma, expedite healing with minimal scarring and without infection, provide strength until the natural tensile strength of the healing wound is sufficient to maintain closure, and maintain appropriate positioning of tubes or drains.

PREREQUISITE NURSING KNOWLEDGE

• The skin is the largest organ of the body and has two major tissue layers. The outermost layer, the epidermis, is made of stratified, squamous cells with keratin and melanin. This layer protects against environmental exposure, restricts water loss, and gives color. The inner layer, the dermis, is made of fibroelastic connective tissue with capillaries, lymphatics, and nerve endings and provides nourishment and strength. The layer beneath the dermis is the subcutaneous tissue, composed of areolar and fatty connective tissue to provide insulation, shock absorption, and calorie reserve.

• The natural components of wound healing include three overlapping phases of healing: inflammation, proliferation, and maturation.

image Inflammation: Wound extends through the epidermis, disrupts blood vessels, and exposes collagen, activating the clotting cascade and inflammatory response. Vascular and cellular responses are designed to protect the body against foreign substances and limit blood loss via vasoconstriction and development of a clot providing hemostasis. The inflammatory response activates macrophages and clears the wound of cellular debris. Hemostasis with fibrin formation creates a protective wound scab. Kinins and prostaglandins produce local vasodilation and increase permeability of the vasculature, thereby promoting development of inflammatory exudate. Inflammation brings chemical stimuli for wound repair. Wounds left open for 3 hours show a dramatic increase in vascular permeability, which results in thick inflammatory exudate and may limit the therapeutic value of antibiotics.5,21

image Proliferation and epithelialization: This phase of wound healing is characterized by generation of new tissue, angiogenesis, and collagen formation. After an incision, the divided parts of the epithelium are closed by cellular migration and mitosis, forming an epithelial bridge that protects the wound against bacteria. When the skin edges are slightly everted with suturing, epithelial bridging occurs within 18 to 24 hours. Wounds that have approximated skin edges may take 36 hours to epithelialize. If the edges are inverted, it may take up to 72 hours to completely epithelialize.5

image Maturation is the remodeling phase of wound tissues during which collagen is reorganized to increase strength of the new tissue.

• Wound healing occurs via primary or secondary intention.

• Primary intention is used with limited tissue loss; the wound is clean, and the wound edges can be approximated and closed, frequently with sutures or staples.

• Secondary intention is used when either a large amount of tissue has been lost or the wound is contaminated.21 Wound dressing techniques are used to clean the wound and encourage development of granulation tissue and reepithelialization for wound closure.

• The goals of primary wound closure are to stop bleeding, prevent infection, preserve function, and restore appearance.

• Principles of proper wound closure include the following:

• Risk factors for surgical site infections include intrinsic factors (such as age, active skin condition, smoking status, body mass index, and comorbidities) and extrinsic factors (e.g., preoperative, perioperative, and postoperative patient care practices, such as preoperative skin preparation and postoperative dressings).14 Risk factors for infection in a traumatic laceration include extremes of age, history of diabetes mellitus, chronic renal failure, jagged wound edges, stellate shape, visible contamination, injury deeper than the subcutaneous tissue, and presence of a foreign body.10,15,18

• Hair removal around suture site is not necessary before suturing unless the hair interferes with the procedure. Removal of hair has been associated with higher risk of infection. If hair must be removed, an electric clipper is preferred. A razor can cause abrasions and microscopic skin nicks that may increase the risk of infection.6,14,16,19

• Depending on the clinical setting, referral to an appropriate specialist (e.g., vascular, orthopedic, plastic, or general surgeon) may be warranted for wounds with damage to the blood supply, nerves, or joint; wounds on the face; or wounds with extensive tissue damage or infection.

• Wounds contaminated or infected with saliva, feces, or purulent exudate or that have been open longer than 8 hours may benefit from delayed closure on or after the fourth day to decrease the risk for infection.

• Wounds may be closed with several techniques: sutures, staples, adhesive skin strips (i.e., Steri-Strips, or skin adhesives.

image Staples provide the strongest closure, skin adhesives and sutures are next strongest, and adhesive skin strips are the weakest.1

image Stapling is faster, less expensive, and more cosmetically acceptable than suturing in the repair of many types of traumatic lacerations. Staples are useful for lacerations to the scalp, trunk, and extremities. They are slightly more painful to remove.

image Adhesive skin strips (i.e., Steri-Strips) and skin adhesives are found to be equal in cosmetic outcomes and acceptability.12,15 They are best used on wounds that are not under tension.

image Skin adhesives such as 2-octyl cyanoacrylate (Dermabond, Ethicon, Inc.) have been shown to be equivalent to sutures in repair of simple, clean wounds on children. Adhesives should not be used over joints; on hands, feet, lips, or mucosa; on infected, puncture, or stellate wounds; or in patients with poor circulation or a propensity to form keloids.6 They are best suited for short (less than 6 to 8 cm), low-tension, clean-edged, straight to curvilinear wounds that do not cross joints or creases.2,7,8

• When considering suturing:

image Curved needles are either tapered or cutting. Needles used for skin closure have an angle of 135 degrees.

image Tapered needles are used in soft tissues (intestine, blood vessels, muscle, and fascia) and produce minimal tissue damage.

image Cutting needles are used to approximate tougher tissue, such as skin. Reverse cutting needles have a cutting edge on the outside of the curve and provide a wall of tissue, rather than an incision, for the suture to rest against. This method resists suture cut-through and is therefore preferred.

image Most needles are swaged, or molded, around the suture, providing convenience, safety, and speed in suture placement.

image Needles should be handled only with needle holders to prevent needle damage to surrounding tissue and injury to the user.

image Suture material is characterized by tissue reactivity, flexibility, knot-holding ability, wick action, and tensile strength. Suture size is indicated by “0.” The higher the number that precedes “0,” the smaller the suture (e.g., 4-0 is smaller than 3-0).

image Sutures are absorbable or nonabsorbable, braided, or monofilament.

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