learning zone Techniques for acute wound closure CONTINUING PROFESSIONAL DEVELOPMENT Summary Authors Keywords

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1 learning zone CONTINUING PROFESSIONAL DEVELOPMENT Page 55 Techniques for acute wound closure Page 66 Acute wound closure multiple choice questionnaire Page 67 Read Lynda Hawkes s practice profile on osteoporosis Page 68 Guidelines on how to write a practice profile Techniques for acute wound closure NS327 Reynolds T, Cole E (2006) Techniques for acute wound closure. Nursing Standard. 20, 21, Date of acceptance: July Summary This article provides an overview of the assessment and management of the common types of acute wound that frequently present to accident and emergency departments, minor injury units and walk-in centres, and which require closure. Authors Tanya Reynolds is nurse consultant in accident and emergency care, accident and emergency department, Homerton Hospital; Elaine Cole is lecturer/practitioner in accident and emergency/trauma, St Bartholomew School of Nursing and Midwifery, City University/Barts and The London NHS Trust, London. tanya.reynolds@homerton.nhs.uk Keywords Accidents and Emergencies; Wound closure techniques; Wounds These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For related articles and author guidelines visit our online archive at and search using the keywords. NURSING STANDARD Aims and intended learning outcomes The patient with a wound is one of the most common presentations to accident and emergency (A&E) departments, minor injury units or walk-in centres. Because of the ongoing expansion of nursing in these areas, nurses are increasingly taking on the management of these patients. The care of the patient with an acute wound by professionals other than medical staff may be by a dedicated minor injury specialist, such as an emergency nurse practitioner, who will see and manage the patient throughout his or her treatment. Alternatively, a nurse will undertake only the wound closure aspect of care after the wound has been assessed by another professional. This article aims to provide an overview of the assessment and management of the common types of acute wound that present frequently to A&E, minor injury units and walk-in centres and which require closure. After reading this article you should be able to: Describe the different types of acute wound that may require primary closure. Discuss the principles of assessment for patients with acute wounds that require closure. Identify the different methods of wound closure and explain the principles of each technique. Discuss the principles underpinning the safe use of local anaesthesia. Outline the principles of tetanus prophylaxis. Summarise the care and advice that is given to patients on discharge from A&E. Introduction It is estimated that up to three million patients with acute wounds are treated each year in the UK (Wardrope and Edhouse 2000). This constitutes a significant proportion of the workload of A&E departments, as well as GP surgeries and walk-in centres. Some wounds can be managed without the need for closure, but a greater proportion will require intervention to ensure they heal successfully. Wound closure can be categorised into two types: Primary wound closure is the closure of a wound, preferably within the first 12 hours after injury. Secondary wound closure is the purposeful delay in wound closure to allow an intervention, such as use of antibiotics, before the wound is closed. This may happen following debridement of the wound edges. february 1 :: vol 20 no 21 ::

2 learning zone emergency nursing FIGURE 1 Anatomy of the skin Muscle The purpose of primary wound closure is to facilitate healing by (Castille 1998, Clark 2004): Supporting the tissues while the natural process of healing takes place. Realigning tissues to ensure good cosmesis. Eliminating dead space, thereby reducing the risk of haematoma formation and infection. This can be done in a number of ways: by ensuring the wound is very clean and removing debris; ensuring the wound edges are adequately apposed; and sometimes by the use of sub-cuticular sutures. Time out 1 For any practitioner undertaking wound closure, knowledge of the layers of the skin and underlying structures is essential. Before proceeding, draw the layers of the skin and list the structures that could be found underneath. Check your results with Figure 1 and Box 1. Wounds that may require closure Wounds are classified according to their mechanism of injury. When assessing and Hair follicle Epidermis Dermis Subcutaneous fat (adipose tissue) BOX 1 Structures that may be exposed when examining an acute wound Subcutaneous fat Tendon sheath (hands and feet) Tendons Muscle Bone Major blood vessels Nerves Other underlying structures, such as organ, for example, testicle describing a wound it is essential that the correct terminology is used. This is important for three reasons. First, from a medico-legal perspective, patients notes are sometimes called in evidence during a coroner s or criminal investigation. Therefore an accurate record of how the wound occurred and the subsequent treatment undertaken is mandatory. Second, the Nursing and Midwifery Council (NMC) (2005) states that record keeping is an integral part of nursing practice and that documentation should be factual, consistent and accurate. Third, if a wound will be assessed and potentially reviewed by several different professionals, accurate documentation will help to ensure that there is continuity of care and appropriate and effective treatment. Many practitioners use the term laceration when describing all acute wounds. This is a mistake as laceration implies a specific mechanism of injury. Poor descriptions of injuries are common and therefore if in doubt about the cause of the wound, it is preferable to describe it as a wound (Milroy and Rutty 1997). There are many types of wound, however, the following classifications are for wounds that may require closure: Wound This can be defined as a breach to the external surface of the body. Laceration A laceration is caused by blunt force, such as a direct blow to the skin with a heavy object or against a solid structure (Cole 2003). This causes a tearing or splitting of the skin which may result in a superficial or deep wound. Incision An incised wound is an injury to the skin caused by a sharp cutting implement such as a knife, broken glass, metal edge or scalpel (Milroy and Rutty 1997). Penetrating A wound caused by an object penetrating the skin and possibly underlying structures. This type of wound will need careful exploration. There may be underlying injury or a foreign body present where primary closure may be contraindicated. Crush injury When tissue is crushed the force of the injury can cause skin and underlying 56 february 1 :: vol 20 no 21 :: 2006 NURSING STANDARD

3 structures to split open (Walsh and Kent 2001). This type of wound may be jagged with skin loss rendering it unsuitable for suturing, but it may require closure with adhesive skin closure strips. Time out 2 Reflect on your practice. How do you describe a wound? Do you use the term laceration for all acute wounds? Discuss this issue with other practitioners who regularly manage acute wounds. Principles of acute wound assessment All wounds that require closure need careful assessment. It is essential that wounds are assessed for the integrity of nerves, tendons and vascular supply, and also to exclude the presence of foreign bodies which may need removal before closure (Autio and Olson 2002, Clark 2004). Likely foreign bodies include glass, metal or grit, all of which could lead to infection or tattooing if left in situ. Excessive bleeding and macerated or badly damaged tissue can detract from a thorough assessment. Bleeding will need to be controlled to allow an accurate examination to be conducted (Clark 2004). Haemostasis is usually achieved through direct pressure. However, if bleeding persists the wound must be reviewed urgently by a skilled practitioner. The depth of wound should be established to ascertain whether sub-cuticular sutures are indicated (Clark 2004). If the base of the wound cannot be visualised, then its depth can be assessed with the gentle use of a probe. Deep wounds, where the base cannot be easily visualised, wounds where tendons may be damaged or the nerve or vascular supply is compromised must be assessed by a practitioner experienced in the management of such wounds. Deeper wounds to the chest or abdomen are not routinely probed by nurse practitioners or nurses, as they usually require examination and exploration by a surgeon. Specialist referral is necessary for wounds such as flexor tendon injuries or wounds involving cosmetic challenges such as the vermillion border of the lip or the cartilage of the ear (Reynolds 2004). It is essential that an accurate history is elicited from the patient to ensure systematic assessment and appropriate management of the wound. While assessment of wounds may differ between healthcare establishments, the essential principles are shown in Table 1. Wounds can be painful and distressing for the patient, and this can make the assessment more TABLE 1 Principles of wound assessment Assessment How did the wound occur? When did the injury occur? Site and depth of the wound Past medical history Medication history Allergies Tetanus status Occupation and dominant hand Rationale To establish mechanism of injury and classification of the wound To exclude serious or other injuries To assess potential contamination risk (Clark 2004) To ensure primary closure is appropriate To assess for infection risk (wounds more than six hours old are more prone to infection) (Moulton and Yates 1999) To ascertain the most appropriate method of wound closure, for example, wounds over joints or those requiring high tensile strength usually require sutures (Autio and Olson 2002) To ensure the base of wound can be visualised To detect pathology that may delay or influence healing To detect medication that may delay or influence healing To avoid prescribing contraindicated medications as part of wound management To avoid allergic reactions during the wound management process and during subsequent treatment To ensure the patient has tetanus immunity To assess the effect of the injury on the patient s lifestyle To ensure treatment is appropriate for the patient s lifestyle NURSING STANDARD february 1 :: vol 20 no 21 ::

4 learning zone emergency nursing challenging for the practitioner. Careful explanation of any procedures beforehand may help to allay some of the patient s fears, and the administration of analgesia as soon as the patient arrives will often make assessment easier. The management of children with wounds presents a unique challenge for practitioners (Mattick 2002). To some children the thought of needles and sutures may be terrifying and so careful consideration of the wound, the child s demeanour and the wound closure options available should be made to ensure the best outcome. Discussion with parents or carers is also advisable. Time out 3 Imagine you are examining an acute wound. How would you know if you were looking at: Subcutaneous fat? A tendon? A muscle? An arterial bleed? Write down your answers and discuss them with an experienced practitioner or consult Marieb (2003). Wound cleansing before closure Before closing any wound, regardless of the method used, it is essential that the wound is thoroughly cleaned. This is to ensure that dirt, superficial foreign bodies or excess contaminants are removed from the wound. Thorough cleansing will help to minimise the risk of wound infection and help to prevent a prolonged inflammatory phase as the wound heals. Dirty wounds should initially be washed with soap and running water before more formal cleansing. Acute, traumatic wounds should be irrigated with a degree of pressure (using a Steripod ; a pressurised canister of solution or a syringe and needle) to further clean the wound and remove debris (Towler 2001, Cole 2003). There are differing opinions about which solution is best for acute wound cleansing before closure. Many practitioners use normal saline as it is safe and cost-effective. However, a systematic review suggests that clean, drinkable water is a safe, cheaper alternative to other wound cleansing solutions (Fernandez et al 2003). This should be drawn from a tap that is frequently used, from a direct water supply with a nozzle that is regularly swabbed for contamination (Lawrence 1997). Traditionally antiseptics such as povidone-iodine have been used to clean wounds before closure. There is much debate over the efficacy of such practice and possible detrimental effects to wound healing (Cole 2003). Nevertheless, if a broad spectrum antiseptic such as povidone iodine is needed, Rabenberg et al (2002) suggest that diluting it with one part solution to nine parts water provides a safe, non-toxic compromise, or follow the manufacturer s instructions. Time out 4 Before reading the next section, list as many different methods of wound closure as you can. Wound closure techniques The common methods of acute wound closure discussed should not be attempted without previous training and education, and supervision where necessary. Tissue adhesive Tissue adhesives (cyanoacrylate) are a useful method of closing simple traumatic wounds and can be used following training. Tissue adhesives are usually supplied in sterile units, which can be disposed of after single use. They are easy and quick to use, and cause less discomfort than more invasive methods such as sutures or staples (Cole 2003). Risk of needlestick injuries is eliminated as no sharps are used (Richardson 2004). Studies comparing use of tissue adhesives with sutures to close wounds have found no difference in the end cosmetic result between the two methods (Maw et al 1997, Bruns et al 1998, Hollander and Singer 1998, Penoff 1999). In addition, adults found the procedure less painful and less wound contamination has been found in wounds closed with tissue adhesive than with sutures (Quinn et al 1997). When applying tissue adhesive, it is essential that bleeding has been stopped or the adhesive will not work. Application of tissue adhesive is usually a two-person technique and should not be attempted by a lone practitioner, unless the wound is very small, the edges well-apposed and the practitioner skilled in its application. Following cleaning, the wound edges should be apposed as closely as possible, while the adhesive is applied either in a continuous line or dotted along the wound edges (Cole 2003). The wound edges should be held together for at least 30 seconds to allow polymerisation to occur (Richardson 2004), although individual manufacturer s instructions should be followed. 58 february 1 :: vol 20 no 21 :: 2006 NURSING STANDARD

5 Tissue adhesive should never be instilled into the wound and the wound edges pushed together, as this will cause pain and excessive scarring. It will also increase the risk of infection. Care should be taken when using adhesive on the face to avoid it running into the eyes. This can be avoided by lying the patient down and covering the eyes with a damp gauze pad during application. Tissue adhesive is particularly useful in the management of acute wounds in children because of ease and rapidity of use (Barnett et al 1998). In addition it is less painful than other methods of wound closure (Mattick 2002). Adhesive tissue strips These are sterile strips that can be applied to wound edges to bring them together. They are available in different widths, and can be elasticated to allow ease of movement (Richardson 2004). They are easy to use, following instruction, and relatively painless to apply. Adhesive tissue strips are useful for wounds that are superficial, straight and not under high tension (Autio and Olson 2002). They are also useful for flap wounds and patients with frail skin, such as older patients or those on steroid therapy, where a suture might tear the skin, for example, a pre-tibial laceration. They are unsuitable for wounds where bleeding cannot be stopped and for hirsute areas such as the scalp (Cole 2003). Care should be taken when using them on confused or non-concordant patients, as they can be easily removed. When applying adhesive tissue strips, ensure that the surrounding skin is clean and dry to allow adequate adhesion (Richardson 2004). Following the same principles as suturing, and after the wound edges have been apposed (either with forceps or gloved fingers), the first closure should be made in the centre of the wound. Subsequent strips should be placed to bisect the resulting smaller wounds until closure is complete (Richardson 2004). Tension should be even across the wound and small gaps should be left between the strips to allow exudate to escape (Cole 2003). Adhesive tissue strips can be used in conjunction with other wound closure techniques for support. Adhesive tissue strips require minimal followup after application allowing patients to care for the wound themselves if they have been given appropriate advice (Autio and Olson 2002). Hair apposition technique This technique is underused, but can be used for superficial wounds on the scalp that are not actively bleeding (Cole 2003). Hock et al (2002) suggest it as a good choice for scalp wounds, although the patient s hair needs to be long enough to tie. It may be used in situations where other more conventional methods of wound closure may be inappropriate, such as with children or adults who refuse sutures because of needle phobia. NURSING STANDARD In this method, the wound edges are pulled together by the hair on either side, which is then tied in a knot. Alternatively, the hair can be twisted rather than tied, and secured with a drop of tissue adhesive (Hock et al 2002). The hair apposition technique is a quick and relatively painless method of wound closure that compares with suturing for wound healing, risk of infection and wound breakdown, but is superior in terms of scarring, overall complications and procedurerelated pain (Hock et al 2002). Sutures Sutures are used widely for wound closure. They are appropriate for the management of specific wounds, such as deep, large or jagged wounds, those under tension, mobile areas or wounds in awkward places (Autio and Olson 2002). They are normally inserted into wounds that are less than six hours old but this may differ according to local policy and the site and size of the wound. Sutures usually take longer to place than other wound closure techniques and can be more painful because of the need to infiltrate the area with local anaesthesia before suture insertion. Suturing is not a skill that can be learnt from a book and must be used by practitioners who have appropriate training and are competent to close the wound they are dealing with (Moulton and Yates 1999). Sutures are either absorbable or nonabsorbable, with non-absorbable sutures being commonly used for wounds where only the skin requires closure. Where there are deeper structures exposed, such as subcutaneous fat and muscle, absorbable sutures may be used. These will dissolve over a longer period of time. Nonabsorbable sutures are either monofilament or multifilament. Monofilament such as nylon or polypropylene consist of one material and are less irritant to the tissue and less prone to infection than multifilament sutures such as silk (Cole 2003). Sutures are measured by gauge, and choice of suture size will be influenced by the extent and site of the wound. The common range of suture sizes found in an A&E department will be from 3/0 to 6/0, with the lower number indicating the thicker gauge and the higher number indicating the finer gauge. The novice suturer should seek advice about appropriate suture gauges while developing competence. A general guide for suture sizes and wounds is shown in Table 2. It is usual to use a reverse cutting needle for suturing (Clark 2004). This type of needle is manufactured to facilitate ease of use on tissue such as skin. The type and size of needle is depicted on the suture packet. Suture packs will vary between healthcare establishments but all will contain forceps, suture holder and scissors. Forceps may be toothed or non-toothed but regardless of the type used care should be taken not to crush the wound edges (Richardson 2004). february 1 :: vol 20 no 21 ::

6 learning zone emergency nursing TABLE 2 Suture sizes and removal The interrupted suture is the most commonly used suture for closing traumatic wounds. Following preparation of the patient and the wound and using a strict aseptic technique, the initial suture should be placed centrally to divide the lesion into two smaller wounds. Further sutures should then be placed strategically along the wound so that the tension remains constant throughout (Cole 2003). This can be achieved by having all of the knots on the same side. Following insertion of a suture wound edges should be everted (slightly turned outwards). Figure 2 is a diagrammatic representation of an interrupted suture technique. Complications of suturing For the trained practitioner, suturing can be straightforward. There are, however, common complications that all practitioners using this technique should be aware of (Table 3). Staples Staples are more usually associated with surgical wounds, but they also have a place in the closure of acute traumatic wounds, particularly those in the scalp. A review of contemporary evidence suggests that, overall, staples are quicker and cheaper than sutures for closing scalp wounds (Hogg and Carley 2002). While the insertion of staples is straightforward, training should be provided for any practitioner who wishes to use them for wound closure. As for any method of wound closure, thorough cleansing and preparation of the area are essential. In common with sutures, local anaesthesia should be used before insertion of staples. Staples are associated with good cosmesis and can be inserted quickly (Autio and Olson 2002). However, they do require special equipment for removal which, along with the cost of the staples, sometimes prohibits their use. Local anaesthesia Local anaesthesia is used to ensure that wound closure using sutures or staples is a painless procedure. Nevertheless, some Area Size of suture Suggested removal Face 6/0 nylon Five days (in some circumstances removal after three days may be appropriate) Scalp 3/0 nylon Seven days Arms, upper legs and torso 4/0-5/0 nylon Five to seven days Hands, lower legs and 3/0-4/0 nylon Seven to ten days extensors patients find the administration of local anaesthesia painful, albeit for a short time. Therefore, careful explanation, encouragement and reassurance are necessary to reduce the anxiety and pain of administration (Quaba et al 2005). Local anaesthetic works by causing a reversible block to conduction along the nerve fibres (British National Formulary (BNF) 2005). For wound closure it can be used in different forms, usually either injected ( infiltrated ) or, less commonly, applied topically. Desensitisation of the skin outside of the wound before infiltration can reduce the pain of administration (Quaba et al 2005). Commonly used topical anaesthetics include lidocaine 2.5% and prilocaine 2.5% cream (Emla ) and tetracaine (Ametop ). Although not used commonly before wound closure, if needed, these preparations should be applied for minutes before to ensure efficacy and will usually be effective for about 30 minutes (Autio and Olson 2002). Lidocaine hydrochloride injection (lidocaine) is commonly used for infiltration anaesthesia before wound closure. It is available in various strengths: 0.5%, 1%, and 2%, however, and 1% FIGURE 2 Interrupted suture technique 0.5cm Stage 1: initial bite, approximately 0.5cm from wound edge. Ensure that the needle size is appropriate for the depth of the wound. Stage 2: appropriate placement of sutures, with equal tension along the wound. 60 february 1 :: vol 20 no 21 :: 2006 NURSING STANDARD

7 (10mg/ml) is sufficient for local anaesthesia (BNF 2005). Dosages are calculated using 3mg/kg body weight with the maximum dose for an adult of 200mg (20ml 1% solution). A small percentage of patients may report an allergy to local anaesthesia and adverse side effects such as dizziness, confusion, hypotension and bradycardia have been reported (BNF 2005). The practitioner using local anaesthetic should be alert to signs of allergy or side effects and take appropriate action. Lidocaine can be used by infiltrating directly into the incised or lacerated wound edges (Quaba et al 2005) or to block a nerve to give a more diffuse anaesthesia. The advantage of using a nerve block is that it allows good anaesthesia to small areas, without making them swell due to fluid in the area (for example, a digital nerve block to anaesthetise a finger). Nerve block anaesthesia should only be used by experienced practitioners with a sound knowledge of peripheral nerves. The procedure for infiltration of local anaesthesia following assessment and cleansing is shown in Box 2. For children or patients who find infiltration of local anaesthetic very painful, buffering of the lidocaine with sodium bicarbonate may be considered. Use 1ml of 8.4% sodium bicarbonate mixed with 9ml of local anaesthetic. Buffered local anaesthetic has the same speed of onset and duration of action as unbuffered (Quaba et al 2005). When suturing vascular areas such as faces some experienced practitioners may choose to use a local anaesthetic with the addition of a vasoconstrictor such as adrenaline (epinephrine). This diminishes local blood flow and therefore should not be used for anaesthetising digits or appendages due to the risk of ischaemic necrosis (BNF 2005). Wound management following closure Following closure the wound needs to be managed appropriately to ensure optimum healing and good cosmesis. Most wounds will be dressed following closure. This keeps the wound clean and absorbs exudate, as well as keeping it at an optimum temperature for healing. The choice of product will differ according to local policy but generally following closure, a nonadherent dressing should be selected. An additional benefit of applying a dressing is that if the wound is unsightly, keeping it covered can be more reassuring for the patient. Tetanus prophylaxis Tetanus is caused by the anaerobic bacteria Clostridium tetani, found in the soil and animal faeces. It enters the circulatory system through a wound and while the effects of tetanus in the UK are generally controlled by an immunisation TABLE 3 Common suturing complications Complication Comment Solution Patient fainting Patient inadequately prepared Lie patients down while suturing Sutures too tight Can result in split sutures and/or Tie sutures tight enough to ensure edges devitalised tissue. Can also increase are everted. If suture appears too tight scarring remove and replace it Sutures too loose Will not hold tissue in apposition and Tie sutures tight enough to ensure edges are may delay healing or cause a scar everted. If suture appears too loose remove and replace it. Wound edges overlapping Will not heal optimally and will leave Ensure wound edges are apposed and everted a poor cosmetic finish Wound edges inverted Can result in a depressed scar and Ensure wound edges are apposed and everted delay healing Sutures too near to wound edge May tear the skin Ensure sutures are 4-5mm from wound edge. Do not suture thin, friable skin: consider other wound closure methods Sutures too far from wound edge May cause increased tension and Ensure sutures are 4-5mm from wound edge cross hatch scarring Infection May cause delayed wound healing, Scrupulous cleansing and aseptic technique scarring and systemic illness (Adapted from Clark 2004, Richardson 2004) NURSING STANDARD february 1 :: vol 20 no 21 ::

8 learning zone emergency nursing BOX 2 programme, if acquired the disease can prove fatal (Cassell 2002). In 2003, eight cases of tetanus were reported in England and Wales (Health Protection Agency 2005). The Department of Health (DH) (2005) states that lifelong immunity to tetanus is achieved after five doses of a vaccine such as adsorbed Procedure for infiltration of local anaesthesia 1. Lie the patient down and explain the procedure, offering reassurance and encouragement. 2. Insert a long, fine needle (23g: blue or 25g: orange are commonly used) through the injured edge of the wound, running the needle parallel to the wound edge. 3. Draw back to ensure that the needle is not in a vessel (accidental intravascular or intra-arterial injection can cause cardiovascular collapse or convulsions). 4. Slowly inject 1% lidocaine hydrochloride (3mg/kg) into the wound while withdrawing the needle, using just enough to raise a fine blister. Warmed local anaesthetic is less painful. 5. After a couple of minutes the area should be anaesthetised, however, peak plasma concentrations occur within minutes (BNF 2005). Ensure that full anaesthesia is achieved before commencing wound closure. diphtheria (low dose), tetanus and inactivated poliomyelitis vaccine 0.5ml (Revaxis ) delivered in three doses as a primary course, followed by a booster ten years later and a final booster again ten years later. Not all patients will be up to date with their tetanus immunisations, therefore, it is essential to ascertain the tetanus status of the patient with an acute wound. Lifelong immunity may not protect against tetanus-prone wounds those that are more than six hours old or have been in contact with soil or manure. Patients with tetanus-prone wounds may need human tetanus immunoglobulin 250iu intramuscular injection for further protection. Revaxis vaccine is now used routinely for primary immunisation and boosters, and so the patient should be informed that he or she is being immunised against diphtheria and poliomyelitis, as well as tetanus. Table 4 shows the DH recommendations. Nursing documentation Whatever wound closure method has been used, there are minimum requirements for documentation that must be completed for each patient: Date and time. Signature and name of practitioner. Type and amount of local anaesthesia (if used). Size and number of sutures. Dressing applied. Discharge advice given. TABLE 4 Anti-tetanus prophylaxis Immunisation status Clean wound Tetanus-prone wound Vaccine Vaccine Human tetanus immunoglobulin Fully immunised, that is, has None required None required Only if high risk, for received a total of five doses example, contamination of vaccine at appropriate with manure intervals Primary immunisation None required (unless next None required (unless Only if high risk complete, boosters dose due soon and next dose due soon and (see above) incomplete but up to date convenient to give now) convenient to give now) Primary immunisation A reinforcing dose of vaccine A reinforcing dose of vaccine Yes: one dose of human incomplete or boosters and further doses as required and further doses as required tetanus immunoglobulin not up to date to complete the schedule to complete the schedule in a different site Not immunised or An immediate dose of vaccine An immediate dose of Yes: one dose of human immunisation status followed, if indicated, by vaccine followed, if indicated, tetanus immunoglobulin unknown or uncertain completion of the full by completion of the full in a different site five-dose course five-dose course (Adapted from DH 2005) 62 february 1 :: vol 20 no 21 :: 2006 NURSING STANDARD

9 Time out 5 Before reading the next section, write down what discharge advice you would give to patients with: Tissue adhesive. Adhesive tissue strips. Hair apposition technique. Sutures. Staples. Now compare your answers with the following text. Patient discharge It is important to inform the patient of the type of wound closure that has taken place and this should be given in written and verbal formats (using health advocates as required). There are general principles that the patient needs to be informed of following any type of wound closure: Keep the wound clean and dry. Wear/change dressing as advised. Observe for any signs of wound infection (redness, swelling, increasing pain, bloody or purulent discharge). Should this occur the patient must go to the GP or practice nurse or attend A&E. In addition patients should be told the following, appropriate to the type of wound closure they have had: Tissue adhesive After five days start washing the affected area with soap and water and the adhesive will begin to dissolve gently. Adhesive tissue strips Remove strips after five to seven days (specify to the patient how long) by gently pulling on both ends of the strip, towards the centre of the wound. Hair apposition technique Advise patient not to pull on hair tie with a brush or a comb. After five days the patient should treat the wound as for tissue adhesive. Sutures Have sutures removed following appropriate number of days according to site (see Table 2). This may be in primary care or A&E according to local policy. Staples Have staples removed in five to seven days. This may be in primary care or A&E according to local policy. Time out 6 Consider the following types of acute wound. Decide which wound closure technique you would choose for each wound and what advice you would give each patient. Compare your answers with the information in Table A superficial, straight wound on the forehead of an eight-year-old boy. 2. A deep, jagged laceration to the elbow of a 45-year-old man who is a builder. 3. A superficial, pre-tibial wound on the leg of an 89-year-old woman. 4. A straight 3cm wound on the scalp of a child aged five who is very distressed. 5. A puncture wound to the sole of the foot of a 23-year-old woman. If you are referring the patient to another healthcare provider for follow-up, it is good practice to give the patient a discharge letter which he or she can take to the appointment. If the patient has a co-existing illness or condition TABLE 5 Wound closure techniques Wound Closure Comments A superficial, straight wound on the Tissue adhesive or adhesive tissue Superficial straight wounds can usually forehead of an eight-year-old boy strips be closed without sutures A deep, jagged laceration to the Sutures would be most Wounds that are deep, jagged and elbow of a 45-year-old man who appropriate for this wound over a flexor surface usually require is a builder sutures. The patient s occupation may also have some influence A superficial, pre-tibial wound on the Adhesive tissue strips would Skin in this area can be delicate leg of an 89-year-old woman be most appropriate and friable and so sutures are usually inappropriate A straight 3cm wound on the scalp Tissue adhesive or hair apposition Closure method may be influenced of a child aged five years who is very technique would be most by the co-operativeness of the patient distressed appropriate A puncture wound to the sole of the This should not be closed, but Puncture wounds are often deep and may foot of a 23-year-old woman thoroughly cleansed and allowed to be more prone to anaerobic bacterial heal by secondary intention infection NURSING STANDARD february 1 :: vol 20 no 21 ::

10 learning zone emergency nursing which may influence the wound healing status, he or she should be given the appropriate advice related to the condition. For example, if patients are taking anti-coagulant medication their sutures or tissue strips may need to be left in situ for longer periods. Conclusion Acute wound closure presents the practitioner with many challenges. The wound must be accurately assessed and thoroughly cleaned before the most suitable method of closure is chosen. This technique should then be used appropriately and safely to get the best cosmetic result for the patient, while ensuring the procedure is quick and comfortable. Patients require specific advice on how to care for the wound and any follow-up that may be required. Accurate documentation is essential. Wound closure is a skill that requires training and practice. While they develop competence, novice practitioners should ensure they are supervised while undertaking all wound closure techniques NS Time out 7 Now that you have completed this article you may like to write a practice profile. Guidelines to help you are on page 68. References Autio L, Olson KK (2002) The four S s of wound management: staples, sutures, Steri-Strips, and sticky stuff. Holistic Nursing Practice. 16, 2, Barnett P, Jarman FC, Goodge J, Silk G, Aickin R (1998) Randomised trial of histoacryl blue tissue adhesive glue versus suturing in the repair of paediatric lacerations. Journal of Paediatrics and Child Health. 34, 6, British National Formulary (2005) British National Formulary No. 50. British Medical Association and the Royal Pharmaceutical Society of Great Britain, London. Bruns TB, Robinson BS, Smith RJ et al (1998) A new tissue adhesive for laceration repair in children. Journal of Pediatrics. 132, 6, Cassell OC (2002) Death from tetanus after a pretibial laceration. British Medical Journal. 324, 7351, Castille K (1998) Suturing. Nursing Standard. 12, 41, Clark A (2004) Understanding the principles of suturing minor skin lesions. Nursing Times. 100, 29, Cole E (2003) Wound management in the A&E department. Nursing Standard. 17, 46, Department of Health (2005) Tetanus pdf (Last accessed: December ) Fernandez R, Griffiths R, Ussia C (2003) Water for wound cleansing (Cochrane Review). The Cochrane Library. Issue 4. John Wiley & Sons, Chichester. Health Protection Agency (2005) Notifications, Deaths and Vaccine Uptake Rates, (Last accessed: December ) Hock MO, Ooi SB, Saw SM, Lim SH (2002) A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study). Annals of Emergency Medicine. 40, 1, Hogg K, Carley S (2002) Staples or sutures for repair of scalp laceration in adults. Emergency Medicine Journal. 19, 4, Hollander JE, Singer AJ (1998) Application of tissue adhesives: rapid attainment of proficiency. Academic Emergency Medicine. 5, 10, Lawrence JC (1997) Wound irrigation. Journal of Wound Care. 6, 1, Marieb EN (2003) Human Anatomy and Physiology. Sixth edition. Pearson Education Inc, San Francisco CA. Mattick A (2002) Use of tissue adhesives in the management of paediatric lacerations. Emergency Medicine Journal. 19, 5, Maw JL, Quinn JV, Wells GA et al (1997) A prospective comparison of octylcyanoacrylate tissue adhesive and suture for the closure of head and neck incisions. Journal of Otolaryngology. 26, 1, Milroy CM, Rutty GN (1997) If a wound is neatly incised it is not a laceration. British Medical Journal. 315, 7118, Moulton C, Yates D (1999) Lecture Notes on Emergency Medicine. Second edition. Blackwell Science, Oxford. Nursing and Midwifery Council (2005) Guidelines for Records and Record Keeping. NMC, London. Penoff J (1999) Skin closures using cyanoacrylate tissue adhesives. Plastic and Reconstructive Surgery. 103, 2, Quaba O, Huntley JS, Bahia H, McKeown DW (2005) A user s guide for reducing the pain of local anaesthetic administration. Emergency Medicine Journal. 22, 3, Quinn J, Maw J, Ramotar K, Wenckebach G, Wells G (1997) Octylcyanoacrylate tissue adhesive versus suture wound repair in a contaminated wound model. Surgery. 122, 1, Rabenberg VS, Ingersoll CD, Sandrey MA, Johnson MT (2002) The bactericidal and cytotoxic effects of antimicrobial wound cleansers. Journal of Athletic Training. 37, 1, Reynolds T (2004) Ear, nose and throat problems in accident and emergency. Nursing Standard. 18, 26, Richardson M (2004) Procedures for cleansing, closing and covering acute wounds. Nursing Times. 100, 4, Towler J (2001) Cleansing traumatic wounds with swabs, water or saline. Journal of Wound Care. 10, 6, Walsh M, Kent A (2001) Soft tissue injury. In Walsh M, Kent A (Eds) Accident & Emergency Nursing. Fourth edition. Butterworth Heinemann, Oxford, Wardrope J, Edhouse J (2000) The Management of Wounds and Burns. Second edition. Oxford University Press, Oxford. 64 february 1 :: vol 20 no 21 :: 2006 NURSING STANDARD