A 5-year-old boy consulted you for a wound which he incurred a few minutes ago while

playing basketball.

The integumentary system is formed by the skin and its derivative structures (see Figure 1-1).
The skin is composed of three layers: the epidermis, the dermis, and subcutaneous tissue
(Kanitakis, 2002). The outermost level, the epidermis, consists of a specific constellation of cells
known as keratinocytes, which function to synthesize keratin, a long, threadlike protein with a
protective role. The middle layer, the dermis, is fundamentally made up of the fibrillar structural
protein known as collagen. The dermis lies on the subcutaneous tissue, or panniculus, which
contains small lobes of fat cells known as lipocytes. The thickness of these layers varies
considerably, depending on the geographic location on the anatomy of the body. The eyelid, for
example, has the thinnest layer of the epidermis, measuring less than 0.1 mm, whereas the
palms and soles of the feet have the thickest epidermal layer, measuring approximately 1.5 mm.
The dermis is thickest on the back, where it is 30–40 times as thick as the overlying epidermis

Open Wounds
An open wound is an injury involving an external or internal break in body tissue, usually
involving the skin. Nearly everyone will experience an open wound at some point in their life.
Most open wounds are minor and can be treated at home.
Falls, accidents with sharp objects, and car accidents are the most common causes of open
wounds. In the case of a serious accident, you should seek immediate medical care. This is
especially true if there’s a lot of bleeding or if bleeding lasts for more than 20 minutes.

Types of Wound:
Abrasion - An abrasion occurs when your skin rubs or scrapes against a rough or hard surface.
Road rash is an example of an abrasion. There’s usually not a lot of bleeding, but the wound
needs to be scrubbed and cleaned to avoid infection.
Laceration - A laceration is a deep cut or tearing of your skin. Accidents with knives, tools, and
machinery are frequent causes of lacerations. In the case of deep lacerations, bleeding can be
rapid and extensive.
Puncture - A puncture is a small hole caused by a long, pointy object, such as a nail or needle.
Sometimes, a bullet can cause a puncture wound.
Punctures may not bleed much, but these wounds can be deep enough to damage internal
organs. If you have even a small puncture wound, visit your doctor to get a tetanus shot and
prevent infection.
Avulsion - An avulsion is a partial or complete tearing away of skin and the tissue beneath.
Avulsions usually occur during violent accidents, such as body-crushing accidents, explosions,
and gunshots. They bleed heavily and rapidly.

Demographic Data:
▰ Name: Patient X
▰ Age: 5 y/o
▰ Sex: Male
▰ Address: Tetuan, Zamboang City
▰ Religion: Roman Catholic
▰ Nationality: Filipino

Treatment:
▰ Cleanse
Minor wounds can be treated at home. First, wash and disinfect the wound to remove
all dirt and debris. Use direct pressure and elevation to control bleeding and swelling.
When wrapping the wound, always use a sterile dressing or bandage. Very minor
wounds may heal without a bandage. You’ll need to keep the wound clean and dry for
five days. You should also make sure you get plenty of rest.
Pain typically accompanies a wound. You can take acetaminophen (Tylenol) as directed
on the package. Avoid products with aspirin since they can cause or prolong bleeding.
Apply ice if you have bruising or swelling, and avoid picking at scabs. If you’re spending
time outdoors, use a sunscreen that’s sun protection factor (SPF) 30 on the area until it’s
completely healed.

▰ Pain Medication
▻ Paracetamol/ NSAIDs (Ibuprofen, celecoxib)
*Suture
When sutures are removed will depend on where they are on the body. According to American
Family Physician, some general guidelines are as follows:
 scalp: 7 to 10 days
 face: 3 to 5 days
 chest or trunk: 10 to 14 days
 arms: 7 to 10 days
 legs: 10 to 14 days
 hands or feet: 10 to 14 days
 palms of hands or soles of feet: 14 to 21 days

*Tetanus Shot

Healing Process
1. Hemostasis is the process of the wound being closed by clotting. Hemostasis starts
when blood leaks out of the body. The first step of hemostasis is when blood vessels
constrict to restrict the blood flow. Next, platelets stick together in order to seal the
break in the wall of the blood vessel. Finally, coagulation occurs and reinforces the
platelet plug with threads of fibrin which are like a molecular binding agent. The
hemostasis stage of wound healing happens very quickly. The platelets adhere to the
sub-endothelium surface within seconds of the rupture of a blood vessel's epithelial
wall. After that, the first fibrin strands begin to adhere in about sixty seconds. As the
fibrin mesh begins, the blood is transformed from liquid to gel through pro-coagulants
and the release of prothrombin. The formation of a thrombus or clot keeps the platelets
and blood cells trapped in the wound area. The thrombus is generally important in the
stages of wound healing but becomes a problem if it detaches from the vessel wall and
goes through the circulatory system, possibly causing a stroke, pulmonary embolism or
heart attack.

2. Inflammation is the second stage of wound healing and begins right after the injury
when the injured blood vessels leak transudate (made of water, salt, and protein)
causing localized swelling. Inflammation both controls bleeding and prevents infection.
The fluid engorgement allows healing and repair cells to move to the site of the wound.
During the inflammatory phase, damaged cells, pathogens, and bacteria are removed
from the wound area. These white blood cells, growth factors, nutrients and enzymes
create the swelling, heat, pain and redness commonly seen during this stage of wound
healing. Inflammation is a natural part of the wound healing process and only
problematic if prolonged or excessive.

3. The proliferative phase of wound healing is when the wound is rebuilt with new tissue
made up of collagen and extracellular matrix. In the proliferative phase, the wound
contracts as new tissues are built. In addition, a new network of blood vessels must be
constructed so that the granulation tissue can be healthy and receive sufficient oxygen
and nutrients. Myofibroblasts cause the wound to contract by gripping the wound edges
and pulling them together using a mechanism similar to that of smooth muscle cells. In
healthy stages of wound healing, granulation tissue is pink or red and uneven in texture.
Moreover, healthy granulation tissue does not bleed easily. Dark granulation tissue can
be a sign of infection, ischemia, or poor perfusion. In the final phase of the proliferative
stage of wound healing, epithelial cells resurface the injury. It is important to remember
that epithelialization happens faster when wounds are kept moist and hydrated.
Generally, when occlusive or semiocclusive dressings are applied within 48 hours after
injury, they will maintain correct tissue humidity to optimize epithelialization.
 4. Maturation phase, also called the remodeling stage of wound healing, the maturation
phase is when collagen is remodeled from type III to type I and the wound fully closes.
The cells that had been used to repair the wound but which are no longer needed are
removed by apoptosis, or programmed cell death. When collagen is laid down during the
proliferative phase, it is disorganized and the wound is thick. During the maturation
phase, collagen is aligned along tension lines and water is reabsorbed so the collagen
fibers can lie closer together and cross-link. Cross-linking of collagen reduces scar
thickness and also makes the skin area of the wound stronger. Generally, remodeling
begins about 21 days after an injury and can continue for a year or more. Even with
cross-linking, healed wound areas continue to be weaker than uninjured skin, generally
only having 80% of the tensile strength of unwounded skin.

Suture removal

When your sutures are removed will depend on where they are on your body. According
to American Family Physician, some general guidelines are as follows:
 scalp: 7 to 10 days
 face: 3 to 5 days
 chest or trunk: 10 to 14 days
 arms: 7 to 10 days
 legs: 10 to 14 days
 hands or feet: 10 to 14 days
 palms of hands or soles of feet: 14 to 21 days
A 5-year-old boy consulted you for a wound which he incurred a few minutes ago while
playing basketball.

 Name: Patient X
 Age: 5 y/o
 Sex: Male
 Address: Tetuan, Zamboang City
 Religion: Roman Catholic
 Nationality: Filipino

Wound at left arm with complaints of pain

Abrasion with bleeding

Treatment:
 Cleanse
 Pain Medication
▻ Paracetamol/ NSAIDs (Ibuprofen, celecoxib)
*Suture
*Tetanus Shot

Evaluation
 Pain assessment
 Follow-up visit

Health Maintenance:
 Protective gear and other safety precautions
 Tetanus immunization status
 Health teaching on:
 Hand washing with soap
 Application of and-aid or light bandage
 Direct pressure