Self-harm wounds: assessment and management

Self-harm (SH) is the collective term for self-poisoning, self-inflected injury or self-mutilation irrespective of the apparent purpose of the act (National Institute for Health and Care Excellence (NICE), 2013). The act of SH tends to be without suicidal intent and is followed by a sense of relief and relaxation. It can be a coping mechanism, often as a result of trauma, psychological illness, abuse, a deep-seated sense of powerlessness or negative feelings, such as anger, guilt, frustration, hopelessness and self-hatred (MIND, 2021). These overwhelming emotional feelings are converted into a visible, physical wound, which the individual can find easier to deal with (Sutton, 2007).

The UK has the highest recorded SH rate of all European countries (Mental Health Foundation, 2017). In 2019, the prevalence of non-suicidal SH nearly tripled in England compared with the previous 10 years (Mayor, 2019). Early figures from the COVID-19 pandemic demonstrated a 38% decrease in rates in reported SH in April 2020 (Kapur et al, 2021) with 2-4% of people in the UK indicating that they had self-harmed in the previous week (Kapur et al, 2021). News reports have suggested that the pandemic has had a deep impact on the younger generation, with greater numbers of children presenting in emergency departments after self-harming or taking overdoses. Although females have a higher prevalence rate of SH, males may display behaviours not generally categorised as SH, such as punching walls (MIND, 2021). Other high risk groups include those aged under 25 years old who have experienced some form of trauma, sexual abuse, drug and alcohol dependency or those with poor self-efficacy and coping skills (National Collaborating Centre for Mental Health, 2020).

A wide range of implements can be used to cause SH (Box 1) and often common areas for injury and preferable for concealment include the thighs, stomach, and lower and upper arms are (Sutton, 2007; MIND, 2021).

Box 1.Commonly used self-harm implements

• Razor blades
• Knives
• Shards of glass
• Needles
• Scissors
• Lighted cigarettes
• Cigarette lighter
• Finger nails
• Boiling water
• Carpentry nails
• Hammer
• Iron
• Safety pins
• Baseball bat
• Hotplate/oven

Source: Sutton (2007)

SH can be defined in both compulsive and impulsive behaviours. Compulsive SH involves a strong urge or craving to inflict injury. This form of SH involves detailed planning of the injury and following aftercare. Initial relief is obtained from injury but often compulsion reoccurs, resulting in reopening of the soft tissue and disruption in healing (Hunt, 2017). Impulsive SH is spontaneous with little planning or aftercare. This can be associated with alcohol, drug taking and psychological issues. Presentation of these wounds often includes infection, deep skin damage which require suturing or surgical intervention (Kilroy-Findley, 2015).

The skin

The skin is the largest organ in the body and there are two main divisions; the outer epidermis and deeper dermis. The epidermis is made up of five layers of cells. The dermis is divided into two main layers (Figure 1). The functions of the skin are as follows (Blows, 2018):

• Barrier and immune defence
• Touch and sense
• Excretion
• Thermoregulation
• Nutrient store
• Synthesis of vitamins
• Physical protection for organs and underlying structure
• Water-resistant barrier.

Figure 1. Layers of the skin

A break in the skin caused by a wound means that these functions and barriers are temporarily lost resulting in a disruption of homeostasis. SH can increase the risk of: complications to the skin, soft tissue damage, scarring, non-healing wounds and infection (Hunt, 2017).

Assessment

A holistic wound assessment is essential to identify the causative and contributory factors of wounding (Mitchell, 2020). Accurate and timely wound assessment underpins of effective clinical decision-making, and agreeing on appropriate patient-centred goals and referral to a mental health team, social worker or appropriate allied worker is essential for holistic support (Hunt, 2017; Mitchell, 2020). Self-inflicted wounds are often ‘bizarre looking’ (Benbow, 2011). They may present in a variety of forms such as blisters, purpura, oedema, erythema or nodules and can often be misleading, which can lead to misdiagnosis (Benbow, 2011).

Assess the patient

Assessment involves gathering and interpreting information about the patient. A holistic assessment should include specific questions relating to the patient's health and wellbeing. This will provide the clinician with a strong foundation to manage the patient's skin and wound, identifying biological, psychological and sociological factors that may delay wound healing (Mitchell, 2020). It is essential to develop a positive therapeutic relationship with any individual who has self-harmed to gain trust, encourage adherence to wound treatment and management strategies and establish the underlying reason for SH (Wright, 2010). Initially, patients traditionally tend to care for their own SH wounds with household materials such as towels, flannels and basic first-aid kits (Kilroy-Findley, 2015).

The following checklist provides a guide for the nurse when assessing a patient:

Personal and medical background

• Ask the patient's age: the highest rate of SH is reported in women aged 16-24 years (Mental Health Foundation, 2016)
• Assess risk: individuals who SH should be assessed for risk of further injurious behaviour, as well as potential suicide (Ousey and Ousey, 2012). Assessment should identify the patient's mental capacity and willingness to undergo a further psychological assessment. Refer to the local mental health service
• Assess for contributing factors to the act of SH, for example alcohol or drug misuse. It may be necessary to refer to local alcohol and drugs services
• Past medical history including any previous wounds: this is particularly relevant for recurrent SH wounds
• Medical and family background. Include questions about any potential stressors in the patient's family dynamics or personal relationships. This may warrant referral to the psychological therapy team
• Ask the patient about any allergies, previous investigations or surgical procedures
• Ask the patient if they have any chronic medical conditions
• Obtain a list of medications
• Assess the patient's nutritional status and any supportive therapies or dietary supplements. The Malnutrition Universal Screening Tool (MUST) (BAPEN, 2011; NICE, 2017) is useful for nutritional screening
• Lifestyle choices, current activities, smoking
• Socioeconomic circumstances, employment, occupation.

Management of the wound

• Confirm the patient's identity, explain and discuss the full procedure and obtain consent
• Ask the patient if they have any allergies
• Wash hands and put on aprons and gloves
• If the patient presents after initial wounding, immediate action may be required to control the bleeding, address shock from hypovolaemia (Hill and Mitchell, 2020), and restore blood perfusion by removing ligatures or stabilising a puncture wound (Ousey and Ousey, 2012)
• Review the history and duration of the wound. This should include how the wound was caused, for example any instruments used and type of wound. Repeated injury and inflammation can result in elevated, thick or nodular hypertrophic scars (Benbow, 2011)
• Review the level of tissue injury: does the wound involve the epidermis, dermis, fat, fascia, muscle, tendon and/or bone? Document findings
• Wound site: document the location of the wound on a body map and the care plan
• Wound size: wound size should be measured and documented in the patient's notes on each dressing change
• Wound depth: if necessary, take a measurement of the wound depth using a sterile swab. This procedure should be carried out by qualified practitioners only who are familiar with the anatomy and structures in close proximity of the wound
• Colour and type of wound bed tissue: document the colour of the wound bed and percentage of types of tissue. Colour of tissue is used to distinguish between viable and non-viable tissue (Atkin et al, 2019)
• Assess for infection. Identification of how the wound was caused and how long the wound has been present will give an indication of the risk of infection. This would be a good opportunity to explain infection risks to the patient, and the classical signs and symptoms of infection. Advise the patient that localised heat or pain and changes in body temperature may be a sign of infection
• Assess the presence or absence of pain. Ask the patient if they are experiencing any pain and does the pain affect quality of life? Use a valid pain tool for assessment (Mitchell, 2020)
• Assess the periwound for the presence of conditions such as eczema, excoriation, maceration and moisture-associated skin damage (Mitchell and Hill, 2020)
• Clean the wound: in most cases tap water can be used for wound irrigation (Peate and Stephens, 2020). If the presence of infection is suspected or the patient's general health is compromised sterile, the use of saline is advised (Peate and Stephens, 2020). Avoid using gauze swabs for irrigation, because these cause trauma and pain on wound contact; they will also help spread the bacteria around the wound if they are not removed. Irrigating fluid should simply be poured over the wound (Peate and Stephens, 2020)
• For superficial uncomplicated injuries of 5 cm or less in length consider using tissue adhesive or skin closure strips
• Assess the patient's knowledge of health and level of health literacy. The educational needs of the patient must be evaluated on an individual basis (Mitchell, 2020)
• Discuss the use of a ‘rescue pack’. In general practice, rescue packs are used to improve a patient's ability to manage their wounds pre- and post-injury. The contents of the pack are simple and easy for patients to understand. The pack should include guidance on how to use and replace the products/dressings and a list of ‘red flags’ highlighting when to seek clinical advice. Table 1 provides an example of the contents of a rescue pack
• Provide guidance and information about scarring, for example on the oils, lotions and creams to moisturise healed skin and scar tissue. Pressure to the skin surface can flatten and soften scar tissue (this should be avoided if this causes discomfort), massage therapy and static or dynamic splints (Benbow, 2011; Monstrey et al, 2014). Medical invasive procedures may be suggested by the health professionals, if indicated
• Discuss self-care and provide education. Give the patient reassurance, confidence and encourage ownership with their self-care pathway. Provide contact information for relevant services and ensure that replacement rescue pack processes are in place (Hunt, 2017).

Conclusion

The management of patients who SH and SH wounds requires time, patience, good communication and listening skills and a non-judgemental holistic approach. It is important that SH wounds are appropriately assessed and treatments and interventions are agreed between the health professional and the patient. Health practitioners must empower patients take ownership and responsibility, and provide patients with education to reduce serious injury, infection, scarring and the need to attend urgent services.

LEARNING POINTS

This article has sought to provide:

• Clinical guidance on self-harm (SH) wound assessment
• An awareness of the complications of wound healing in SH wounds
• Guidance on the management of SH wounds