wound care

1. 1
Wound Care and Dressing

2. 2

3.  Regulates body temperature.
 Prevents loss of essential body fluids, and penetration of toxic
substances.
 Protection of the body from harmful effects of the sun and
radiation.
 Excretes toxic substances with sweat ( waste removal).
 Mechanical support.
 Immunological function mediated by Langerhans cells.
 Sensory organ for touch, heat, cold, socio-sexual and emotional
sensations.
 Vitamin D synthesis from its precursors under the effect of
sunlight and introversion of steroids.
3

4. - A loss of continuity of the skin or mucous
membrane which may involve soft tissues,
muscles, bone and other anatomical structures.
4
- Any disruption to layers of the skin and underlying
tissues due to multiple causes including trauma,
surgery, or a specific disease state.

5. Classification of wound healing
(According to the amount of tissue loss)
 Primary intention healing (e.g closed surgical
incision)
 Secondary intention healing (e.g pressure ulcer)
 Tertiary intention healing (wounds left open for
3-5 days & then closed with sutures, staples, etc…)
5

6. Healing is a quality of living tissue; it is also referred to as
regeneration (renewal) of tissue.
A. The inflammatory phase: initiated immediately after
injury & lasts 3-6 days.
B. The regenerative (Proliferative) phase (day 4-day21)
C. The maturation (Remodeling) phase (day 21- 1 or 2 yrs)
(Manley, Bellman, 2000)
6

7.  Two major processes occur during the
inflammatory phase:
1. Hemostasis (cessation of bleeding) which is
achieved by a. vasoconstriction of the blood
vessels in the affected area, b. deposition of
fibrin, c. formation of the blood clot from the
platelets.
2. Phagocytosis: Macrophages which arise from the
blood monocytes engulf microorganisms and
cellular debris.
7

8. 1. Fibroblasts (connective tissue cells) begin to
synthesize collagen which is a protein
substance that adds strength to the wound.
2. Granulation tissue & neovascularization.
3. Contraction: wound edges pull together to
reduce defect .
8

9.  Begins about day 21 and can extend up to 6
months up to one or two years after the injury.
 Fibroblasts continue to synthesize collagen
 The collagen fibers recognized into a more
orderly structure
 The scar become a thin ,less elastic, white line
9

10. Developmental consideration/Age
Nutrition
Life-style
Medication
Infection
Wound perfusion
10

11. Description and
Characteristics
Cause
Type
Open wound; painful
Sharp instrument eg. Knife
Incision
Close wound, skin
appears ecchymotic
(bruised) because of
damaged blood vessels
Blow from a blunt instrument
Contusion
Open wound; involving
the skin ; painful
Surface scrape, either unintentional
(eg, scraped knee from fall) or
intentional (eg, dermal abrasion to
remove pockmarks)
Abrasion
Open wound; can be
intentional or
unintentional
Penetration of the skin and, often the
underlying tissues from a sharp
instrument
Puncture
Open wound; edges are
often jagged
Tissues torn apart, often from
accidents (eg, machinery)
Laceration
Open wound; usually
accidental ( bullet or
metal fragments)
Penetration of the skin and the
underlying tissues
Penetrating
wound
11

12.  Clean wounds: Operations in which a viscus
is not opened. This category includes non-
traumatic, uninfected wounds where is no
inflammation encountered and no break in
technique has occurred.
 Clean-contaminated: A viscus is entered but
without spillage of contents. This category
included non- traumatic wounds where a
minor break in technique has occurred but no
evidence of infection.
12

13.  Contaminated: Gross spillage has occurred
or a major break in the sterile technique has
occurred. Contaminated wounds shows
evidence of inflammation.
 Dirty or infected : Old traumatic wounds
from a dirty source, with delayed treatment,
devitalised tissue, clinical infection, fecal
contamination or a foreign body.
13

14. I. Partial-thickness: Confined to the skin, the
dermis and epidermis.
II. Full-thickness : Involve the dermis,
epidermis, subcutaneous tissue, and possibly
muscle and bone.
14
Partial Thickness Full Thickness

15. A complex process.
Involve examination of the entire wound.
Nurses visually assess wounds and
document their findings to monitor and
evaluate the progress of wound healing.
15

16. What to assess?
1.Location
2.Dimensions/Size
3.Tissue viability
4.Exudates/Drainage
5.Peri-wound condition
6.Pain
7.Stage or extent of tissue damage , dictates
how often a wound is re-assessed
8.Swelling
16

17.  Risk for Impaired Skin Integrity
 Impaired Skin Integrity
 Impaired Tissue Integrity
 Risk for Infection
 Pain
17

18. A- Intrinsic risk factors:
1. Extremes age: Defined as “ Children aged 1 year
and under, and people aged 65 years and over’.
2. Underling Conditions/Disorders
A.Diabetes
B. Respiratory disorders
C. Blood disorders
3. Smoking
4. Nutrition and build
18

19. B- Extrinsic risk factors:
1. Drug therapy as a risk factor: e.g. Cytotoxic
drugs
2. Break in the integrity of the skin
3. Items such as foreign bodies
4. Bypassing of defense mechanisms through
devices e.g. Intubations
19

20.  Wound is swollen.
 Wound is deep red in color.
 Wound feels hot on palpation.
 Drainage is increased and possibly purulent.
 Foul odor may be noted.
 Wound edges may be separated with
dehiscence present.
 Fever
 High WBC count
20

21. Exudate is material, such as fluid and cells, that has
escaped from blood vessels during the
inflammatory process and deposited in or on tissue
surfaces. The Nature and amount of exudate vary
according to: Tissue involved, Intensity and duration of the
inflammation, and the presence of microorganisms.
1. Serous Exudate
 Mostly serum
 Watery, clear of cells
 E.g., fluid in a blister
21

22. 2. A purulent Exudate
 Is thicker than serous exudate because of the
presence of pus.
 It consists of leukocytes, liquefied dead tissue
debris, dead and living bacteria.
 The Process of pus formation is referred to as
suppuration, and the bacteria that produce pus are
called pyrogenic bacteria.
 Purulent exudate vary in color, some acquiring
tinges of blue, green, or yellow. The color may
depend on the causative organism.
22

23. 3. A sanguineous (hemorrhagic) Exudate
 It consists of large amount of blood cells, indicating
damage to capillaries that is very severe enough to
allow the escape of RBCs from plasma
 This type of exudate is frequently seen in open
wounds.
 Nurses often need to distinguish whether the
exudate is dark or bright. Bright indicate fresh blood,
whereas dark exudate denotes older bleeding.
23

24.  Infection
 Hemorrhage
 Dehiscence and possible evisceration
 Fistula formation (opening between an organ
and the skin).
24

25.  This concept is based on the color of the open
wound rather than the depth or size of the
wound.
 On this scheme, the goal of wound care is to protect
( cover) the red, cleanse the yellow, & debride black.
 The RYB code can be applied to any wound allowed
to heal by secondary intention.
25
R=Red Y=Yellow B= Black

26.  Usually in the late regeneration phase of tissue
repair (ie, developing granulation tissue) and are
clean and uniformly pink in appearance
 They need to be protected to avoid disturbance to
regenerating tissue. Examples are superficial
wounds, skin donor sites, and partial- thickness or
second – degree burns.
26

27. Gentle cleansing
Avoid the use of dry gauze or wet- to-dry saline
dressings.
Applying a topical antimicrobial agent.
Appling a transparent film or hydrocolloid dressing.
Changing the dressing as infrequently as possible.
27

28.  Characterized primarily by liquid to semi-liquid
”slough” that is often accompanied by purulent
drainage.
 The nurse cleanses yellow wounds to absorb
drainage and remove nonviable tissue. Methods used
may include .
 Applying wet-to-dry dressing; irrigating the wound; using
absorbent dressing material such as impregnated non-
adherent, hydrogel dressing, or other exudate absorbers;
and consulting with the physician about the need for a
topical antimicrobial agent to minimize bacterial growth.
28

29.  Covered with thick necrotic tissue or
Eschar.
 e.g.. third degree burns and gangrenous
ulcer.
 Required debridement .
 When the eschar is removed, the wound is
treated as yellow, then red.
29

30. 1. To protect the wound from mechanical
injuries.
2. To protect the wound from microbial
contamination.
3. To provide or maintain high humidity of the
wound.
4. To provide thermal insulation.
5. To absorb drainage and /or debride a wound.
30

31. 6. To prevent hemorrhage (when applied as a
pressure dressing or with elastic
bandages).
7. To splint or immobilize the wound site and
thereby facilitate healing and prevent
injury.
8. To provide psychological (aesthetic) comfort.
31

32. The aim:
 Guarantee the safety of the equipment used
(cleaning/disinfection/sterilization).
 Reduce the level of microbial contamination of
the site requiring manipulation (antisepsis).
 Ensure that no microorganisms are introduced
(asepsis).
32

33. Cleaning : Is the removal of dirt, debris and organic material.
Disinfection: Removes or destroys harmful microorganisms
but not bacterial spores or slow viruses.
Sterilization: is the complete destruction or removal of all
living microorganisms including bacterial spores.
Antisepsis: is the reduction of the number of microorganisms
already present on the body site prior to a procedure.
Asepsis: Procedure designed to prevent any introduction of
microorganisms to the site achieved by a non-touching
technique and use of sterile gloves.
33

34. 1. Use physiologic solution, such as isotonic Normal
saline or lactated ringer solution.
2. When possible , warm the solution to body
temperature before use.
3. If the wound is grossly contaminated by foreign
material , bacteria, slough, or necrotic tissue clean
the wound at every dressing change.
4. If a wound is clean , has little exudate , and
reveals healthy granulation tissue , avoid repeated
cleaning.
34

35. 5. Use gauze squares .
6. Consider cleaning superficial non-infected
wound by irrigating them with normal saline
rather than using mechanical means.
7. To retain wound moisture , avoid drying a
wound after cleaning it.
35

36.  Supplies
 Infection prevention
 Wound healing
 Appearance of the skin/recent changes
 Activity/mobility
 Nutrition
 Pain
 Elimination
36