2. INTRODUCTION
• A wound may be described in many ways;
• By its etiology, anatomical location, by whether it
is acute or chronic,
• By the method of closure, by its presenting
symptoms or indeed by the appearance of the
predominant tissue types in the wound bed.
• All definitions serve a critical purpose in the
assessment and appropriate management of the
wound through to symptom resolution or,
healing process.
3. DEFINITION
• This is a disruption of the normal continuity of
the skin and underlying tissues due to an
injury
• A wound is an abnormal break in the
continuity of the tissue of the body which
permits the escape of blood externally or
internally and may allow the entrance of
micro organisms causing infection
4. TYPES OF WOUNDS
Wounds may be classified as follows:
Incision or clean cut – Caused by a sharp
instrument such as a knife or razor, they may
bleed profusely
Laceration or torn- Caused by such things as
machinery or barbed wire
• The edges of the wound are torn and irregular
and usually bleed less freely than incised wounds.
• Dirt is more likely to be present
5. TYPES CONT’
Contusion (bruise): a region of injured tissue or skin
in which blood capillaries have been ruptured.
Caused by a blow from a blunt instrument, fall
against a hard surface, however living the outer
layer of the skin intact
• Contused wound should be evaluated for possible
haematoma deep to the surface or other tissue
injuries that may indicate more morbidity
• An expanding haematoma can damage overlying
skin and demands evacuation
6. TYPES CONT’
Abrasions – Injury where a superficial layer of
tissue is removed, as seen with 1st degree burns.
• The wound is cleansed of any foreign material,
this should be performed within the first day of
injury.
• Local anesthetic can be used for pain, however
treatment of the wound is done using moist
dressings and a topical antibiotic to protect the
wound and aid healing.
7. TYPES CONT’
Avulsions – Injuries where a section of tissue is torn off,
either partially or in total.
• In partial avulsions, the tissue is elevated but remains
attached to the body.
• A total avulsion means that the tissue is completely
torn from the body with no point of attachment.
• In the case of a partial avulsion where the torn tissue
is still well-vascularized and viable, the tissue is gently
cleansed and irrigated and the flap is reattached to its
anatomical position with a few sutures.
8. TYPES CONT’
• If the torn tissue is non-viable, it is often
excised and the wound closed using a skin
graft or local flap.
• Major avulsions describe amputation of
extremities, fingers, ears, nose, scalp or
eyelids and require treatment by a replant
team.
9. TYPES CONT’
Punctured or stab wound- Caused by a sharp
pointed instrument such as garden fork, needle
• These wounds have comparatively small openings
but may be deep causing serious injury
Gun short wounds – A small entry may be
associated with extensive internal injuries and
with large exit wounds
Amputation- This is the surgical or traumatic
removal of all or part of a limb or extremity.
10. WOUND HEALING PROCESS
• Wound healing, is a process in which the skin
(or another organ-tissue) repairs itself after
injury.
• In normal skin, the epidermis (outermost layer)
and dermis (inner or deeper layer) exists in a
steady-state of equilibrium, forming a protective
barrier against the external environment.
• Once the protective barrier is broken, the normal
(physiologic) process of wound healing is
immediately set in motion.
11. CONT’
• The classic model of wound healing is divided
into three sequential, yet overlapping phases:
• Inflammatory phase
• Proliferative phase
• Remodeling phase
12. HEALING PROCESS CONTINUED
HAEMOSTASIS
• Within minutes post-injury, platelets
aggregate at the injury site to form a fibrin
clot.
• This clot acts to control active bleeding
(haemostasis).
13. CONT’
INFLAMMATORY PHASE
• In the inflammatory phase, bacteria and
debris are phagocytosed and removed,
• Phagocytes begin to remove the clot and cell
debris stimulating fibroblast activity
• Fibroblasts secret collagen fibres which begin
to bind the surfaces together
14. CONT’
PROLIFERATIVE PHASE
• The proliferative phase is characterized by;
angiogenesis, collagen deposition, granulation
tissue formation, epithelialization, and wound
contraction.
• In angiogenesis, new blood vessels are formed
by vascular endothelial cells
• In granulation tissue formation, fibroblasts grow
and form a new, provisional extracellular matrix
(ECM) by excreting collagen ( proteins occurring
as a major component of connective tissue)
15. CONT’
• Concurrently, re-epithelialization of the
epidermis occurs, in which epithelial cells
proliferate and 'crawl' atop the wound bed,
providing cover for the new tissue.
• In contraction, the wound is made smaller by
the action of myofibroblasts, which establish a
grip on the wound edges and contract
themselves using a mechanism similar to that
in smooth muscle cells
16. CONT’
IN THE MATURATION AND REMODELING PHASE
• Collagen is remodeled( reorganized/renovated)
and realigned along tension lines and cells that
are no longer needed are removed by apoptosis.
• However, this process is not only complex but
fragile, and susceptible to interruption or failure
leading to the formation of non-healing chronic
wounds.
• Factors which may contribute to this include;
diabetes, venous or arterial disease, old age, and
infection.
17. TYPES OF WOUND HEALING
Healing by first intension
• Primary wound healing or primary closure by use
of sutures
• Describes a wound closed by approximation of
wound margins, or wounds created and closed in
the operating room.
• Best choice for clean, fresh wounds in well-
vascularized areas
• Indications include recent (<24h old), clean
wounds where viable tissue is tension-free and
approximation of skin edges is achievable.
18. CONT’
Healing by secondary intension
• secondary wound healing
• Describes a wound left open and allowed to
close by epithelialization and contraction.
• Commonly used in the management of
contaminated or infected wounds.
• Wound is left open to heal without surgical
intervention.
19. CONT’
Tertiary wound healing or delayed primary
closure
• Certain wounds may be contaminated , and
although they can be closed by primary
intension , they are not because of the
increased risk of infection
• These wounds are closed later when they are
free of infection, this is called healing by
tertiary intension or delayed primary closure
20. FACTORS THAT PROMOTE WOUND
HEALING
Local factors that facilitate wound healing include:
• A good blood supply to provide oxygen and
nutrients and remove waste products
• Infection prevention
• Adequate rest or local immobilization
• A good general health of the patient
• A balanced diet
Protein is required for all the phases of wound
healing, particularly important for collagen
synthesis.
21. FACTORS THAT PROMOTE WOUND
HEALING
Iron - required to transport oxygen.
Minerals- zinc, copper, are important for enzyme
systems and immune systems. Zinc deficiency
contributes to disruption in granulation tissue
formation.
Vitamins A, B complex and C are responsible for
supporting epithelialization and collagen formation..
Carbohydrates and fats. These provide the energy
required for cell function. When the patient does not
have enough, the body breaks down protein to meet
the energy needs.
22. MANAGEMENT OF A PATIENT WITH
WOUNDS
• The most important part of wound management is to
diagnose the etiology of the wound and treat the
underlying cause.
• Wounds heal best in a moist environment and most
wound dressings have been designed to assist this
process.
• This will promote healing with the assistance of
modern wound dressings.
• As wound healing is determined by the general health
of the patient, a comprehensive assessment of the
patient is critical to assist in the planning and
evaluation of any wound treatment.
23. CONT’
History
• The clients’ history must be taken including a history of
the wound it self
• Assessment should include the client’s age, occupation,
living situation, financial status, roles and
responsibilities, spiritual and cultural beliefs and ability
to learn self care and comply with the treatment plan
• Medical history should include information about
chronic conditions like diabetes mellitus which may
delay wound healing, recent surgery and drugs as
some drugs like steroids interfere with the healing
process
24. CONT’
• A complete physical assessment should be
done not just the wound
• Assess the height and weight of the patient,
degree of range of motion, muscle wasting
and level of activity
• Assess circulation such as peripheral pulses ,
color, edema
• Assess temperature and level of pain
25. CONT’
• A complete wound assessment should also be
done
• Describe the actual size of the wound, color,
type of drainage and the condition of the skin
around the wound
26. CONT’
Lab investigations
• Pus swab/ discharge from the wound for culture
and sensitivity to isolate the causative organism
in case of chronic wounds
• Biopsy of the wound to rule out whether it is
malignant or benign in case of chronic wounds
• Blood and urine tests to rule out some conditions
e.g. diabetes mellitus which may delay wound
healing
• Blood for HB to rule out anaemia which delays
wound healing
27. TREATMENT OPTIONS
The treatment recommended depends on age,
health and the nature of the wound. General
medical care may include:
• Cleaning to remove dirt and debris from a fresh
wound, this is done very gently
• Vaccinating for tetanus may be recommended in
some cases of traumatic injury.
• Exploring a deep wound surgically may be
necessary, Local anaesthetic will be given before
the examination
28. CONT
• Removing dead skin surgically. Local
anaesthetic will be given.
• Closing large wounds with stitches or staples.
• Dressing the wound. The dressing depends on
the type and severity of the wound. In most
cases of chronic wounds, the doctor will
recommend a moist dressing.
• Moist dressings promote epithelialisation
(healing by growth of epithelium)
29. CONT’
• Relieving pain with medications, drugs such as
paracetamol may be prescribed or stronger
pain-killing medication.
• Treating signs of infection including pain, pus
and fever.
prescribe antibiotics and antimicrobial dressings
if necessary. Give as directed.
30. CONT’
• Treating other medical conditions, such as
anaemia, that may prevent wound healing.
31. ulcers
• A break in the continuity of the covering
epithelium- skin/ mucous membrane.
32. causes
• Venous disease: varicose veins, DVT
• Arterial obliteration: large or small
• Denervation: peripheral spinal cord lesion
• Trauma
• Infection: osteomyelitis, specific infection
• Malignancy
• Secondary skin tumours
• Pressure sore
33. Identification of an ulcer
• Inspection:
• Size and shape
• Number
• Position
• Edge
• Floor
• Discharge
• Surrounding area
• Whole limb
34. palpation
• Tenderness
• Edge and margin
• Base
• Depth
• Bleeding
• Relations with deeper structure
• Surrounding skin
35.
36.
37.
38.
39.
40.
41.
42. investigations
• Routine blood test
• Urine test
• Bacteriological examination of the discharge
• Skin test
• Chest x-ray
• Biopsy
• X ray of bone and joint
43. Pressure ulcer
• Tissue necrosis with ulceration due to prolonged
pressure
• Most affected areas:
• Ischium
• Greater trochanter
• Sacrum
• Heel
• Malleolus
• occiput
44.
45. Prophylaxis for at risk patients
• Reposition every 2 hours (more often if possible)
• Massage areas prone to pressure ulcers while
changing position of patient
• Use interface air mattress reduce compression
• Clean with mild cleansing agents, keeping skin
free of aggressive agents
• Maintain head of the bed at a relatively low angle
of elevation
• Evaluate and correct nutritional status
• Mobilise patient as soon as possible
46. management
• Stages I and ii ulcers
• Topical antibiotics under moist sterile gauze for early erosions
• Normal saline wet-dry dressings for debridement
• Hydrogels or hydrocolloid dressings
• Stages iii and iv
• Debridement of necrotic tissue
• Bony prominence removal, flaps and skin grafts
• Infectious complications
• Prolonged course of antibiotics
• Surgical debridement of necrotic bone in osteomyelitis
47. DIABETIC ULCER
• Causes
• • Increased glucose in the tissue precipitates infection.
• • Diabetic microangiopathy which affects
microcirculation.
• • Increased glycosylated haemoglobin decreases the
oxygen dissociation.
• • Increased glycosylated tissue protein decreases the
oxygen utilization.
• • Diabetic neuropathy involving all sensory, motor and
autonomous components.
• • Associated atherosclerosis.
48. Sites
• • Foot-plantar aspect—is the commonest site.
• Leg.
• • Upper limb, back, scrotum, perineum.
• • Diabetic ulcer may be associated with
ischaemia.
• • Ulcer is usually spreading and deep
49. Investigations
• • Blood sugar both random and fasting.
• • Urine ketone bodies.
• • Discharge for culture and sensitivity.
• • X-ray of the part to see osteomyelitis.
• • Arterial Doppler of the limb.
50. Treatment
• • Control of diabetes using insulin.
• • Antibiotics.
• • Nutritional supplements.
• • Regular cleaning, debridement, dressing.
• • Once granulates, the ulcer is covered with skin
graft or flap.
• • Toe/foot/leg amputation.
• • Microcellular rubber (MCR) shoes to prevent
injuries; care of foot.
