2. DEFINITION OF WOUND
A wound is a break or cut in the continuity of any body structure,
internal or external caused by physical means.
CLASSIFICATION OF WOUND
According to severity of injury
PUNCTURED /stab wound
3. • Incised wounds:
These are made by a clean cut with a sharp instrument, e.g , those made by the
surgeon in every surgical procedure. Clean wounds (those made aseptically) are
usually closed by sutures after all bleeding vessels have been ligated carefully.
• Contused wounds:
• These are made by blunt force and are characterized by considerable injury of the
soft part, hemorrhage, and swelling
• Lacerated wounds:
• These are with jagged, irregular wire. edges, such as would be made by glass or
• Puncture wounds:
• These result in small openings in the skin, e.g. those made by bullets or knife
5. • Clean wounds:
These are uninfected surgical wounds in which there is no inflammation
and the respiratory, alimentary, genital, or uninfected urinary tracts are
Clean wounds are usually sutured closed; if necessary, a closed
drainage system (e.g.Jackson Pratt) is inserted. The relative probability
of wound infection is 1 to 5%.
• Clean-contaminated wounds:
These are surgical wounds in which the respiratory, alimentary, genital
and urinary tract are entered under controlled conditions; there is no
unusual contamination. The relative probability of wound infection is 3 to
6. Contaminated wounds:
These include open, fresh, accidental wounds, and surgical
procedures with major breaks in aseptic technique or gross spillage
from the gastrointestinal tract; Included in this category are incisions
in which there is acute, nonpurulent inflammation.
The relative probability of wound infection is 10 to 17%.
7. Dirty or infected wounds:
These are those in which the organisms that caused postoperative
infection were present in the operative field before surgery. These
include old traumatic wounds with retained devitalized tissue and
those that involve existing clinical infections or perforated
viscera. The relative probability of wound infection is over 27%.
8. According to status of skin integrity
According to the cause of the wound
Intentional or surgical wound
10. Inflammatory phase
• Within few seconds after injury, inflammation begins
and lasts for about 3 days.
• Injured tissues and mast cells secrete histamine,
resulting in vasodilation of surrounding capillaries and
exudation of serum and while blood cells into damaged
11. Leukocytes reach the wound within few hours.
The neutrophil begins to ingest bacteria and small debris.
The neutrophil dies in a few days.
• During this period the monocyte which transforms into
macrophages cells clean the wound bacteria, dead cells and
• This process continues for about 48 hours. Finally a thin layer
of epithelial tissue forms over the wound, which is later
12. Destructive phase
• This begins before the inflammatory phase ends and lasts for
about 2 to 5 days.
• Macrophages continue its cleaning process and stimulate the
formation of fibroblast.
13. Proliferative phase
This phase begins with the appearance of the new blood vessels
and lasts from 3 to 24 days. Fibroblasts appear alongside the
capillaries. These two together constitute the granulation tissue.
Subsequently there is epithelization. All the cells forming the
surface epithelium undergoes rapid division and migrates as a thin
film covering the wound.
The wound appears pink owing to the new capillaries in the
granulation tissue and the area is soft and tender.
14. Maturation phase
This final phase may take more than one year there is scar
formation by the fibroblasts.
The capillaries and lymphatic endothelial buds in the new tissues
disappear and the scar then shrinks.
The collagen scar continues to regain strength over several months.
15. FACTORS AFFECTING HEALING PROCESS
Extent of the injury
18. TYPES OF DRESSINGS
Dressings are vary by type of material and mode of application.
Non-adherent gauze dressings
Self-adhesive transparent film
19. PURPOSES OF WOUND DRESSINGS
• To prevent infection.
• To prevent further tissue
• To promote healing.
• To absorb inflammatory
exudate and to promote
• To convert the contaminated
wound into a clean wound.
• To prevent hemorrhage.
To prevent skin excoriation.
To apply medication in place.
To restore the function of the part.
To provide physical and mental comfort to
To promote thermal insulation to the
wound surface area.
To provide maintenance of high humidity
between the wound and dressing.
20. DRESSING: SUTURE CARE
Wound care is defined as cleaning, monitoring and promoting healing
in a wound that is closed with sutures, clips or staples.
Purpose of Dressing
• Provide physical, psychological and aesthetic comfort.
• Remove necrotic tissue.
• Prevent, eliminate or control infection.
• Absorb drainage.
21. • Maintain a moist wound environment.
• Protect the wound from further injury.
• Protect the skin surrounding the wound.
• Promote homeostasis as in a pressure dressing.
• Prevent contamination from feces, urine, vomitus, etc.
• For splinting or immobilization of wound.
22. Types of Dressing
• Dry dressing:
Clean wounds are dressed by the application of 4 to 8 layers of gauze
folded into suitable size and shape.
The surrounding of the wound is cleaned by some antiseptic and dried
and dry dressing is applied after the application of medicine to the
23. • Wet dressing:
It is used if wounds are infected and there is pus.
The wet dressing compresses the hot, it stimulated the supportive
process. The dressing is made of many layers of gauze or cotton pad
covered with gauze.
• Pressure dressing:
It is done when there is bleeding or oozing from the wound.
The dressing consists of thick pad and binder of sterile gauze applied
over the wound with a firm bandage
24. General Instructions
• Maintain aseptic technique to prevent cross infection to the wound and to
• All the material touching the wound should be sterile.
• Wash hands before and after each dressing to avoid cross infection.
• All equipment should be thoroughly disinfected, so that they will be free
• Use masks, sterile gloves and gown for large dressing to minimize the
25. • Dressing is changed at least 15 minutes after the room has been cleaned
and avoids meal timings.
• Clean wound should be dressed before infected or discharging wounds.
• Wounds that are draining freely should be dressed frequently, according to
the doctor's order.
• Avoid coughing, sneezing and talking when the wound is opened.
• While dressing avoid contamination with patient’s skin. Clothing and bed
linen with soiled instruments and dressings.
26. • Clean the wound from cleanest area to the least clean area, e.g. clean the
wound from is center to the periphery.
• If the dressings are adherent to the wound due to drying of the secretions
or blood, wet it with normal saline before it is removed from the wound.
• While dressing, keep the wound edges as close as possible to promote
• Measure the amount of discharge from the wound. Note the color, amount,
and consistency of the drainage.
• Before doing the dressing, inspect the wound for any complication and if it
is present, report immediately to avoid further complications.
27. Preliminary Assessment
• Check the doctor's order for specific instructions.
• Identify the correct patient, bed number and general condition.
• Check the nurse's record to note the condition of the wound in
• Check the abilities of the patient for self-help understanding and
• Check the availabilities of the equipment.
30. A sterile tray containing:
Gloves, Masks and Gowns,
cotton balls, gauze pieces,
cotton pads and dressing
31. A trolley containing:
Cleaning solutions as necessary,
ointments and powders as
Vaseline gauze in sterile
Roller gauze in sterile container,
Chittle forceps in a solution,
sterile gauze, cotton and pad
bandages, adhesive plaster, pins
Mackintosh and draw a covered
bucket to put soiled dressing.
• Explain the procedure to the patient, using sensory preparation.
• Inspect the wound for redness, swelling or signs of dehiscence or
• Observe the characteristics of any drainage.
• Clean the area around the wound with an appropriate cleansing
• Swab from clean area towards the less clean area. (Clean the
wound from the center to periphery).
• Apply medications if ordered.
33. • Apply sterile dressing - apply gauze pieces first and then the cotton
• Remove the gloves and discard it in the bowl with lotion.
• Secure the dressing with bandage or adhesive tapes.
34. AFTER CARE
• Assess the patient to dress up and to take a comfortable position. Change
the garments if soiled with drainage.
• Remove the mackintosh and towel. Replace the bed linen.
• Take all equipment to the utility room. Discard the soiled dressing in a
covered container and send for incineration.
• Wash hands and record the procedure on the nurse's record with date and
• Teach the patient/family about wound care and signs and symptoms of
35. SUTURING THE WOUND
• Materials and equipment:
Suture materials can conveniently be divided into two broad groups:
absorbable and non-absorbable. Two major mechanisms of absorption
result in the degradation of catgut, are gradually digested absorbable
Sutures of biological origin, such as catgut, are gradually digested by
tissue enzymes. Sutures manufactured from synthetic polymers are
mainly broken down by hydrolysis in tissue fluids and are the preferred
36. • Non-absorbable sutures, such as nylon, are made from a variety of
non-biodegradable materials, and are ultimately encapsulated or
walled off by fibroblasts.
• The sizes and tensile strengths of all suture materials are
standardized. Size denotes the diameter of the material the
smaller the diameter, the less tensile strength it will have. Stated
numerically, the higher the first number, the smaller the diameter of
• Examples of suture size used are: Trunk and lower limbs 3/0,
Scalp 2/0, 3/0 or 4/0, Upper limbs 4/0, Most wounds 4/0, Face 5/0,
37. SURGICAL DRESSING
A dressing is a protective covering applied to a wound.
• The goal of a wound care is to promote tissue repair and regeneration, so that
skin integrity is restored.
• Dressing is used as a protective cover over the wound which helps meet the goal
of wound care.
• Most dressings especially for the surgical wounds consist of three layers.
• The dressings applied directly over the wound called contact layer, allows
drainage to pass into the middle layer.
• This layer should be able to remove without causing further tissue damage.
• This middle layer dressing absorbs the drainage and the outer layer keeps the
two inner layers in place.
38. Purposes of dressings:
There are many different types of dressings, but all have essentially the same
purposes as follows:
• Remove necrotic tissue
• Prevent, eliminate, or control infection
• Absorb drainage of discharge
• Control bleeding Apply medication
• Maintain a moist wound environment
• Promote quick healing
• Provide comfort
• Protect the wound from further injury
• Protect the skin surrounding the wound.
39. Advantages of Dressings
Dressings have advantages and disadvantages.
The advantages of wound dressing are as follows:
• Dressings absorb drainage to help promote wound healing
• Dressings protect the wound from mechanical injury
• Dressings when used as a pressure dressing or with elastic bandages
promote homeostasis help prevent hemorrhage, and aid in wound edge
40. • Dressing splint or immobilize the wound, facilitating healing and
preventing further trauma
• Dressings prevent contamination from the external environment
• Dressings provide physical, psychological and esthetic comfort.