Wound It is a break in the continuity of the
skin, mucous membranes, bone, or any body
TYPES OF WOUNDS
It is cause by sharp instrument. Ex knife or
Cause by blowFrom a blunt Object.
Closed woundSkin appears ecchymotic
Surface scrape, either Unintentional or
Intentional It is an open wound Involving the
Penetration of the Skin and often, the
Underlying tissues From a sharp Instrument.
Tissues torn apart Often from accidents
Penetration of the Skin and the Underlying
tissues. (eg.gun short )
THE RYB COLOR CODE
This concept is based on the color of an open
wound - Red, Yellow, Black
Red wound - are usually in the late regeneration
phase of tissue repair and are clean and uniformly
pink in appearance
this type of wound needs to be protected
Protect the Red wound
a. gentle cleansing
b. avoiding the use of dry gauze or wet to dry
c. applying a topical antimicrobial agent
d. changing the dressing as infrequent as possible.
Characterized by primarily by liquid to
semiliquid “slough” that is often accompanied
by purulent discharges.
Yellow wounds should be Cleanse to absorb
drainage and remove nonviable tissue.
Apply wet to wet dressing.
Exudate absorbent dressings
This type of wound is covered with necrotic
BLACK WOUNDS requires debridement
( removal of infected and necrotic material)
GUIDELINES IN WOUND CLEANING
Use Isotonic saline or lactated ringers solution
to clean or irrigate the wound.
Warm the solution to body temperature before
If wound is grossly contaminated by foreign
material, bacteria, or necrotic tissue, clean the
wound at every dressing change.
If wound is clean, has little exudate, and reveals
healthy tissue avoid repeated cleaning
Use gauze squares. Avoid using cotton balls and
other products that shed fibers onto the wound
surface. The fibers become embedded in the
granulation tissue and act as a foci for infection
Consider cleaning superficial noninfected wounds
by irrigating them rather than by mechanical
Purpose of wound Dressings
To protect the wound from mechanical injury
To protect the wound from microbial
To provide or maintain high humidity of the
To provide thermal insulation
To absorb drainage or debride the wound
To prevent haemorrhage
To splint or immobilize the wound site and
prevent further injury