Fundamental of Nursing B.Sc. Nursing First Year Kathmandu University

1. Wound and
wound drainage
Prepared by: Geeta Rai, Lecturer

2. content
● Definition and classification of wound and wound
drainage
● Process of wound healing (review)
● Factors influencing wound healing
● Management of wound

3. Definition
A wound is a disruption of the integrity and function
of tissues in the body

4. Classification of wound
There are many ways to classify surgical and
traumatic wounds. Wound classification systems
describe onset and duration of healing process (e.g.,
the status of skin integrity, cause of the wound, or
severity or extent of tissue injury or damage).

5. Contd…
Body wounds are either intentional or unintentional.
Intentional trauma occurs during therapy. Examples
are operations or venipunctures. Although removing
a tumor, for example, is therapeutic, the surgeon
must cut into body tissues, thus traumatizing them.

6. Contd…
Unintentional wounds are accidental; for example,
a person may fracture an arm in an automobile
collision. If the tissues are traumatized without a
break in the skin, the wound is closed. The wound is
open when the skin or mucous membrane surface is
broken.

7. Contd…
Wounds may be described according to how they
are acquired
Partial thickness: confined to the skin, that is, the
dermis and epidermis; heal by regeneration.
Full thickness: involving the dermis, epidermis,
subcutaneous tissue, and possibly muscle and bone;
require connective tissue repair.

8. Contd…
They also can be described according to the
likelihood and degree of wound contamination:
Clean wounds are uninfected wounds in which
there is minimal inflammation and the respiratory,
gastrointestinal, genital, and urinary tracts are not
entered. Clean wounds are primarily closed wounds.

9. Contd…
Clean-contaminated wounds are surgical wounds
in which the respiratory, gastrointestinal, genital, or
urinary tract has been entered. Such wounds show
no evidence of infection.

10. Contd…
Contaminated wounds include open, fresh,
accidental wounds and surgical wounds involving a
major break in sterile technique or a large amount of
spillage from the gastrointestinal tract. Contaminated
wounds show evidence of inflammation.

11. Contd…
Dirty or infected wounds include wounds
containing dead tissue and wounds with evidence of
a clinical infection, such as purulent drainage.

12. Contd…
Wounds, excluding pressure ulcers and burns, are
classified by depth, that is, the tissue layers involved
in the wound.

14. Wound drainage (exudate)
● Serous; clear watery plasma
● Purulent; Thick yellow, green, tan or brown
● Serosanguineous; Pale, pink, watery, mixture of
clear and red fluid
● Sanguineous; Red bright, indicates active
bleeding

15. Serous

16. Purulent

17. Serosanguineous

18. Sanguineous

19. Types of Wound Healing
The types of healing are influenced by the amount of
tissue loss. Primary intention healing occurs where
the tissue surfaces have been approximated
(closed) and there is minimal or no tissue loss; it is
characterized by the formation of minimal
granulation tissue and scarring.

20. Contd…
It is also called primary union or first intention
healing. An example of wound healing by primary
intention is a closed surgical incision. Another
example would be the use of tissue adhesive, a
liquid glue that can be used to seal clean lacerations
or incisions and may result in less noticeable scars.

21. Contd…
A wound that is extensive and involves considerable
tissue loss, and in which the edges cannot or should
not be approximated, heals by secondary intention
healing. An example of wound healing by secondary
intention is a pressure ulcer.

22. Contd…
Secondary intention healing differs from primary
intention healing in three ways:
(1) The repair time is longer,
(2) the scarring is greater, and
(3) the susceptibility to infection is greater.

23. Contd…
Wounds that are left open for 3 to 5 days to allow
edema or infection to resolve or exudate to drain
and are then closed with sutures, staples, or
adhesive skin closures heal by tertiary intention.
This is also called delayed primary intention.

25. Process of wound healing
Healing is a quality of living tissue; it is also referred
to as regeneration (renewal) of tissues. Healing can
be considered in terms of types of healing, having to
do with the primary care provider’s decision on
whether to allow the wound to seal itself or to
purposefully close the wound, and phases of
healing, which refer to the steps in the body’s natural
processes of tissue repair.

26. Contd…
The phases are the same for all wounds, but the rate
and extent of healing depends on factors such as
the type of healing, the location and size of the
wound, and the health of the client.

27. Phases of Wound Healing
Wound healing can be broken down into three
phases:
● inflammatory,
● proliferative, and
● maturation or remodeling

28. Hemostasis
A series of physiological events designed to control
blood loss, establish bacterial control, and seal the
defect occurs when there is an injury. During
hemostasis injured blood vessels constrict, and
platelets gather to stop bleeding. Clots form a fibrin
matrix that later provides a framework for cellular
repair.

29. Inflammatory Phase
In the inflammatory stage damaged tissue and mast
cells secrete histamine, resulting in vasodilation of
surrounding capillaries and movement/migration of
serum and white blood cells into the damaged
tissues. This results in localized redness, edema,
warmth, and throbbing.

30. Contd…
The inflammatory response is beneficial, and there is
no value in attempting to cool the area or reduce the
swelling unless the swelling occurs within a closed
compartment (e.g, spinal cord injury, ankle or neck).

31. Contd…
Leukocytes (white blood cells) reach a wound within
a few hours. The primary acting white blood cell is
the neutrophil, which begins to ingest bacteria and
small debris. The second important leukocyte is the
monocyte, which transforms into macrophages.

32. Contd…
The macrophages are the “garbage cells” that clean
a wound of bacteria, dead cells, and debris by
phagocytosis. Macrophages continue the process of
clearing a wound of debris and release growth
factors that attract fibroblasts, the cells that
synthesize collagen (connective tissue). Collagen
appears as early as second day and is the main
component of scar tissue.

33. Contd…
In a clean wound the inflammatory phase
establishes a clean wound bed. The inflammatory
phase is prolonged if too little inflammation occurs,
as in a debilitating disease such as cancer or after
administration of steroids.

34. Contd…
Too much inflammation also prolongs healing
because arriving cells compete for available
nutrients. An example is a wound infection in which
the increased metabolic energy requirements
present in an infected wound compete for the
available calorie intake.

35. Proliferative Phase
With the appearance of new blood vessels as
reconstruction progresses, the proliferative phase
begins and lasts from 3 to 24 days. The main
activities during this phase are the filling of a wound
with granulation tissue, wound contraction, and
wound resurfacing by epithelialization.

36. Contd…
Fibroblasts are present in this phase and are the
cells that synthesize collagen, providing the matrix
for granulation. Collagen mixes with the granulation
tissue to form a matrix that supports the
reepithelialization.

37. Contd…
Collagen provides strength and structural integrity to
a wound. During this period a wound contracts to
reduce the area that requires healing. Finally the
epithelial cells migrate from the wound edges to
resurface.

38. Contd…
In a clean wound the proliferative phase
accomplishes the following: the vascular bed is
reestablished (granulation tissue), the area is filled
with replacement tissue (collagen, contraction, and
granulation tissue), and the surface is repaired
(epithelialization).

39. Contd…
Impairment of healing during this stage usually
results from systemic factors such as age, anemia,
hypoproteinemia, and zinc deficiency.

40. Maturation
Maturation, the final stage of healing, sometimes
takes place for more than a year, depending on the
depth and extent of the wound. The collagen scar
continues to reorganize and gain strength for several
months.

41. Contd…
However, a healed wound usually does not have the
tensile strength of the tissue it replaces. Collagen
fibers undergo remodeling or reorganization before
assuming their normal appearance.

42. Contd…
Usually scar tissue contains fewer pigmented cells
(melanocytes) and has a lighter color than normal
skin. In individuals with darkly pigmented skin, the
scar tissue may be more highly pigmented than
surrounding skin.

43. Complications of Wound Healing
● Hemorrhage
● Infection

44. Dehiscence
When an incision fails to heal properly, the layers of
skin and tissue separate. This most commonly
occurs before collagen formation (3 to 11 days after
injury). Dehiscence is the partial or total separation
of wound layers.

45. Contd…
A patient who is at risk for poor wound healing (e.g.,
poor nutritional status, infection, or underlying
diseases such as diabetes mellitus or peripheral
vascular disease) is at risk for dehiscence.

46. Contd…
Obese patients have a higher risk of wound
dehiscence because of the constant strain placed on
their wounds and the poor healing qualities of fat
tissue.

47. Contd…
Dehiscence can happen in abdominal surgical
wounds and occurs after a sudden strain such as
coughing, vomiting, or sitting up in bed. Patients
often report feeling as though something has given
way.
When there is an increase in serosanguineous
drainage from a wound in the first few days after
surgery, be alert for the potential for dehiscence.

48. Evisceration
With total separation of wound layers, evisceration
(protrusion of visceral organs through a wound
opening) occurs. The condition is an emergency that
requires surgical repair.

49. Contd…
When evisceration occurs, place sterile gauze
soaked in sterile saline over the extruding tissues to
reduce chances of bacterial invasion and drying of
the tissues. If the organs protrude through the
wound, blood supply to the tissues can be
compromised.

50. Contd…
Then contact the surgical team, do not allow the
patient anything by mouth (NPO), observe for signs
and symptoms of shock, and prepare the patient for
emergency surgery.

51. Factors influencing wound healing
● Nutrition
● Tissue Perfusion
● Infection
● Age
● Psychosocial Impact of Wounds

52. Wound management
● Moist Wound Healing
● Nutrition and Fluids
● Preventing Infection
● Positioning
● Preventing Pressure Ulcers

53. END

54. REFERENCE
● Berman, Audrey T., Synder, S. and Frandsen, G.
2016. Kozier and Erb’s Fundamentals for
Nursing: concepts and practice 10th Edition.USA:
Pearson
● Potter , P., Perry, A. Stockert P. and Hall, A.
2013. Fundamentals of Nursing . 8th edition.
Canada : Mosby Elsevier