wounds healing types ,classifications

2. “ PRESENTATION TOPIC
ON
WOUNDS ”
Presented by:
Mr. Manjunath. Beth
Associate professor
&
HOD OF MSN DEPARTMENT

3. WOUNDS

4. objectives
At the end of this topic, you should be able to:-
Define the term “Wound”
List the causes of wounds
Outline the classification of wounds
Define the term “wound healing”
Describe the phases of wound healing
Highlight the types of wound healing
Describe factors affecting wound healing
Outline the complications of wound healing
Discuss the management of wounds

5. DEFINITION
A wound is a type of physical trauma
whereby the integrity of the skin or of
any tissue is compromised
It is a separation or discontinuity of the
skin, mucous membrane or tissue
caused by physical, chemical or
biological insult

6. ETIOLOGY
The etiology of wounds can be
classified as follows:-
Blunt injuries
Penetrating injuries
Surgical insult
Burn injuries

7. BLUNT INJURIES
RTA
Falls
Assault
Sport injuries
Bite injuries [animal or human]

11. Penetrating injuries
Stab wounds
Gunshot wounds

16. Surgical wounds
Wounds caused by a surgical
procedure

17. Classification of Surgical Wounds
 Based on the risk of infection & degree of
contamination
- Clean (Class-I)
- Clean-contaminated (Class-II)
- Contaminated (Class-III)
- Dirty (Class-IV)

18. 1- Clean wounds
 No inflammation
 No break in sterile technique
 Wound primarily closed/Not
drained
 Aero- digestive, genitourinary &
Biliary tract not entered
 Potential infection rate 1%-5%
 Examples
 Thyroidectomy
 Mastectomy
 Lipoma excision

19. 2- Clean-contaminated Wound
 No inflammation/Infection present
 Minor break in sterile technique
 Aerodigestive or genitourinary
tract entered without spillage
 Potential infection rate 8% - 10%
 Examples
 Simple appendectomy
 Prostatectomy
 Cholecystectomy

20. 3- Contaminated Wound
 Traumatic wounds
 Acute inflammation present
 Major break in sterile technique
 Gross spillage/contamination
from respiratory,
gastrointestinal, biliary, or
genitourinary tracts
 Potential infection rate 15% -
20%
 Example
 Traumatic wounds

21. 4- Dirty/Infected Wound
 Organisms present at surgical site
prior to procedure/Existing
infection
 Presence of pus
 Perforation (Gastrointestinal,
biliary, respiratory, genitourinary
tract)
 Potential infection rate 27% - 40%
 Example
 Appendiceal abcess
 Peritonitis

22. Burn injuries
Thermal burn
Chemical burn
Electrical burn
Radiation burn
Cold injury

23. TYPES OF BURNS
23
Thermal
exposure to flame or a hot object
Chemical
exposure to acid, alkali or organic substances
Electrical
result from the conversion of electrical energy
into heat. Extent of injury depends on the type of
current, the pathway of flow, local tissue
resistance, and duration of contact
Radiation
result from radiant energy being transferred to
the body resulting in production of cellular toxins

24. Chemical Burn
4/1/2011 24

25. Electrical Burn
4/1/2011 25

26. COLD INJURY

29. WOUND CLASSIFICATION
Aim:
Wound classification systems provide
frameworks that:-
Aid diagnosis and stratification
Ensure uniformity of documentation
Offer prognostic information
Guide management

30. Types of wound classification
Wounds can be classified as follows:-
According to the etiology
According to Rank-Wakefield classification system
According to the duration of the wound healing
According to the integrity of the skin
According to wound depth
According to morphological characteristics
According to degree of contamination
According to severity

31. According to the etiology
Surgical wounds
These are wounds caused by surgical
procedure
Penetrating wounds
Wounds caused by penetrating trauma
Blunt wounds
Wounds caused by blunt trauma
Burn wounds
Wounds caused by burn injuries

32. According to Rank-Wakefield
classification system
Tidy wounds
These are wounds inflicted by sharp
instruments and contain no devitalized
tissue
Such wounds can be closed primarily with
the expectation of quite primary healing
They are usually single with clean cut
Associated fractures are uncommon in
tidy wounds
Examples: surgical incisions, cuts from
glass and knife wounds

34. Untidy wounds
These are wounds resulting from
crushing, tearing avulsion, vascular
injury or burns, and contain devitalized
tissue
They are usually multiple and irregular
Commonly associated with fractures
Such wounds can not be closed
primarily and therefore should be
allowed to heal by second intention

35. Tidy Vs Untidy
Tidy Untidy
- Incised - Crushed
- Clean - Contaminated
- Devitalized tissue
- Often tissue loss
- Healthy tissue
- Seldom tissue loss

37. According to the duration of
the
wound healing
Acute wounds
Acute wounds are wounds that usually
heal in the anticipated time frame
Duration of the wound: immediately to
few weeks
Examples are wounds acquired as a result
of trauma or an operative procedure

38. Chronic wounds
Wounds that fail to heal in the
anticipated time frame and often
reoccur
Duration of the wound ⇒ > 4 weeks to
3 months
Wounds occur as a result of an
underlying condition such as
extended pressure on the tissues, poor
circulation, or even poor nutrition
Pressure ulcers, venous leg ulcers, and
diabetic foot ulcers are examples

40. Abnormal wound healing

Hypertrophi
c scar
 Keloid

41. Acute Vs Chronic
 Acute wounds
 Wounds that heal in expected period of time
 Eg. Lacerations
 Chronic wounds
- Wound that fails to heal over an extended period of
time
- Caused by inadequate circulation or in which
healing is delayed as a resul
- eg. Ulcers

42. According to the
integrity of the
skin
Open wounds
Type of wounds in which the skin has
been compromised and underlying
tissues are exposed
Open wounds can be classified into a
number of different types, according
to the object that caused the wound
Examples include incised wounds,
laceration, punctured wounds etc

43. Closed wounds
Wounds in which the skin has not been
compromised, but trauma to underlying
structures has occurred
Closed wounds have fewer categories, but
are just as dangerous as open wounds
Examples of closed wounds are:
Contusions - (more commonly known as a
bruise) - caused by blunt force trauma
that damages tissue under the skin
Hematoma - (also called a blood tumor) -
caused by damage to a blood vessel that
in turn causes blood to collect under the
skin

44. Classification
1- Closed Vs Open
Closed wounds
Skin Intact / Underlying tissue damag
e.gs contusion, bruise, hematoma.
Open wounds
-Complete break of the epithelial protective
surface.
e.gs abrasion, laceration, puncture, degloved
wound , bites.

45. According to wound depth
Superficial wounds
Only the epidermis is affected and has
to be replaced
A truly superficial wound does not bleed
and heals within a few days
Examples include most abrasions and
blisters

46. Partial-thickness wounds
The epidermis and part of the dermis is
affected
A partial-thickness wound does bleed
If left uncovered, a blood clot will cover the
wound and a scar will form
The missing tissue will then be replaced,
followed by regeneration of the epidermis
A partial-thickness wound can take from several days
to several weeks to heal, depending on the patient
and the wound treatments chosen

47. Full-thickness wounds
A full-thickness wound involves the epidermis
and the dermis
The underlying fatty tissue, bones, muscles, or
tendons may also be damaged
If full-thickness wounds cannot be sutured, the
healing process will create new tissue to fill
the wound, followed by regeneration of the
epidermis
The full-thickness wound takes longer time to
heal than does a partial-thickness wound,
sometimes as long as several months

49. According to morphological
characteristics
Bruises / contusion
These are closed wounds
Caused by blunt trauma that damage the
tissue under the skin without breaking the
skin
Characterized by skin discoloration due to
bleeding into the tissues
Blows to the chest, abdomen, or head with
a blunt instrument can cause contusions

51. Hematoma
These are also closed wounds caused
by damage to a blood vessel that in
turn causes blood to collect under the
skin
Initially this is fluid, but it will clot within
minutes or hours ⇒ later after few days
the hematoma will again liquefy →
increased risk of secondary infection →
pus formation

53. Crush wounds
Crush wounds are caused by a great or
extreme amount of force applied over a
long period of time
These occur when a heavy object falls
onto a person, splitting the skin and
shattering or tearing underlying structures
They are often accompanied by
degloving injuries and compartment
syndrome

55. Abrasions
An abrasion is a shearing injury of the
skin I which the surface is rubbed off
Most are superficial and will heal by
epitheliazation

58. Lacerated wound
Caused by tearing of tissues
Wounds have irregular borders
Loss of tissue is limited to skin and s/c
tissue

61. Penetrated wound
Cause by sharp pointed objects like
nails
Have relatively small opening
May be very deep
Infection/ foreign particles might have
been carried deep in to wound
opening is inadequate for drainage
eg: punctured wound on foot due to
gathered nail

64. Perforating wound
Have two opening one of entrance
and other of exit
E.g. gunshot wounds

71. According to degree of
contamination
Clean wounds
No break in aseptic technique
Incision is made under sterile condions
No inflammation is encountered
The respiratory tract, alimentary, genital
or uninfected urinary tracts are not
entered
Primary closure
No drain
Eg Herniorrhaphy,

72. Clean Contaminated wounds
Operative wounds in which the
respiratory, alimentary, genital or urinary
tract is entered under controlled
conditions and without unusual
contamination

73. Contaminated wounds
Open, fresh or accidental wounds;
operations with major breaks in sterile
technique or gross spillage from the
gastrointestinal tract; and incisions in
which acute, non-purulent
inflammation is encountered

74. Dirty or Infected wounds
Old traumatic wounds with retained
devitalized tissue and those that involve
existing clinical infection

75. Tetanus Prone Vs Tetanus Non-prone
Tetanus Prone
wound age >6hrs
wound depth > 1cm
presence of devitalized tissue
contaminated wounds
Animal bites
Tetanus Non-prone
. wound age <6hrs
. wound depth <1cm
. absence of devitalized tissue
. non contaminated wounds

78. According to severity
Simple wounds
The integrity of the skin is traumatized
without loss or destruction of tissue
and without the presence of a
foreign body in the wound
Complex wounds
Tissue is lost or destructed by means
of a crush, burn, or foreign body in
the wound

79. Diabetic wound

80. WOUND HEALING
Definition
Wound healing, or wound repair, is
the body's natural process of
restoring normal function and
structure after injury
The entire wound healing process is
a complex series of events that
begins at the moment of injury and
can continue for months to years

81. Phases of wound healing
Three phases of wound healing
include:-
Inflammatory phase
Proliferative phase
Maturation and remodeling phase

85. HEMOSTASIS:
After client get injured, homeostasis begins in which
blood vessels constrict and the platelets create
substances that help stop bleeding through clotting.
1. INFLAMMATION: (first stage)
i. Client body responds to trauma by raising level of
inflammation.
ii. The blood vessels dilate after homeostasis is
achieved.
iii. This allows white blood cells, nutrients, enzymes,
antibodies, and other beneficial elements reach the
affected area to accelerate wound healing.
iv. At this stage, client will experience the effects of
inflammation, such as heat, pain, swelling, and
redness.

86. DIFFERENCE BETWEEN
THE
INFECTION
AND
INFLAMMATION?

89. 2.PROLIFERATION: (Second Stage)
a. The second stage in the wound healing process is
proliferation in which new, healthy granulation tissue
replaces the wound.
b. It is important that the blood vessels receive enough
nutrients and oxygen to form granulation tissue.
c. The tissue consists of a mixture of collagen and
extracellular matrix, which helps develop a new
network of blood vessels.
d. During the process, the color of granulation tissue will
change. If it is pink or red, it usually means that it is
healthy.
e. It indicates infection when the color of granulation
tissue is rather dark.

90. f. During this stage, the body will also work on
damaged mesenchymal cells (Mesodermal tissue
forms of connective tissue, blood and smooth muscles)
and change them into fibroblasts.
g. They work more as bridges to ensure easy
movement of cells around the affected area.
h. These fibroblasts usually take three days to
appear if the wound is healthy.
i. They secrete collagen and liquids and give
strength to the wound site.
j. wound will continue to grow stronger through
this stage.

91. 3. MATURATION:
a. Maturation or remodeling is the end stage of the
wound healing process.
b. It takes place soon after the wound has closed up.
c. This stage may continue for a couple of years and
involves repair of the dermal tissues to improve
their tensile strength.
d. During this stage, functional fibroblasts will replace
non-functional one and the number of blood vessels
in the area will also decrease gradually.

92. d. As the process continues for quite some time,
it is important to stick to the treatment plan
even when the client notice the maturation
has begun.
e. If the client leave the treatment too early, the
wound may break down again because the
area is up to 20% weaker even after
maturation.

93. VIDEO OF WOUND HEALING
PHASES

94. Types of wound healing
Healing by primary intention (Primary
closure)
Healing by secondary intention (Secondary
closure)
Healing by tertiary intention (Delayed
primary closure)

95. Healing by primary intention
(Primary closure)
Healing by primary intention (Primary
closure) occurs when a wound is created
aseptically with minimal tissue damage
Healing takes place by the approximation
of tissue edges with suture, staples, wound
sealant etc

96. Primary Intention
 For clean wounds
 Wound is sutured/closed
 Healing occurs from side-to-
side
 Healing occurs rapidly with little
inflammation and minimal
scarring

97. Healing by secondary intention
(Secondary closure)
Occurs in wounds that are already infected
and are usually left open and allowed to
heal by epitheliazation and wound
contraction
May be caused by infection, excessive
trauma, tissue loss, or inability to re-
approximate the tissue
It is a slow process

98. Secondary Intention
 For contaminated/dirty wounds
 Wound is intentionally left open
 Healing occurs from the bottom–
up
 Granulation tissue containing
myofibroblasts forms wound
contraction
 Scar formation is extensive

99. Healing by tertiary intention
(Delayed primary closure)
Wounds that are heavily contaminated and
are likely to develop an infection if closed
primarily may be left open for 3-5 days
This allows the wound to be cleaned and
allows the body’s natural defenses to
decrease bacterial count
The wound can then be closed and allowed
to heal, producing a wound with
characteristics similar to primary closure

100. Tertiary Intention (Delayed Primary Closure)
 For contaminated/dirty
 Wound is left open until
clean for 4-6 days
 Then, wound is
closed
 Suturing
 Skin grafting
 Flap

101. Factors affecting wound healing
Local factors affecting wound healing
Systemic factors affecting wound healing

102. Factors affecting wound healing
SystemicLocal
AgeIschemia
Stress
Infection
Ischemia
DiabetesForeign body
Edema Steroids
Smoking
Immunocompromise
Malnutrition

103. Local factors affecting
wound
healingInfection
Surgical Technique
Movement
Hematoma formation
Tissue ischemia
Presence of foreign body
Exposure to radiation

104. Systemic factors affecting
wound healing
Aging Smoking
DrugsNutritional status
Steroids
Diseases states
Uremia
anti-neoplastics
NSAIDs
Jaundice
Diabetes
Malignancies
Immunosuppression

105. Complications of wound healing
Hemorrhage
Adhesions
Suture complications
Hypertrophic scar
(scratch/mark)
Malignant changes
Infection
Herniation

106. Dehiscence: (bursting open of closed wound).
Evisceration:(surgical removing of an organ from a patient)
Adhesions: (abnormal union of bodily tissues most common
in the abdomen).
Fistula formation:(abnormal opening / passage from the
supporting cavity).
Sinus formation:( a wide passage / channel containing
blood).
Keloids:(raised pinkish scar tissue at the site of injury).
OTHER COMPLICATIONS ARE

107. Wound Management
1- Assessment of
wounds
- duration since injury
-identification of possible contamination & foreign
body.
-- extent of wound
- associated neurovascular or tendon injury
- need of tetanus prophylaxis
- identification of risk factors that might affect
healing.

108. 2- Wound preparation
- irrigation helps in:
- to visualize areas of the wound.
- to remove Fb
- foreign body
removal
- necrotic tissue debridement (surgocal removal of fb & dead
tissue from a wound in order to prevent from infection & promote
healing)
- evacuation of hematoma (localised sweeling filled with blood).
- Haemostasis (surgical procedure of stopping the flow of
blood)

109. 3-Wound Closure
Timing The choices are:
(1) close at the time of initial
presentation
(2) delay closure until after a period of
healing or wound care, and
(3) to allow the wound to heal on its own.
Methods
The closure methods available include:
(1) primary closure by direct
approximation
(2) delayed primary closure,
(3) secondary closure-left to heal on itsown.
(4) skin grafting; and

110. 4- Dressing
maintain a moist clean environment
prevent pressure and mechanical trauma
reduce edema
stimulates repair
comfort and aesthetic appearance

111. Other adjuncts
 Antibiotics
o Prophylactic
o Therapeutic
 Tetanus Prophylaxis

112. MANAGEMENT OF WOUNDS
Surgical dressing with:-
Primary closure
Delayed closure
Delayed primary closure
Skin grafting
Flaps
Wound dressing
Skin grafting
Flaps (movable piece of tissue partly connected to the body)

113. Special wounds
 Human bites
 Management
o Thorough irrigation with saline or plain water
o Adequate debridement
o Leave wound open
o Broad-spectrum antibiotics
o Tetanus Prophylaxis
o Wound observation
 Dog bites
 Management
o Vigorous irrigation
o Leave wound open
o Tetanus prophylaxis
o Antibiotics
o Post exposure anti rabies prophylaxis (1ml, IM)
on the 1st, 3rd, 7th, 14th and 28th day of bite.

114. SUMMARY
Discussed regarding the;
Define the term “Wound”
List the causes of wounds
Outline the classification of wounds
Define the term “wound healing”
Describe the phases of wound healing
Highlight the types of wound healing
Describe factors affecting wound healing
Outline the complications of wound healing
Discuss the management of wounds