wound

1. COURSE TITLE: SURGICAL NURSING 1
TOPICS: WOUNDS AND ULCERS
CLASS: LEVEL 300 SANDWICH NURSING
BY
MUMUNI HADIRU IDDRIS

2. OBJECTIVES
By the end of this topic students will be able to:
1. Define a wound
2. State the classifications of wounds and
example/types of each class
3. Describe the process/phases of wound healing
4. Explain factors that facilitate and factors that
impair wound healing.
5. Describe the types of tropical ulcers (Non-
specific ulcers and Buruli ulcer)
6. Explain the management of tropical ulcers

3. OVERVIEW OF THE SKIN

4. DEFINITION OF WOUND
 A cut or break in continuity of any
tissue, caused by injury (trauma) or
operation.
It is a circumscribed injury which is caused
by an external force and it can involve any
tissue or organ.

5. PARTS OF A WOUND
Wound edge
Wound
corner
Surface of
the wound
Base of the wound
Cross section of a simple wound
Wound edge
Wound
cavity
Skin surface
Surface of
the wound
Subcutaneus tissue
Superficial fascia
Muscle layer
Base of the wound

6. CLASSIFICATION OF WOUNDS
Wounds can be classified in several ways
1. According to surface covering
2. According tothe depth of injury
3. According to the cause or origin
4. According to the type of injury/how they are
acquired
5. according to the level of contamination

7. CLASSIFICATION ACCORDING TO
SURFACE COVERING
Open Wounds; these are wounds with a break in
the skin or mucous membrane. These wounds are
caused by trauma by a sharp object. E.g. surgical
incisions, gunshot wounds etc.

8. CLASSIFICATION ACCORDING TO
SURFACE COVERING
• Closed Wounds are wounds with no break in the
continuity of the skin. The causes are straining,
bone fractures or tear of visceral organs.

9. CLASSIFICATION OF WOUNDS
ACCORDING TO THE DEPTH OF INJURY
•
•
•
•
•
•
Superficial
Partial thickness
Full thickness
Deep wound

10. CLASSIFICATION OF WOUNDS ACCORDING
TO THE DEPTH OF INJURY CONT’D
a. Superficial wound: affecting only the surface
structures such as epidermis.
b. Partial thickness:
c. Full thickness:
d.Severe wounds: involving blood vessels, bones,
muscles, nerves, tendons or ligaments.

11. CLASSIFICATION ACCORDING TO THE CAUSE
Intentional wounds; these are wounds
that are deliberately created. E.g.
incised/operations, venipunctures and
stab wounds
Unintentional/Accidental Wounds;
wounds that occur under unexpected
conditions. E.g. traumatic injury, knife
wound.

12. CLASSIFICATION ACCORDING TO THE TYPE
OF INJURY/HOW THEY ARE AQCUIRED
OPENED WOUNDS
a. Laceration wounds
b. Incision wounds
c. Abrasion wounds

13. INCISIONS/INCISED WOUND(cut)
• Open wound, deep or shallow with well-defined
edges usually longer than deep caused by a
sharp instrument, example a knife or scalpel.
• E.g. Operated wounds

14. LACERATIONS
 Skin tear or tissue torn apart wounds with
irregular edges caused by a blunt trauma.
 This type of wound is often from accidents,
e.g. machinery cut, animal bites or cut from
a broken glass.

15. ABRASION
• superficial wounds in which the topmost
layer of the skin ( epidermis) is scraped, e.g.
A scraped knee from a fall. Denuded skin

16. PENETRATING WOUND
Penetrates the skin and mucus membrane to
deeper/underlying tissues and entering a body
cavity or organ, e.g. wounds from
bullets,metal fragments. Usually unintentional

17. PUNCTURED WOUND
• Punctured wound: caused by an object
puncturing the skin, it both enters and
emerges from a body cavity or organ e.g. a
needle or nail, gunshot wound. Intentional
or unintentional.

18. CLASSIFICATION ACCORDING TO
THE TYPE OF INJURY CONT’D
• Closed wounds
a. Contusions:
b. Hematomas

19. CONTUSIONS
Caused by a blunt force trauma that damages
tissue under the skin.
Blow from a blunt instrument. Blood trapped
under the surface of the skin. The wound is closed
and the skin appears bruised, hence they are
often known as bruises. (ecchymosis)

20. HEMATOMAS
• Also called blood tumors, caused by damage to a
blood vessel that causes collection of blood
under the skin. Tumor like mass of blood trapped
under the skin.

21. • CRUSHING INJURIES: cased by a great or
extreme amount of force applied over a
period of time.

22. AVULSION
• Tearing away of tissue from supporting structures

23. CLASSIFICATION ACCORDING TO THE DEGREE
OR LIKELIHOOD OF WOUND CONTAMINATION
Clean wounds: Are primarily closed wounds.
They are uninfected wound in which the
respiratory, alimentary, genitourinary or
oropharyngeal tracts are NOT entered. (does not
involve a body cavity) this type of wound heals
without infection.

24. CLASSIFICATION ACCORDING TO THE DEGREE OR
LIKELIHOOD OF WOUND CONTAMINATION
• CLEAN-CONTAMINATED WOUNDS: surgical
wounds in which the respiratory, alimentary,
genital and urinary tract has been entered
without unusual contamination.
• Such wounds show no evidence of infection
(although it involves a body cavity that normally
harbors microbe, it is made under aseptic
conditions)

25. CLASSIFICATION ACCORDING TO THE DEGREE OR
LIKELIHOOD OF WOUND CONTAMINATION CONT’D
Contaminated wounds: these include
surgical, fresh, accidental wounds involving
a major break in sterile technique or a large
amount of spillage from the GIT. These type
of wounds show evidence of inflammation.

26. CLASSIFICATION ACCORDING TO THE DEGREE OR
LIKELIHOOD OF WOUND CONTAMINATION CONT’D
• Dirty wounds: are traumatic wounds with delayed
repair, these type of wounds contain foreign
bodies, dead tissue and there is evidence of
infection such as purulent discharge.

28. WOUND HEALING PROCESS
 Wound healing takes place in three (3) ways;
 Healing by First (Primary) Intention;
 Healing by Second Intention (secondary wound
healing
 Healing by Third Intention(Tertiary or delayed
primary closure)

29. 1. HEALING BY FIRST (PRIMARY) INTENTION
Healing by First (Primary) Intention; wounds
with little loss of tissue.
Wound is closed by approximation of wound
margins or by placement of graft or wounds
created and closed in the operating room.

30. 2. HEALING BY SECOND INTENTION
 Healing by Second Intention (secondary wound
healing, Spontaneous healing).
 The wound edges do not approximate, the
wound is left open without surgical intervention
until it becomes filled by scar tissue.
 It takes longer time to heal and the chance of
infection is high. E.g. burns, pressure sores.

31. 3. HEALING BY THIRD INTENTION
 Healing by Third Intention(Tertiary or delayed
primary closure).
 A combination of primary and secondary
intention. Wounds that are heavily contaminated
for primary closure but are well vascularized after
4-5 days of open observation.
 After this time the inflammatory process has
reduced bacteria concentration in the wound
which can then be closed.

32. STAGES OF WOUND HEALING
There are three phases of wound healing namely;
1. Inflammatory/lag phase
2. Proliferative/fibroblastic phase
3. Maturation/remodeling phase

33. 1. INFLAMMATORY PHASE
• Begins at time of injury/cell death and lasts 3-5days.
• Immediate responses are vasoconstriction and clot
formation. A blood clot is produced by a complex
chain reaction called the coagulation cascade.
• This is characterized by the formation of a fibrin
mesh which temporarily closes the wound and
gradually dries out to become a scab.
• At this stage, wounds usually produce large
amounts of blood and serous fluid, which help to
cleanse the wound of surface contaminants

34. INFLAMMATORY PHASE

35. INFLAMMATORY PHASE
• After 10 minutes of vasoconstriction and cloth formation,
the tissue damage stimulates the release of inflammatory
mediators such as prostaglandins and histamine from
cells such as mast cells.
• These mediators cause blood vessels adjacent to the
injured area to become more permeable and to
vasodilate.
• These can be detected by the presence of localized
heat/warmth, swelling, erythema, pain and functional
disturbance.

36. INFLAMMATORY PHASE
• Wound exudate is produced during this stage of
healing due to the increased permeability of the
capillary membranes.
• Exudate contains proteins and a variety of nutrients,
growth factors and enzymes which facilitate
healing. It also has antimicrobial properties.
• Neutrophils are the first type of white blood cell to
be attracted into the wound, usually arriving within
a few hours of injury.

37. INFLAMMATORY PHASE
• After 2–3 days macrophages become the
predominant leucocyte in the wound bed.
• Macrophages are present throughout all stages of
the healing process.
• Macrophages are responsible for controlling the
transition between the inflammatory and
proliferative phases of healing

38. 2. PROLIFERATIVE PHASE
• It begins about the fourth day after injury and
lasts 2-4 weeks
• During this phase the wound is filled with new
connective tissue.
• A decrease in wound size is achieved by a
combination of the physiological processes of;
1.
2.
3.
granulation
contraction
epithelialization.

39. GRANULATION
• Granulation is the term used to describe the new
wound matrix made up of collagen and an
extracellular material called ground substance.
• These provide scaffold/framework into which new
capillaries will grow to form connective tissue.
• The growth of new blood vessels is termed
angiogenesis. This is stimulated by macrophage
activity and tissue hypoxia resulting from the
disruption of blood flow at the time of injury.

40. GRANULATION
• Macrophages produce a variety of substances that
stimulate angiogenesis. These include:
• Transforming growth factor (TGF), which
promotes formation of new tissue and blood
vessels, and
• Tumour necrosing factor (TNF), which facilitates
the breakdown of necrotic tissue, stimulating
proliferation.
• Healthy granulation tissue does not bleed easily
and is a pinky red colour.

41. WOUND CONTRACTION
• After connective tissue production, fibroblasts
congregate around the wound margin.
• Fibroblast contract, pulling the wound’s edges
together. This plays a significant part in the
healing of large, open wounds.
• If the tension around the skin exceeds the
counter force of wound contraction, healing will
be delayed.

42. WOUND CONTRACTION
 Basal epithelial cells at the wound
margin flatten (mobilize) and
migrate into the open wound.
 Basal cells at margin multiply
(mitosis) in horizontal direction.
 Basal cells behind margin undergo
vertical growth (differentiation)
 In wounds healing by secondary
intention epithelialization occurs
once granulation tissue fills the
wound bed.

43. MATURITION PHASE
• Begins as early as 3 weeks after injury and
may continue for a year.
• At this stage collagen is reorganized to
provide tensile strength.
• Initially scar tissue is raised and reddish. As
the scar matures, its blood supply decreases
and it becomes flatter, paler and smoother.

44. MATURITION PHASE
• Mature scar tissue is avascular and contains NO
hairs, sebaceous or sweat glands.
• The tensile strength of scar tissue compared with
normal skin is about 80%.
• The formation of keloid and hypertrophic (raised)
scars are abnormalities associated with this stage
of healing.
• Hypertrophic scarring occurs directly after initial
repair, while keloid scarring may occur some time
after healing.

45. FACTORS THAT IMPAIRE WOUND HEALING
LOCAL FACTORS
• Wound/local infection
• Foreign body
• Necrotic tissue
• Recurrent/Repeated injury
• Impaired
oxygenation/poor blood
supply
• Tissue tension
• Haematoma
• Local x-iradiation
GENERAL FACTORS
• Aging
• Nutritional deficiencies
• Anaemia
• Cancers
• Uraemia/Jaundice
• Diabetes
• Generalized infection
• Cytotoxic drugs and
steroids
• Ateriosclerosis/Thrombosis
• Obesity

46. FACTORS THATFACILITATE/PROMOTE /FAVOUR
WOUND HEALING
Young age younger people’s ability to heal is
strong, they also have strong immunity as such
their wound heal faster than older people
Absence of other disease
Good general health
Intake of adequate proteins and vitamins
Proper use of antibiotics
Strict aseptic technique in wound dressing
Small injury

47. TROPICAL ULCERS
 Tropical ulcers are common debilitating
conditions.
 They cause tissue loss and pain which temporarily
invalids the person.
There are two types of tropical ulcers;
1.
2.
Non-specific
Buruli ulcer

48. NONE SPECIFIC TROPICAL ULCERS
Organism: No specific organism is normally
detected, but initial infection is often accompanied
by cellulitis, probably caused by a streptococcus.
Transmission:
1. flies are responsible for contamination of
wounds.
small
2. Scratches by the host can be a potent method of
instilling organisms into the skin.
3. Biting insects also another source of
transmission.

49. NONE SPECIFIC TROPICAL ULCERS
 OCCURRENCE
 Tropical ulcers are found in the warm, moist
areas in the world, where temperature and
humidity are fairly constant.
 DISTRIBUTION/INCIDENCE
 All ages and both sexes are susceptible

50. CLINICAL FEATURES OF NONE SPECIFIC
TROPICAL ULCERS
• Initially wound becomes red and indurated.
• Cellulitis spread to regional lymph nodes
• Systemic fever
• Ulcer that refuses to heal
• Pain
• Incubation period; Uncertain but probably
between 1 and 5 days

51. TREATMENT
• Administration of systemic and local antibiotics.
• Rest affected limb
• Eusol can be used to clean ulcer.
• Horney to remove sloughs and promotes wound
healing
• Hydrogen peroxide solution can be used in the
removal of small sloughs
• Soaking wound in seawater to clean out ulcers
• Debridement of wound to remove dead tissue can
be done surgically

52. NONE SPECIFIC TROPICAL ULCERS
• CONTROL AND PREVENTION
• Tropical ulcers can be prevented by taking
scrupulous care over minor cuts and abrasions.
• Cleaned wound and apply antiseptic lotion or gel
and cover with dressing.
• Flies can be controlled by proper sanitation

53. PREVENTION
• BCG Immunization gives some protection
• Prevent skin contact with infected persons
• Restrict infected persons from bathing or
swimming in water
• Protection against insect bites as much as possible
• Health education

54. REFERENCES/RECOMMENDED TEXTBOOKS
Bloom, A. & S.R., Toohey’s Medicine for Nurses, London: Churchill
Livingstone.
Bucher et al. (2005). Medical-Surgical Nursing, assessment and
management of clinical problems (7th edition). Mosby Elsevier. USA.
Brunner, L.S. & Suddarth, D. S. (2008). Textbook of
nursing. 11th ed. Philadelphia: J. B.
medical and
Lippincott Co.
surgical
Daniels N. N. (2007). Contemporary Medical- Surgical
Thompson Corporation. USA.
Nursing (vol. 1 &2).
Ignatavicius, D. (2002). Critical thinking study guide for medical-surgical
nursing. Critical thinking for collaborative care, 4th ed. St Louis: Saunders.
Watson, J.E., Watson’s Medical-Surgical Nursing and Related Philosophy,
London: Bailliere Tindall