NURSING

1. WOUND DRESSING
Prof. (Dr.) Virendra Singh

2. DEFINITION:-
 Wound, any break in the external or internal surfaces
of the body involving a separation of tissue, and
caused by external injury or force.
 A wound is a break or cut in the continuity of any
body structure, external or internal caused by
external injury or force.

3. WOUND

4. CLASSIFICATION OF WOUNDS
1.Mechanism of injury
Incision- open wound:- Means wound involving break in
skin or mucus membrane. Eg. Surgical incision, gunshot
wound.
Contusion- closed wound:- Means wound involving no
break in skin integrity caused by blow by blunt object. Eg.
bleeding in underlying tissues, bone fracture or tear of
visceral organs.

5. Abrasion- Superficial wound involving scrapping or
rubbing of skins surface by friction. Eg. Fall skinned knee
or elbow.
 Intentional wound:- Wound resulting from
therapy. Eg. Surgical incision, introduction of
needle in the body parts.
 Unintentional wound:- wound occurring
unexpectedly. Eg. Knife wound, burn and
pressure ulcer.
 Superficial wound:- wound involving only
epidermal layers of skin. Eg. Abrasion, first
degree burn.

6. Penetrating wound:- wound involving break in
epidermal skin layer, dermis and deeper tissue or organs.
Eg. Gunshot or stab wound.
Perforating penetrating wounds- wound in which
foreign object enters in exits internal organs.
laceration- tear of tissue with irregular wound edges. Eg.
Knife injury, industrial accidents.

7. 2. According to depth
Partial thickness- confined to the skin
Full-thickness- involving the dermis,
epidermis, subcutaneous tissues and
possibly muscle and bone.

8. Decubitus ulcer

9. Gunshot wound

10. Stab wound

11. Lacerating wound

12. 3. Degree of contamination
Clean-an aseptically made wound, that does
not enter the alimentary, respiratory or genito-
urinary tracts.
Clean contaminated-are surgical wounds in which the
alimentary, respiratory and genitals or urinary tract
has been entered.
Contaminated- wounds exposed to excessive amount’s
of bacteria. Eg. Open traumatic wound.
Infected wound-wounds containing dead tissues and
with evidence of clinical infection (purulent
discharged).

13. PHASES OF WOUND HEALING
1. INFLAMMATORY PHASE-starts
immediately after injury and lasts 3-6 days
or 4-6 days.
2 major processes occur during this phase …
HEMOSTATIS AND PHAGOCYTOSIS
Hemostatis- blood vessels constrict,
platelets aggregates and bleeding stops,
scabs forms, preventing entry of infectious
organisms.

14.  Inflammation-increase blood flow, to
wound resulting localized redness and
edema, attractsWBC and wound growth
factors.
 WBC arrive-clear debris from wound.

15. 2. PROLIFERATIVE PHASE-extends from
day 3 to about day 21 post injury.
collagen synthesis establishment of
new capillaries  creation of granulation
tissue wound contraction
epitheliazation.

16. 3. REMODELLING OR MATURATION PHASE
-final healing stage may continue for I year
or more.
Remodeling of scar tissue to provide wound
strength.

17. TYPES OF WOUND HEALING
 FIRST INTENTION HEALING-partial
thickness wounds.
- a clean incision is made with primary
closure, minimal scarring.
-expected when the edges of clean surgical
incisions are sutured together, tissue loss
is minimal or absent if the wound is not
contaminated with microorganism.
-e.g.-abrasion or skin tear.

18.  SECOND INTENTION HEALING-
granulation
-accompanies traumatic open wounds with
tissues loss or wounds with a high
microorganisms count.
-go though a process involving scar tissue
formation a heal slowly because of the
volume of tissue needed to fill the defect.
-e.g.-contaminated surgical wound,
pressure ulcer.

19. FACTORS AFFECTING WOUND HEALING
 Developmental considerations
(healthy children and adults)
 Nutrition
 Lifestyle
 Medications
 Contamination and infection
 e

20. COMPLICATIONS OF WOUND HEALING
 1. HEMORRRHAGE
-risk of hemorrhage is greatest during the ist
48 hours after surgery.
-emergency -N@- should apply pressure
dressing to the wound and monitor vital
signs.
 2. INFECTION
-surgical infection is apparently 2-11 days
post operatively.

21. N@- watched for presence of changed in
wound color, pain or drainage-culturing of
the wound.
 3. DEHISCENCEWITH POSSIBLE
EVISCERATION
-may occur 4-5 days postoperatively.
-involves an abdominal wound in which the
layers below the skin separates.
N@- an increase in flow of serosanguinous
drainage into the dressing can indicate

22. impending dehiscence.
- If occurs N@ should be quickly
supported by sterile dressing soaked in
sterile normal saline.
-position? Client in bed with knees
bent…why?To decrease pull on the
incision. and? Notify physician……

23. WOUND MANAGEMENT
 1. DRESSINGS - material applied to wound
with or without medication, to give
protection and assist in healing.
-what are the purposes?
a) To protect the wound from mechanical
injury
b) Splint or immobilized the wound.
c) Absorbs dressing
d) Prevent contamination from bloody
discharges

24. e.) Promote homeostasis,(pressure dressing)
f.) Debride the wound
g.) to kill or inhibit microorganism
h.) provide a physiologic environment
conducive to healing
i.) provide mental and physical comfort for
the patient.

25. Pressure dressing

26. What are the types of dressings?
a. DRYTO DRY DRESSINGS
-used primarily for wounds closing by
primary intention.
>adv-offers good protection, absorption &
provide pressure
>dadv-they adhere to the wound surface
when drainage dries.
- when remove can cause pain and
disruption of granulation tissue.

27.  b. WET TO DRY DRESSINGS
-used for untidy or infected wounds that must
be debrided and closed by secondary
intention.
>how can it be done?
-gauze saturated with sterile saline or
antimicrobial sol’n. is packed into the wound,
the wet dressing are then covered by dry
dressings
>when to changed?
-when it becomes dry

28.  b. WET TOWET DRESSINGS
-used on clean open wounds or on
granulating surfaces.
>adv-provide a more physiologic
environment (warmth moisture) which can
enhance the local healing processes and
assure greater patient comfort.
>dadv-surrounding tissues can become
ulcerated. high risk for infection.

29.  2. DRAINS- device or a tube used to draw
fluids from an internal body cavity to the
surface.
-what are the purposes?
a) placed in the wounds only when
abdominal fluid collections are present.
b) placed near the incision site
> wound drainage-drains placed within the
wounds are attached to a portable
suction with a collection container.
e.g. hemovac, jackson-pratt, penrose drain.

30.  3. BINDERS AND BANDAGES
-what are the purposes?
a) Creates pressure over the body parts
b) Immobilize body parts
c) Reduce or prevent edema
d) Secure a splints
e) Secure dressing

31. UNEXPECTED OUTCOMES &
RELATED INTERVENTIONS
1. Inflamed and tender wounds which evidence
of drainage and foul odor.
N@ a. Monitor clients for signs of infection
(fever, increase in WBC count).
b. notify physician
c. obtain wound culture as ordered.
2. Increase wound drainage
N@ a. changed dressing frequently
b. notify physician
3.Wound bleeds during dressing change

32. PAPER AND PENCIL TEST
 PART 1
1. Based on your readings, dressings may be
used for what 6 reasons?
2. During dressings changes, wounds and
surrounding tissues must be inspected for?
3. What will be the assessment data you must
collect prior to any dressing?
4. Describe on how to set-up, prepare
materials needed for dressing thus,
maintaining sterility. Draw a picture to help
explain your answer.

33.  PART 2
Explain what should be done in each of the following
situations to avoid contamination during wound
dressing.
1. You are in the middle of a sterile dressing change
with the wound exposed and realize that you need
more dressings from the CSR.
2. You begin to sneeze prior to beginning a sterile
procedure.
3. A patient with abdominal wound is walking in the hall
when his dressing falls onto the floor.
4. When removing the cap from any sterile solution
bottle, be sure the cap is placed with the inner side
up.Why is this critically important?