This document gives you an inside information about Wounds.

1. WOUNDS
PRESENTED BY GLORIA E.
KUAGBENU(MRS)

2. layers of the skin
EPIDERMIS
DERMIS
SUBCUTANEOUS TISSUE

3. The skin
• The skin is the body’s largest organ and is the
primary defense against infection.
• The body’s complex physiological processes
promote skin and wound healing, restoring
the function and structure of the skin.
• A disruption in the integrity of body tissue is
called a wound.

4. Wound
• A wound is a break in the continuity of the
skin or mucous membrane

5. Causes of wounds
1. Accidents or injuries/trauma
2. Surgical incision
3. Chemicals e.g. acid, alkaline
4. Temperature extremes (frostbite) ,burns
5. Radiation
6. Infections

6. Signs and symptoms
1. Bleeding or oozing of blood
2. Redness
3. Swelling
4. Pain and tenderness
5. Heat
6. Possible fever with infection
7. Loss of function (or mobility)
8. Oozing pus, foul smell (in infected wounds
only)

7. Classification of wounds
1. Cause of Wound
• Intentional wounds occur during treatment or
therapy. These wounds are usually made under
aseptic conditions. Examples include surgical
incisions and venipunctures.
• Unintentional wounds are unanticipated and
are often the result of trauma or an accident.
These wounds are created in an unsterile
environment and therefore pose a greater risk
of infection.

8. Classification cont.
2. Cleanliness of Wound
• Clean wounds are intentional wounds that
were created under sterile conditions, and the
respiratory, alimentary, genitourinary, and
oropharyngeal tracts were not entered.
• Clean-contaminated wounds are intentional
wounds that were created by entry into the
alimentary, respiratory genitourinary, or
oropharyngeal tract under controlled
conditions.

9. Cleanliness of wound cont.
• Contaminated wounds are open, traumatic wounds
or intentional wounds in which there was a major
break in aseptic technique, spillage from the
gastrointestinal tract, or incision into infected urinary
or biliary tracts. These wounds have acute
nonpurulent inflammation present.
• Dirty and infected wounds are traumatic wounds
with retained dead tissue infected with
microrganisms or intentional wounds created in
situations where purulent drainage was present.

10. Classification cont.
3. Classification by Thickness of Skin Loss
• Superficial epidermal (first-degree) wounds are confined
to the epidermis layer, which comprises outermost layer
of skin.
• Partial-thickness (first- to second-degree) wounds
involve the epidermis and upper dermis, the layer of skin
beneath the epidermis. Deep (second-degree) wounds
involve the epidermis and deep dermis.
• Full-thickness (third degree) wounds refer to skin loss
that extends through the epidermis and the dermis and
into subcutaneous fat and deeper tissues.

11. Types of wounds
1. Open
• Open wounds can be classified according to the
object that caused the wound. The types of
open wound are:
• Incisions or incised wounds, caused by a clean,
sharp-edged object such as a knife, a razor or a
glass splinter. They bleed profusely and heal
faster with little contamination

12. gular tear-like wounds caused
auma, the wound is large and
is less profuse, usually
d takes longer time to heal by
ion.

13. Open wounds cont.
• Abrasions (grazes, scrape, rug) are superficial
wounds in which the topmost layer of the skin(the
epidermis) is scraped off leaving a raw tender area.
• Abrasions are often caused by a sliding fall onto a
rough surface.
• Exposure of nerve endings makes this type of wound
painful, and the presence of debris from the scraped
surface (rug fibers, gravel, sand) makes abrasions
highly susceptible to infection.

14. Open wounds cont.
• Puncture wounds are caused by pointed object
puncturing the skin, such as a nail, pencil or
needle.
• If a piece of the object remains in the skin, or if
there is little bleeding due to the depth and
location of the puncture, infection is likely.
• Anaerobic bacteria like clostridium tetani may
infect the wound. The entry point of the object is
usually small but underlying tissues may be
damaged.

15. Open wounds cont.
• Gunshot wounds are caused by a bullet or
similar projectile driving into or through the
body. There may be two wounds, one at the site
of entry and one at the site of exit, generally
referred to as a "through-and-through.“ Damage
to internal organs occur
• Avulsion results when the skin or tissue is torn
away from the body, either partially or
completely. The bleeding and pain will depend
on the depth of tissue affected.

16. Identify the types of wound

17. Identify the types of wound

18. Types of wounds cont.
2. Closed
• Closed wounds have fewer categories, but are just as
dangerous as open wounds. The types of closed wounds
are:
• Contusions or bruises, caused by a blunt force trauma
that damages tissue under the skin causing bleeding
beneath the skin surface.
• A bruise in a light-skinned individual will change from red
to purple to greenish yellow before fading; in a dark-
skinned person, the bruise will first look dark red then
darker red, brown, or purple, and slowly fade.

19. Closed wounds cont.
• Hematomas, also called a blood tumor,
caused by damage to a blood vessel that in
turn causes blood to collect under the skin.
• Crush injury, caused by a great or extreme
amount of force applied over a long period of
time.

20. Lesson objectives
• By the end of the lesson students will be able
to:
1. Describe the phases of wound healing
2. Describe the types of wound healing
3. Describe the exudates from wounds
4. Explain the factors affecting wound healing

21. Wound healing
A complex integrated sequence of cellular
physiologic and biochemical events initiated by
injury to tissue.
All repair occurs with an overlapping series of
events to restore the function and integrity of the
damaged tissue
Phases
1. Hemostasis and inflammation
2. Reconstruction/proliferation
3. Maturation

23. Wound healing cont.
1.Hemostasis and Inflammatory Phase
• This phase occurs immediately after injury and
lasts about 3 to 4 days.
• Hemostasis is the cessation of bleeding,
vasoconstriction of large blood vessels in the
affected area occurs.
• Platelets aggregate to form a platelet plug and
stop the bleeding.

24. • Activation of the clotting factors forms
fibrinous meshwork, which further entraps
platelets and other cells.
• This provides initial wound closure, prevents
excessive loss of blood and body fluids, and
inhibits contamination of the wound by
microorganisms.

25. Hemostasis and inflammatory phase
cont.
• Inflammation is the defensive adaptation of
tissue to injury and involves both vascular and
cellular responses which eventually increases
blood supply to the site and phagocytosis
initially by neutrophils and subsequently
macrophages.
• Release of histamine, increases capillary
permeability (plasma leaking) and vasodilation

26. • Macrophages also secrete several factors,
including fibroblast activating factor (FAF) and
angiogenesis factor (AGF).
• FAF attracts fibroblasts, which form collagen
• AGF stimulates the formation of new blood
vessels to support and sustain the wound and the
healing process.
• Inflammatory response is characterized by
redness, heat, pain, swelling and loss of function

27. Inflammatory response

28. Wound healing cont’d
2. Reconstructive (Proliferative) Phase
• The reconstructive phase begins on the 3rd or
4th day
• This phase contains the process of:
I. collagen deposition
II. angiogenesis
III. granulation tissue development
IV. wound contraction

29. Collagen deposition
• Fibroblasts synthesize and secrete collagen for
tissue repair.
• Initially, collagen is gel-like, but within several
months it cross-links to form collagen fibrils and
adds tensile strength to the wound to prevent
gaping
• the deposited collagen causes a raised ‘‘healing
ridge’’ which may be visible under the injury or
suture line

30. Proliferative phase cont.
• Angiogenesis, the formation of new blood vessels,
begins within hours after the injury.
• The endothelial cells in preexisting vessels begin to
produce enzymes that break down the basement
membrane.
• The membrane opens, and new endothelial cells build
a new vessel.
• These capillaries grow across the wound, increasing
blood flow, which increases the supply of nutrients and
oxygen needed for wound healing.

31. Proliferative phase cont.
• Granulation tissue is filled with new
capillaries that are fragile and bleed easily,
thus giving the healing area a red/pink,
translucent, granular appearance

32. Proliferative phase cont.
Wound contraction
• As granulation tissue is formed, growth of
epithelial tissue, begins.
• Epithelial cells migrate into the wound from the
wound margins.
• Eventually, the migrating cells contact similar cells
that have migrated from the outer edges.
• Contact stops migration. The cells then begin to
differentiate into the various cells that compose
the different layers of skin.

33. • Contraction is noticeable 6 to 12 days after
injury and is necessary for closure of all
wounds.
• The edges of the wound are drawn together by
the action of myofibroblasts, specialized cells
that contain bundles of parallel fibers in their
cytoplasm.
• If the wound does not close by epithelialization,
the area becomes covered with plasma protein
and dead cells called eschar.

34. Wound healing cont.
3. Maturation Phase
• Maturation, the final stage of healing, begins
about the 21st day and may continue for up to 2
years or more, depending on the depth and
extent of the wound.
• During this phase, the scar tissue is remodeled
(reshaped or reconstructed by collagen
deposition, lysis and debridement of wound
edges).

35. Maturation phase cont.
• Although the scar tissue continues to gain
strength, it remains weaker than the tissue it
replaces.
• Capillaries eventually disappear, leaving an
avascular scar (a scar that is white because it
lacks a blood supply).
• The scar tissue becomes strong but not as the
original tissue

37. Types of wound healing
• Primary intention -healing occurs in wounds
that have minimal tissue loss and edges that are
well approximated (closed).
• The wound is clean and dry with minimal
granulation tissue and scarring within a week if
there are no complications, such as infection,
necrosis, or abnormal scar formation.
• Example emergency laceration repair,
closure of the surgical wound

38. Primary closure of wounds

39. Types of wound healing cont.
• Secondary intention healing is seen in wounds
with extensive tissue loss and wounds in which
the edges are gaping.
• The wound is left open, and granulation tissue
gradually fills in the deficit.
• Repair time is longer
• Tissue replacement and scarring are greater
• The susceptibility to infection is increased
because of the lack of an epidermal barrier to
microorganisms

40. Secondary wound closure

41. Types of wound healing cont.
• Tertiary intention healing, also known as
delayed primary closure, is indicated when
primary closure of a wound is undesirable.
• Conditions in which healing by tertiary intention
may occur include poor circulation or infection.
• Suturing of the wound is delayed until the
problems resolve and more favorable conditions
exist for wound healing

43. Wound discharges
• Discharges or exudates are fluids and cells
from the wound site
• The nature and amount of exudate vary
depending on the tissue involved, the
intensity and duration of the inflammation,
and the presence of microorganisms .

44. Examples of wound discharges
1. Serous exudate - clear fluid (serum)
2. Purulent exudate- dead and living bacteria,
leucocyte and dead cells
3. Hemorrhagic exudate /sanguineous exudate-
red blood cells

45. Function of wound exudates
1. Dilution of toxins produced by bacteria and
dying cells
2. Transport of leukocytes and plasma proteins,
including antibodies, to the site
3. Transport of bacterial toxins, dead cells,
debris, and other products of inflammation
away from the site

46. Types of wound tissue
1. Necrotic tissue/eschar- dark or brown tissue
2. Slough- yellow or white tissue
3. Granulation tissue- pink or beefy red tissue
4. Epithelial tissue- pink or shiny tissue from
wound edge
5. Closed/ resurfaced-new skin or scar

47. Slough

48. Eschar

49. Granulation tissue

50. Epithelial tissue

51. Factors affecting wound healing
1. Blood circulation and oxygen delivery to the
wound
2. Nutrition
3. Obesity
4. Smoking
5. Medications – steroids, aspirin
6. Chronic diseases
7. Infection
8. ongoing trauma
9. debris and foreign bodies in the wound

52. Lesson objectives
By the end of the lesson, students will be able to:
1. describe assessment and examination of a
patient with a wound
2. describe the care of patient with a wound:
• Emergency care
• Subsequent wound care
3. explain the complications of wound healing

53. Wound assessment
History taking-It is important to obtain the data
in chronological order:
• when and how the wound occurred,
• the initial location and size,
• associated symptoms, such as pain and
itching.
• the aggravating and alleviating factors

54. • Allergies to tape, latex, medications, or other
substances.
• An assessment of the client’s nutritional status
should evaluate albumin level, weight

55. Wound assessment cont.
Physical examination-
• Document the location and size and noting length,
width, and depth in centimeters.
• The appearance of the wound bed and surrounding
skin is assessed for sinus tracts, undermining,
tunneling, exudate, necrotic tissue, and signs of
infection.
• Evaluate the skin, nails, hair, color, capillary refill,
temperature, pulses, edema of the extremity, and
hemosiderin (an iron pigment that is a product of
RBC hemolysis) in the periulcer area.

57. Nursing diagnoses for wound
1. Impaired skin integrity related to surgical incision
2. Impaired tissue integrity related to pressure over
bony prominence
3. Risk for impaired skin integrity related to physical
immobilization
4. Risk for infection related to nutritional deficiency
5. Acute pain related to inflammatory process
6. Disturbed body image related to changes in body
appearance secondary to scars, drains, and removal of
body parts
7. knowledge deficit (wound care) related to lack of
exposure to information

58. General Care of wounds
1. Educate client on measures to promote wound healing
e.g. balanced diet, exercise
2. Reassure patient of competency of staff
3. Encourage local and general rest
4. Observe the vital signs, amount and type of drainage
5. Encourage the intake of foods high in protein, vitamin C,
K, zinc and adequate fluid intake
6. Dress wound aseptically with antiseptic solution e.g.
normal saline and debridement of wound if slough is
present

59. Care of wounds cont.
7.Administer prescribed medications such as analgesics,
antibiotics ,TT, ATS
8. Use aseptic measures to prevent wound infection
9. Position client in such a way that pressure is relieved
from the wound
10. Range of motion exercises should be done to promote
blood circulation to wound
11. Encourage skin hygiene such as bathing twice daily
12. Avoid skin trauma

60. Comfort measures
• Tape should be supported and removed
carefully by freeing all edges and lifting straight
up to prevent stress on sensitive tissue.
• Position the client to decrease strain on the
wound.
• Administer prescribed analgesics 30 to 60
minutes prior to dressing changes, depending
on the drug’s time of peak action.

61. Matching wound colour and care
• Black………………….. Black wounds contain
necrotic tissue (eschar). Eschar may be either
black, gray, brown, or tan. These wounds need
debridement (sharp, mechanical, chemical,
autolytic) and cleansing dressing
• Green…………………. antimicrobial dressing
• Wet yellow…………. Yellow wounds have either
fibrinous slough or purulent exudate from bacteria.
They need antimicrobial dressing(damp-damp),
irrigation to remove purulent exudate, and
removal of nonviable slough

62. • Dry yellow…………. rehydrating dressing
• Red……………………… Red wounds are the colour
of normal granulation tissue and are in the
proliferative phase of wound repair. These
wounds need to be protected from trauma and
kept moist and clean.
• Hypergranulation. antimicrobial dressing
• Pink……………………. protect.

63. Complications of wound healing
1. Hemorrhage
2. Infection
3. Dehiscence
4. Evisceration
5. Keloid
6. Contracture/deformity
7. Fistula formation
8. Sinus formation

64. Cleansing of wounds
• The goal of cleansing the wound is to remove
debris and bacteria from the wound bed with
as little trauma to the healthy granulation
tissue.

65. Wound dressing
Reasons for wound dressing
1. Protect the wound from mechanical injury
2. Protect wound from microbial contamination
3. Maintain moist wound healing
4. Absorb drainage or debride a wound
5. Prevent haemmorrhage
6. Splint or immobilize the wound site

66. Emergency care of wounds
1. Assesses the type and extent of injury that the
client has sustained.
2. If hemorrhage is detected, sterile dressings and
pressure should be applied to stop the bleeding
using standard precautions.
3. Elevate the affected part
4. Vital signs should be monitored frequently and
notify the doctor immediately.
5. When dehiscence or evisceration occurs, the
client should be instructed to remain quiet and
to avoid coughing or straining.

67. 5. The client should be assisted into the dorsal
recumbent position to prevent further stress on
the wound.
6. Sterile dressings soaked with sterile normal saline,
should be used to cover the wound and
abdominal contents to reduce the risk of bacterial
contamination and drying of the viscera.
7. Notify the surgeon immediately and prepare the
client for surgical repair of the area.

68. Types of dressing materials
• Transparent dressing- applied to burns and
donor sites
• Hydrocolloid dressing- used over pressure
ulcers, wounds with slough and exudates
• Non-adherent dressings e.g. vaseline gauze
• Gauze dressings

69. Types of dressing
• Dry to dry dressing
• wet-to-dry dressing
• Wet to dump dressing

70. Procedure for wound dressing
Preparation
• Wash hands put on mask and Prepare a
dressing trolley as follows
• Clean the shelves and rail of the trolley with
soapy water, rinse and dry with an antiseptic
lotion and dry
• Turn off fans, ensure less traffic activities

71. Requirement
Top shelf
Draped with sterile towel and has:
• 2 gallipots for lotion
• 2 pair of dressing forceps
• 2 pair of dissecting forceps
• Sinus forceps
• Probe
• Stitch scissors
• Kidney dish for cotton and gauze swabs

72. Bottom shelf
• Bottles of lotion
• Adhesive plaster
• Scissors
• Bandages
• receiver for used instruments
• mackintosh and towel
• Receptacle for soiled dressing and used swabs
• Packaged dressing set
• Packaged dressing materials

73. Procedure for wound dressing
1. Explain procedure and ensure privacy
2. Wash and dry hands
3. Put on mask and prepare and take trolley to
the bed side
4. Assist patient into desired position
5. Protect bed clothes with mackintosh and towel
and expose the area
6. Pour out lotions into gallipots
7. Remove plaster and bandage

74. 8. Wash and dry hands
9. Remove soiled dressing using dissecting forceps
or disposable gloves and discard and wash hands
10. Put cotton /gauze into lotion and squeeze out
excess lotion
11. Clean wound with the swab soaked in normal
saline or methylated spirit using forceps or sterile
gloves starting from inside of the wound to the
periphery using one swab at a time

75. 12. Clean wound with series of swabs until clean
13. Apply sufficient sterile dressing and secure into
position
14. Inform patient about the state of the wound
15. Thank patient and make him comfortable
16. Discard trolley, decontaminate used items and
remove gloves
17. Wash and dry hands, remove screen, document
and report the state of the wound

76. Wound drains
• A surgical drain is a tube used to remove pus,
blood or other fluids from a wound
• Depending on the amount of drainage, a patient
may have the drain in place one day to weeks.
• Wound drains are placed in the operative site and
the other end is usually passed through a separate
small stab wound near the main incision.
• Drains have protective dressings that will need to
be changed daily or as needed.

77. Types of drains
1. Opened drains e.g. Penrose drains are flexible
and function by gravity . They have an open
end that drains onto dressings .
2. Closed suction drainage systems commonly
have a reservoir that is capable of creating
negative pressure or a vacuum. E.g Hemovac
and Jackson-Pratt drains

78. Wound drain

79. Care of drainage tubes
Requirement is same as for wound dressing but add a
sterile safety pin, sterile scissors
Steps
1. Refer to dressing of wound up to point 12
2. For the penrose tube, open the sterile safety pin,
grasp the end with forceps and clip in position
3. Remove any stitch holding the drain in position
4. Gently rotate the tube pull and hold with safety pin
and cut 1cm with sterile forceps
5. Swab with cleansing lotion, apply dressing and
secure in position

80. For Closed system drainage system,
• Maintain the patency of the system and
assess the amount, type, and colour of the
drainage.
• Gently hold and Clean around the tube
• Rotate tube to prevent adhesions
• Apply dressing and secure in place taking care
to prevent accidental removal

81. • Empty the drainage bag when 2/3 full and
document the amount, colour, odour and
consistency of the drainage
Removal of tube
• To remove the tube, cut the stitch holding it in
place swab and gently pull out the tube into a
receiver
• Clean and cover the stab wound

82. Sutures / stitches
• Stitches or sutures are used to close cuts and
wounds.
• Sutures are a surgical means of closing a wound
by sewing, wiring, or stapling the edges of the
wound together.
• They can be used in every part of the body,
internally and externally.
• Stitches are used to close a variety of wounds
such as laceration, incisions

83. • For surface closures, steel staples or sutures
made of wire, nylon, cotton, or other
materials are used.
• These need to be removed as the wound
heals.

84. Types of sutures
• Absorbable sutures rapidly break down in the
tissues.
• This type of suture does not have to be
removed e.g. vicryl, chromic gut
• Nonabsorbable sutures, maintain their strength
and do not break down in tissues
• These sutures are used to close skin or external
wounds and require removal once the wound
has healed e.g. silk, prolene

85. Suture patterns
• Continuous suture is one in which a continuous,
uninterrupted length of material is used
• They are made with one thread, tied at the
beginning and end of the suture line.
• Interrupted suture is one in which each stitch is
made with a separate piece of material.
• Sutures are each tied individually

86. Interrupted stitch

87. Surgical Staples
• Surgical staples are also useful for closing many
types of wounds and have the advantage of being
quicker, more economical, and causing fewer
infections than stitches.
• Disadvantages of staples are permanent scars if
used inappropriately and imperfect aligning of
the wound edges, which can lead to improper
healing.
• Staples are used on scalp lacerations and
commonly used to close surgical wounds.

88. Removal of staples
• To remove staples, insert the end tips of the
stapler remover under each wire staple.
• The end tips are placed in the middle of the
staple; slowly squeeze together the handles
of the stapler remover, freeing the staple from
the skin.

89. Removal of sutures
• Different parts of the body require suture
removal at varying times.
• Face: 3-5 days
• Scalp: 7-10 days
• Trunk: 7-10 days
• Arms and legs: 10-14 days
• Joints: 14 days

90. Procedure for stitch removal
1. Refer to wound dressing up to step 12
2. Clean the wound with series of swabs and
place a sterile swab near the wound
3. Count the number of stitches
4. Take dissecting and stitch removing scissors,
grasp ends of stitch with dissecting forceps and
pull gently to expose the area between the
knot and skin

91. 5. Cut stitch between the knot and skin
6. Pull out suture gently and slowly
7. Inspect the removed sure carefully and discard
on a piece of gauze
8. Note the number of sutures removed
9. Clean the wound, apply dressing and secure in
position
10. Thank and make patient comfortable
11. Discard and decontaminate instrument
12. Document and report findings

92. Wound irrigation
• Wound irrigation is the steady flow of a solution across
an open wound surface to achieve wound hydration,
remove debris, and assist with visual examination.
Requirements
• Sterile and Disposable gloves
• Protective gown and goggles
• Sterile dressing material
• irrigation syringe
• Irrigation solution (normal saline, povidone iodine)
• Kidney dish to receive used irrigation fluid
• Mackintosh and towel to protect bed

93. Procedure for wound irrigation
1. Assess the patient’s condition and identify any allergies,
specifically to povidone-iodine or other topical solutions
or medications.
2. Assess the wound, including the amount and character
of drainage and the size and condition of the wound
and surrounding tissue.
3. Irrigation should be performed using strict aseptic
technique.
4. Wash hands, wear a protective gown and put on clean
gloves.
5. If applicable, remove soiled dressing and discard with
gloves.
6. Put on goggles, if needed.

94. 7.Hold the filled syringe just above the top edge of
the wound and gently instill fluid into the wound,
slowly and continuously until the syringe is empty.
8.Be sure the solution flows from the clean to dirty
area of the wound. Use enough force to flush out
debris, but do not squirt or splash fluid.
9. Irrigate all portions of the wound. Do not force
solution into the wound’s pockets. Repeat irrigation
procedure until the prescribed amount of solution
is administered or the solution draining from the
wound is clear.

95. 10.Remove and discard disposable irrigation
equipment .
11.Clean around the wound with normal saline
solution and wipe intact skin.
12.Gently pat dry the wound’s edges, unless the
wound should be covered with a wet-to-dry dressing
(dry only surrounding skin). Work from cleanest to
most contaminated part of wound.
13.The patient should be positioned comfortably to
allow further drainage into the basin.
14.Apply dressings as ordered.

96. 15. Record the date and time of irrigation,
amount and type of irrigant, appearance of the
wound, sloughing tissue or exudate, amount of
solution returned, skin care performed around
the wound, dressings applied, and the patient's
tolerance of the treatment.

97. Heat and cold therapy
Heat
• Heat reduces pain and promotes healing
through vasodilation
• Increases oxygen and nutrients to aid in
inflammatory response
• Reduces edema by promoting removal of
excessive interstitial fluid
• Promotes muscle relaxation

98. Heat and cold therapy cont’d
Cold
• Cold decreases pain by vasoconstriction
• Decrease blood flow to the area decreases
inflammation and edema
• Raises the threshold of pain receptors thereby
decreasing pain
• Decreases muscle tension

99. THE END
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