2. WOUND
• Break in skin or mucous membranes.
• Injury to any of the tissues of the body,
especially that caused by physical means and
with interruption of continuity is defined as a
wound.
3. WOUND HEALING
• Wound healing is a natural and spontaneous
phenomenon.
When tissue has been disrupted so severely
that it cannot heal naturally :
• dead tissue and foreign bodies must be
removed
• infection treated
• the tissue must be held in apposition
4. • Until the healing process provides the wound
with sufficient strength to with stand stress
without mechanical support.A wound may be
approximated(closed) with sutures, staples, clips,
skin closure strips, or topical adhesives.
• Classification of wounds
1. Intentional Vs. Unintentional
2. Open Vs. Closed.
3. Degree of contamination.
4 . Depth of the wound
5. Intentional Vs. Unintentional wounds
• Intentional wound: occur during therapy. For example:
operation or venipuncture.
• Unintentional wound: occur accidentally.
• Example: fracture in arm in road traffic accident.
• Open Vs. Closed wounds
• Open wound: the mucous membrane or skin surface is
broken.
• Closed wound: the tissue are traumatized without a break
in the skin.
6. • Degree of contamination
• Clean wounds: are uninfected wounds in which minimal
inflammation exist, are primarily closed wounds.
• Clean –contaminated wound: are surgical wounds in which
the respiratory, alimentary, genital, or urinary tract has
been entered. There is no evidence of infection.
• Contaminated wounds: include open, fresh, accidental
wounds. There is evidence of inflammation.
• Dirty or infected wounds: includes old, accidental wounds
containing dead tissue and evidence of infection such as
pus drainage.
7. • Depth of the wound
• Partial thickness: the wound involves dermis
and epidermis.
• Full thickness: involving the dermis, epidermis,
subcutaneous tissue, and possibly muscle and
bone.
8. Types of wounds
1. Incision: open wound, painful, deep or shallow, due to
sharp instrument.
2. Contusion: closed wound, skin appears ecchymotic because
of damaged blood vessels, due to blow from blunt instrument.
3. Abrasion: open wound involving skin only, painful, due to
surface scrape.
4. Puncture: open wound, penetrating of the skin and often
the underlying tissues by a sharp instrument.
5. Laceration: open wound edges are often jagged, tissues
torn apart. Often from accidents.
6. Stab wound: open wound, penetration of the skin and the
underlying tissues, usually unintentional.
9. PHYSIOLOGY OF WOUND HEALING
• Wounds heal by either Primary or Secondary intention
1.Primary intent- wound edges are brought together and sutured
Describes the healing of clean lacerations or surgical incisions by closure with
sutures,steri-strips or skin adhesives.
skin edges are approximated (closed) as in a surgical wound
Inflammation subsides within 24 hours (redness, warmth, edema)Resurfaces
within 4 to 7 days
Secondary intent.
Healing by secondary intention- wound edges are not brought together and
must heal by granulation, contraction and epithelialization
Describes the healing of large wounds due to greater tissue loss either by
burns,pressure ulcer or severe laceration.
The wound is left open
Scar tissue forms during healing.
10. Phases of Wound Healing
• Inflammatory Phase
• Acute Phase = Vasoconstriction and clot formation Followed by
demolition phase Chronic inflammation results in wound is
overwhelmed by necrotic tissue Characteristics: Edema, Erythema,
Pain, Necrotic tissue and Exudate 2.
• Proliferative Phase
• Granulation Tissue fills wound bed Angiogenesis Epidermal cells
migrate across granulation tissue Contraction of wound edges
Characteristics: Deep red granulation tissue, Transudate,
Epithelialization occurring .
• Maturation Phase Increase in tensile strength through collagen
synthesis Resulting scar tissue 70-80% as strong as original skin
Characteristics: Decrease vascularization, Increase tensile strength,
Decrease size of scar
11. Wound Healing Inflammatory Response Proliferative
Phase: 3-24 days
• Serum and RBC’s form fibrin network
• Increases blood flow with scab forming in 3 to 5 days
• Proliferative Phase: 3-24 days
• Granulation tissue fills wound
• Resurfacing by epithelialization
• Remodeling: more than 1 year
• collagen scar reorganizes and increases in strength
• Fewer melanocytes (pigment), lighter color
12. Factors influencing wound Healing
• Age
Nutrition: protein and Vitamin C intake
• Obesity; decreased blood flow and increased risk for infection
• Tissue contamination: pathogens compete with cells for oxygen and
nutrition
• Hemorrhage
• Infection: purulent discharge
• Dehiscence: skin and tissue separate
• Evisceration: protrusion of visceral organs
• Fistula: abnormal passage through two organs or to outside of body
13. • Complications of wound healing
• 1. Hemorrhage: some escape of blood from a
wound is normal, but persistent bleeding is
abnormal.
• 2. Hematoma: localized collection of blood
underneath the skin, and may appear as a
reddish blue swelling.
• 3. Infection
14. RISK ASSESSMENT
What are we going to asses?
• Nutritional status
• Alteration in sensation or response to discomfort
• Co-morbid conditions
• Medications that delay healing
• Decreased blood flow to lower extremities when
ulceration is present
• The assessment should include the patient’s skin
condition, as well as those conditions which increase
the risk for skin breakdown and influence the potential
for wound healing. They are:
15. . Assess for;-
• The patient’s level of incontinence and nutritional status
• If there is any alteration in sensation or response to
discomfort
• Co-morbid conditions or medications that delay the
patient’s ability to
• heal; and
• Decreased blood flow to the lower extremities when
ulceration is present
• These conditions will influence the patient’s propensity for
skin breakdown and also the potential for healing.
16. What must you asses for and
document in a wound patient?
• Location of the wound
• Stage and Size
• Etiology
• Undermining
• Tunneling
• Exudate
• Color of wound bed
• Necrotic Tissue
• Granulation Tissue
• Effectiveness of Treatment
It is important to note the effectiveness of the treatment. If the
current treatment is not effective, then it needs to be revised.
17. Pressure ulcer Assessment
Tissue Type
• Granulation Tissue: red and moist
• Slough: yellow stringy tissue attached to wound bed; removal
essential for healing
• Eschar: necrotic tissue which is brown or black appearance must be
debrided
Wound Deterioration of Skin
• surrounding ulcer
• Redness, warmth edema
• Exudate
• Amount, color, consistency, odor
18. • 24 Assessment In emergency settings Bleeding?
• Foreign bodies or contamination?
• Size of wound?
• Need for protection of wound?
• Need for tetanus antitoxin
• 25 Assessment Stable Setting Wound appearance Character of
drainage
• Serous
• Sanguineous(oozing red blood like)
• Serosanguineous(containing blood mixed with serum like content)
• Purulent
19. Pressure Ulcer wound Staging.
Pressure ulcers-Refers to injury to skin and underlying
tissues resulting from prolonged pressure to the skin.
Those at risk are patients with conditions that limits their
ability to change position.
They are classified into 4 main stages i.e;
Pressure Ulcer Stages Stage I: No Skin Break
Assess for the following;Skin temperature(always warm),
consistency (firm), sensation (pain or itching)
Persistent redness in light skin tones
Persistent red, blue or purple hue in darker skin tones
20. • Pressure Ulcer Stages Stage II and Superficial
Stage III
• Partial-thickness skin loss (epidermis and/or
dermis
• Abrasion, blister or shallow crater
• Stage III
• Full-thickness skin loss (subcutaneous damage or
necrosis and may extend down to but not
through fascia
• Deep crater
21. Stage IV:
• Full thickness skin loss and destruction,
necrosis of the tissue, damage to muscle,
bone, tendons and joint capsules and sinus
tract
• Exposed bone/tendon is visible or directly
palpable.
22. Pressure Ulcer Summary
Stage I - Red non-blanchable
Stage II - Partial thickness skin loss
Stage III – Full thickness skin loss involving
underlying subcutaneous tissue
Stage IV – Full thickness skin loss with extensive
destruction damage to muscle bone
23. WOUND DRESSING
• DRESSING
• A dressing refers to a sterile pad or compress
applied to a wound to promote healing and
the wound from further harm.
• Wound dressing utilizes aseptic techniques
• N/B;Bandages-Holds a dressing inplace
24. PURPOSE OF WOUND DRESSING.
• To promote wound granulation and healing
• To prevent undue contamination of wound
• To decrease purulent wound drainage
(dressing material absorbs the drainage0
• To apply medication to the wound
• To provide comfort
25. Principles of wound Healing
• 1. Use Standard Precautions at all times.
• 2. When using a swab or gauze to cleanse a
wound, work from the clean area out toward the
dirtier area.
• 3. When irrigating a wound, warm the solution
to room temperature, preferably to body
temperature, to prevent lowering of the tissue
temperature. Be sure to allow the irrigant to flow
from the cleanest area to the contaminated area
to avoid spreading pathogens.
27. Important consideration During wound
Assessment and Care.
• Level of consciousness and understanding of
the patient
• Vital signs
• Allergy to tape or cleaning solutions
Bleeding tendencies
• Doctor’s order
• Bleeding or drainage from wound site
• Condition of the wound
28. Nursing Diagnosis
• Impaired Skin Integrity Impaired Tissue
Integrity
• Risk for Infection
• Pain
• Imbalanced Nutrition, Less than body
requirements
• Impaired circulation
29. CARE PLANNING
• Overall strategy and scope of the treatment plan depends on
patient’s condition, prognosis, and reversibility of the wound.
• Before selecting any treatment plan, identify the likelihood of the
wound healing and the benefits of pursuing a specific treatment
plan.
• Document all factors that may affect healing. Keep in mind that
under ideal circumstances a wound needs at least 2 to 4 weeks to
show evidence of healing. Many hospice patients will not have 2 to
4 weeks. In many terminally ill patients we do not expect a wound
to heal, so aggressive intervention may not be appropriate.
• Review advance directives or other care instructions that may
impact the scope or selection of treatment options.
• Comfort should always guide the selection of the treatment
approach.
30. GOAL
• Prevent complications or the deterioration of an existing wound
• Prevent additional skin breakdown
• Minimize harmful effects of the wound on the patient’s overall condition
• Promote wound healing
• Appropriate care planning goals for hospice patients may include:
• Preventing complications of the wound, such as infection or odor
• Of course, you will work to prevent additional breakdown of the skin
• We want to do our best to minimize harmful effects of the wound on the
• patient’s overall condition. This would be things like depression, social
• isolation or general discomfort.
• In many of our hospice patients, we know that promoting wound healing
• may be unrealistic. Therefore, let’s take a look at some specific
• interventions for wound care that might be more feasible.
31. Interventions of Dressing
Conciderations includes;
• When choosing wound care interventions, some of the things to
consider are:
• Condition and Prognosis – If patient has poor potential for healing
or has a prognosis of less than 1 week, then aggressive measures
may not be appropriate.
• Caregiver ability – Treatment needs to be provided consistently by
all caregivers. So you want to choose one that will offer continuity
and ease of use.
• Goal is to keep a moist wound environment which promotes re-
epitheliazation and healing. Too much moisture can delay healing
and cause further tissue damage (maceration).
• Frequency of change-Research has shown that the prolonged
period that the modern dressings remain in place, speeds up the
healing time and decreases the chance of infection.
32. DOs and DONTs which will facilitate
proper and better wound healing are;
• Keep wound clean and scab free(clean and particulate
matter free wounds tend to heal faster due to cleanliness
enhances quicker epithelization)
• Keep wound moist(Epithelial cells survive best in moist
environments)
• Avoid steroid creams(they would cause more inflammation)
• Suturing wound splints skin (sutures splints the skin
together and allows ease for collagen fiber reconstruction)
• Wounds actually shrinks(Physiologically,wounds shrink
upon healing,there suture the edges as close as possible to
ensure a better impression during healing)
33. Wound Preparation
• Remove hairs(This helps reduce bacteria
residing within hair follicles,hence promoting
healing while minimizing infections)
• Scrubbing the wound(Helps reduce both
bacteria and particulate matter)
• Irrigation with saline(Reduces bacterial count)
34. Basic Elements of Wound Care
• Cleanse Debris from the Wound
• Possible Debridement
• Absorb Excess Exudate
• Promote Granulation and Epithelialization When
Appropriate
• Possibly Treat Infections
• Minimize Discomfort
35. GENERAL MANAGEMENT AND
TREATMENT
1.Educate patient/caregiver
2.Position patient approprately
3.Manage the pain
4.Prevent infections
5.Debribe the wound if necessary
6.Teat the cause e.g Bacteria
7.Monitor vitals
8.Assess and manage nutritional status of patient
