1. WWoouunndd HHeeaalliinngg aanndd CCaarree

2. OObbjjeeccttiivveess
 Demonstrate use of four senses in observing
skin/wounds (listening, looking, touching,
smelling)
 List ways to promote healing
 Demonstrate routine care of wounds and
surgical drains

3. OObbjjeeccttiivveess
 Recognize signs/symptoms of inflammation
 Demonstrate use of four senses in observing
dressing over wound site
 Demonstrate correct technique of changing
clean and sterile dressings
 Document and report care related to skin
integrity

4. AAnnaattoommyy ooff SSkkiinn
The skin or integumentary system is the largest
system of the body. Hair, nails, and skin glands
are a part of this organ system.
The skin is a thin, relatively, flat organ that is
classified as a cutaneous membrane. It forms a
protective boundary between the internal
environment of the body and the external
environment.

5. SSkkiinn LLaayyeerrss
Three layers of the skin:
1. Epidermis
2. Dermis
3. Subcutaneous tissue

6. DDiiaaggrraamm ooff tthhee SSkkiinn

7. EEppiiddeerrmmiiss
 The outer skin layer that is in direct contact
with the environment
 The epidermis has five layers
 Contains skin pigment (melanin) that gives
color to the skin
Contains a water repellant protein called
keratin

8. EEppiiddeerrmmiiss
 Cells in the epidermis constantly change and
regenerate (research suggests 35 days)
 Injury to these cells may cause blisters &
calluses

9. DDeerrmmiiss
 Contains no skin cells
 Composed of collagen (a tough fibrous
protein
layer), blood vessels, and nerve cells
 70% of the dermis layer is collagen which is
very important in wound healing
 Dermis restores the physical properties of the
skin and its structural integrity

10. DDeerrmmiiss
 Provides mechanical strength of the skin
 Provides a reservoir storage area for water and
important electrolytes
 Contains a specialized network of nerves and
nerve endings for sensation of pain, pressure,
touch, and temperature

11. DDeerrmmiiss
 Hair follicles
 Collagen makes the skin stretchable & elastic
 Point of attachment for smooth and voluntary
muscles

12. SSuubbccuuttaanneeoouuss LLaayyeerr
 Is not part of the skin itself, but supplies the
major blood vessels and nerves to the skin
above
 Loose spongy texture
 Ideal site for rapid and relatively pain-free
absorption of injected medications
(subcutaneous injection)

13. FFuunnccttiioonnss ooff tthhee SSkkiinn
Functions of the skin are crucial for
maintenance of homeostasis.
1.Protection
Barrier against bacteria, foreign matter,
dehydration, ultraviolet (UV) light
2. Sensation
Sense organ
3. Movement without injury
4. Excretion
Regulating the volume and chemical content of
sweat

14. FFuunnccttiioonnss ooff tthhee SSkkiinn
5. Vitamin D production
Exposure of skin to UV light
6. Immunity
Specialized cells that attack and destroy
pathogenic microorganisms
7. Temperature regulation
Heat production and heat loss (shivering,
vasoconstriction, etc)

15. WWoouunndd -- DDeeffiinniittiioonn
A break in the skin or mucous membrane;
An alteration in the integrity of the skin and
underlying tissues.

16. WWoouunndd -- CCaauusseess
Causes
1. Surgical incisions
2. Trauma
3. Pressure
4. Shearing force
5. Friction
6. Poor circulation

17. RRiisskk FFaaccttoorrss ffoorr DDeevveellooppiinngg aa
WWoouunndd
 Broken skin
 Age (young or old)
 Nutritional Status
 Stress
 Hereditary
 Disease process (acute or chronic)
 Medical therapies - steroids, chemotherapy,
radiation, diuretics

18. TTyyppee ooff WWoouunnddss
1. Intentional - created for therapy
i.e., surgical
2. Unintentional - resulting from trauma
i.e., fall
3. Open wound - skin or mucous membrane is
broken
4. Closed wound - tissues are injured but the
skin is not broken

19. TTyyppee ooff WWoouunnddss
5. Clean wound - not infected, usually
intentional
6. Contaminated wound - high risk of
infection usually unintentional
7. Infected wound - (dirty wound) contains
bacteria; signs of infection

20. TTyyppee ooff WWoouunnddss
8. Chronic wound - wound that does not heal
easily; can be due to pressure or circulation
9.Partial-thickness wound - epidermis &
dermis of the skin is broken (superficial)
10. Full-thickness wound - epidermis, dermis,
subcutaneous tissue are involved and may
involve muscle and bone (penetrating)

21. DDeessccrriippttiioonn ooff WWoouunnddss
Wounds can be described by cause:
1. Abrasion - scraping or rubbing away of the
skin
2. Contusion - closed wound caused by a blow
to the body
3. Incision - open wound with clean straight
edges

22. DDeessccrriippttiioonn ooff WWoouunnddss
4. Laceration – open wound with torn tissues
and jagged edges
5. Penetrating wound – skin and underlying
tissue are pierced
6. Puncture wound - open wound from a
sharp object

23. SSkkiinn TTeeaarrss
 Occur most frequently in the elderly due to
skin changes in the elastic fibers in the
dermis, increased fragility of blood vessels,
changes in the membrane between the
epidermis & dermis, & thickening of collagen
 These changes cause the skin to age and the
skin appears translucent, wrinkled, thin, dry,
fragile & lacking tensile strength

24. SSkkiinn TTeeaarrss
 Upper and lower extremities most common
site
 80% of skin tears occur on the arms and
hands
 Tears are caused by friction and shearing
 Tears are painful and can lead to wound
complications

25. PPrriinncciipplleess ooff TTiissssuuee HHeeaalliinngg
 The body’s ability to handle tissue trauma
is influenced by:
Extent of damage, i.e. skin intact or broken
Person’s state of health, i.e. nutritional status
Body’s response to trauma
Healing is promoted when wound is free of
foreign bodies and bacteria

26. PPhhaasseess ooff WWoouunndd HHeeaalliinngg
Inflammatory or Defensive Stage
 Starts when skin integrity is impaired and
continues from 4 - 6 days
 Homeostasis - blood vessels constrict,
platelets stop bleeding forming clots to
scabs
 Inflammatory response - increased blood flow
and vascular permeability causing redness
& edema

27. PPhhaasseess ooff WWoouunndd HHeeaalliinngg
Inflammatory or Defensive Stage
White blood cells - arrive & clean cell of
debris
Epithelial cells - move to base of wound
margins for 48 hours

28. PPhhaasseess ooff WWoouunndd HHeeaalliinngg
Proliferative or Reconstruction Stage
 Closure begins on day 3 or 4 & continues for
2 - 3 weeks
 Fibroblasts with vitamin C & B for repair
 Collagen - provides strength and structure
 Epithelial cells - duplicate damaged cells

29. PPhhaasseess ooff WWoouunndd HHeeaalliinngg
Maturation Stage
 Final stage of healing & may last for 1
year as the scar strengthens

30. CClleeaanniinngg aa WWoouunndd

31. TTyyppeess ooff WWoouunndd HHeeaalliinngg
 Primary intention - Incision edges of a clean
surgical incision remain close, tissue loss is
minimal & skin quickly regenerates
 Secondary intention - Open wound with
tissue loss and jagged edges, there is a gap
between the edges, granulation tissue
gradually fills in the area of defect with
scar tissue

32. TTyyppeess ooff WWoouunndd HHeeaalliinngg
Tertiary intention
Sometimes called delayed intention or closure
Surgical wounds are left open 3 - 5 days & then
stapled or sutured closed

33. WWoouunndd HHeeaalliinngg
IInnfflluueenncciinngg FFaaccttoorrss
 Age
 Nutrition
 Obesity
 Extent of wound
 Wound stress
 Circulating oxygen
 Smoking
 Drugs
 Chronic diseases
 Infection (local/systemic)

34. SSiiggnnss && SSyymmppttoommss ooff IInnffeeccttiioonn
1. Erythema and edema
2. Painful and tender
3. Drainage & odor - tan, cream, green,
yellow
4. Fever
5. Fatigue

35. Signs & Symptoms of Infection
6. Rash
7. Change in WBC
8. Loss of appetite
9. Mucous membrane sores
10. Elderly: confused, agitated, incontinent

36. WWoouunndd DDrraaiinnaaggee
The exudate deposited in or on tissue
surfaces during inflammatory & destructive
phases of healing.
 Drainage must leave the wound for healing to
occur
 Trapped drainage can lead to infection and
other complications

37. TTyyppeess ooff WWoouunndd DDrraaiinnaaggee
1. Serous drainage
Clear, watery fluid
2. Sanguineous drainage
Bloody drainage
Large amount - suspect hemorrhage
Bright drainage - indicates fresh bleeding
Darker drainage - indicates older bleeding

38. TTyyppeess ooff WWoouunndd DDrraaiinnaaggee
3. Serosanguineous drainage
Thin watery drainage that is blood tinged
4. Purulent drainage
Thick green, yellow, or brown drainage

39. DDrraaiinnss
When large amounts of drainage are
expected, the physician inserts a drain to aid
in healing. drainage systems can be opened or
closed.
 Penrose drain
An open drain that drains exudate onto the
dressing; no suture; safety pin prevents
slippage into the wound; drains by gravity

40. DDrraaiinnss
Hemovac
Closed suction drainage, sutured in place
Jackson-Pratt
Closed suction drainage, sutured
T-tube
Closed drainage, sutured; drains by gravity

41. DDrraaiinnss
 Keep drainage tubes free of kinks
 Drainage collection reservoir is emptied every
eight hours and when 1/2 to 1/3 full
 Drainage volume decreases 2 - 3 days after
insertion
 Report any purulence, foul odor, redness
around insertion site, bleeding

42. HHeemmoovvaacc

43. JJaacckkssoonn -- PPrraatttt

44. TT -- TTuubbee

45. MMeeaassuurriinngg DDrraaiinnaaggee
 Note the number and size of dressings with
drainage (describe amount)
 Weighing dressing before and after removal
 Measuring the amount of drainage in the
collection receptacle
 Record on I&O form

46. WWoouunndd CCoommpplliiccaattiioonnss
 Hemorrhage
 May be internal or external
 Shock
 Low or falling blood pressure; rapid, weak pulse;
rapid respirations; skin - cold, moist, and pale;
restless; confusion; loss of consciousness
 Infection
 Dehiscence
Separation of wound layers, usually abdominal, caused by
wound stress (coughing, vomiting, abdominal distention);
surgical emergency

47. WWoouunndd CCoommpplliiccaattiioonnss
 Evisceration
Separation of wound with protrusion
of abdominal organs, surgical emergency,
cover with normal saline sterile dressings,
notify RN immediately
 Fistula
An abnormal tube-like passage from a normal
cavity or tube to a free surface or to another
cavity

48. WWoouunndd OObbsseerrvvaattiioonnss
 Wound location
May have multiple wounds from surgery or trauma
 Wound size and depth
Measure in centimeters
Size - measure from top to bottom, side to side
Depth - use a sterile swab into the depth of the
open wound, RN supervision
 Wound appearance
Red, swollen, area around wound warm to touch,
sutures, staples - intact or broken

49. WWoouunndd OObbsseerrvvaattiioonnss
 Drainage
COCA (Color, Odor, Consistency, Amount)
 Drains
 Odor of wound
 Surrounding skin
Intact, color, swollen
 Pain
Review facility’s pain assessment tool