WOUND CARE

ARA L. BARLIZO, RM.RN.MAN(UE)

CLINICAL INSTRUCTOR
IMPORTANT NURSING FUNCTIONS ARE MAINTAINING SKIN INTEGRITY AND PROMOTING WOUND HEALING.
 SKIN INTEGRITY
INTACT SKIN REFERS TO THE PRESENCE OF NORMAL SKIN
AND SKIN LAYERS UNINTERRUPTED BY WOUNDS.
APPEARANCE & SKIN INTEGRITY ARE INFLUENCED BY:
INTERNAL FACTORS: GENETICS, AGE, AND
UNDERLYING HEALTH OF THE INDIVIDUAL
EXTERNAL FACTORS: ACTIVITY.
GENETICS AND HEREDITY
-INCLUDING SKIN COLOR, SENSITIVITY TO SUNLIGHT, AND ALLERGIES.
AGE
-SKIN OF VERY YOUNG AND VERY OLD IS MORE FRAGILE AND SUSCEPTIBLE
TO INJURY THAN THAT OF MOST ADULTS.
WOUNDS TEND TO HEAL MORE RAPIDLY IN INFANTS AND CHILDREN,
MANY CHRONIC ILLNESSES AND THEIR TREATMENTS AFFECT SKIN INTEGRITY.
SKIN INTEGRITY
PEOPLE WITH IMPAIRED PERIPHERAL ARTERIAL
CIRCULATION
MEDICATIONS
-CORTICOSTEROIDS- CAUSE THINNING OF THE
SKIN
MANY MEDICATIONS INCREASE SENSITIVITY TO
SUNLIGHT > SEVERE SUNBURNS.
-ANTIBIOTICS (E.G., TETRACYCLINE AND
DOXYCYCLINE),
-CHEMOTHERAPY DRUGS (E.G., METHOTREXATE),
-PSYCHOTHERAPEUTIC DRUGS (E.G., TRICYCLIC
ANTIDEPRESSANTS).
POOR NUTRITION
 WOUND HEALING
HEALING (REGENERATION)
- IS A QUALITY OF LIVING TISSUE;
- (RENEWAL) OF TISSUES.
- CONSIDERED IN TERMS OF:
* TYPES OF HEALING,
* PRIMARY CARE PROVIDER’S DECISION
> TO ALLOW THE WOUND TO SEAL ITSELF
> PURPOSEFULLY CLOSE THE WOUND,
* PHASES OF HEALING
- REFER TO THE STEPS IN THE BODY’S NATURAL
PROCESSES OF TISSUE REPAIR.
- THE SAME FOR ALL WOUNDS, BUT THE RATE AND EXTENT OF
HEALING DEPEND: ON FACTORS SUCH AS:
1. TYPE OF HEALING,
2. LOCATION AND SIZE OF THE WOUND,
3. HEALTH OF THE CLIENT.
 TYPES OF WOUND HEALING
1. PRIMARY INTENTION HEALING
OCCURS WHERE THE TISSUE SURFACES HAVE BEEN APPROXIMATED (CLOSED) AND
THERE IS MINIMAL OR NO TISSUE LOSS;
CHARACTERIZED BY THE FORMATION OF MINIMAL GRANULATION TISSUE AND
SCARRING.
ALSO CALLED PRIMARY UNION OR FIRST INTENTION HEALING.
EXAMPLE:
1. A CLOSED SURGICAL INCISION.
2. THE USE OF TISSUE ADHESIVE, A LIQUID GLUE
- USED TO SEAL CLEAN LACERATIONS OR INCISIONS
- RESULT IN LESS NOTICEABLE SCARS.
 TYPES OF WOUND HEALING
2. SECONDARY INTENTION HEALING

WOUND IS EXTENSIVE AND INVOLVES CONSIDERABLE TISSUE LOSS, IN

WHICH THE EDGES CANNOT OR SHOULD NOT BE APPROXIMATED,
EXAMPLE:
> A PRESSURE ULCER.
DIFFERS FROM PRIMARY INTENTION HEALING IN THREE WAYS:
(1) THE REPAIR TIME IS LONGER,
(2) THE SCARRING IS GREATER,
(3) THE SUSCEPTIBILITY TO INFECTION IS GREATER.
 TYPES OF WOUND HEALING

3. TERTIARY INTENTION HEALING

WOUNDS THAT ARE LEFT OPEN FOR 3 TO 5 DAYS
TO ALLOW EDEMA OR INFECTION TO RESOLVE OR
EXUDATE TO DRAIN
CLOSED WITH SUTURES, STAPLES, OR ADHESIVE SKIN
CLOSURES
ALSO CALLED DELAYED PRIMARY INTENTION.
BODY PRESSURE AREAS
 PHASES OF WOUND
HEALING
1 2 3
Inflammatory Proliferative Maturation or
Remodeling
 begins immediately after injury and lasts
3 to 6 days.

TWO MAJOR PROCESSES OCCUR

DURING THIS PHASE:

1. Hemostasis
Inflammatory cessation of bleeding
scab formation
Phase epithelial cells formation

2.Phagocytosis
macrophages engulf microorganisms
and cellular debris
secretion of an angiogenesis factor
 extends from day 3 or 4 to about
day 21 postinjury
Fibroblasts (connective tissue
cells), migrate into the wound
PROLIFERATIVE starting about 24 hours after
injury, begin to synthesize
PHASE collagen
granulation tissue develops
dried plasma proteins and
dead cells- eschar.
 begins on about day 21 and
can extend 1 or 2 years after
the injury
MATURATION wound is remodeled and
contracted
PHASE scar formation
> hypertrophic scar, or keloid
 Complications of
Wound Healing

HEMORRHAGE INFECTION DEHISCENCE EVISCERATION

 Factors Affecting
Wound Healing
DEVELOPMENTAL CONSIDERATIONS
NUTRITION
LIFESTYLE

MEDICATION
 CLEANING WOUNDS
Wound cleaning involves the removal of debris,
such as foreign materials, excess slough,
necrotic tissue, bacteria, and otheR
microorganisms.
WOUND IRRIGATION AND
PACKING
Irrigation (lavage) is the washing
or flushing out of an area.
Sterile technique is required for a
wound irrigation because there is
a break in the skin integrity
 PRACTICE GUIDELINES
Follow standard precautions for personal protection. Wear
gloves, gown, goggles, and mask as indicated.

Use solutions such as isotonic saline or wound cleansers to

clean or irrigate wounds. If antimicrobial solutions are used,
make sure they are well diluted.
Microwave heating of liquids to be used on the wound is not
recommended. When possible, warm the solution to body
temperature before use.*
 PRACTICE GUIDELINES
If a wound is grossly contaminated by foreign material,
bacteria, slough, or necrotic tissue, clean the wound at every
dressing change. *

If a wound is clean, has little exudate, and reveals healthy

granulation tissue, avoid repeated cleaning.*

Use gauze squares or nonwoven swabs that do not shed fibers.

Avoid using cotton balls and other products that shed fibers
onto the wound surface.*
 PRACTICE GUIDELINES
Clean superficial noninfected wounds by irrigating them with
normal saline.
Avoid drying a wound after cleaning it.
HOLD CLEANING SPONGES WITH FORCEPS OR WITH A STERILE GLOVED
HAND.

Clean from the wound in an outward direction to avoid transferring

organisms from the surrounding skin into the wound.

CONSIDER NOT CLEANING THE WOUND AT ALL IF IT APPEARS TO BE

CLEAN.
 TYPES OF WOUNDS
INTENTIONAL UNINTENTIONAL
trauma occurs are accidental;
during therapy. for example, a
Examples are person may
operations or fracture an arm
venipunctures. in an automobile

collision.
 If the tissues are traumatized without a break in
the skin, the wound is closed. The wound is open
when the skin or mucous membrane surface is
broken.
Ex; Pressure Ulcers and Burns
WOUNDS DESCRIBED ACCORDING TO THE LIKELIHOOD AND
DEGREE OF WOUND CONTAMINATION:
Clean wounds are uninfected wounds in which there is
minimal inflammation and the respiratory, gastrointestinal,
genital, and urinary tracts are not entered. Clean wounds
are primarily closed wounds.

CLEAN-CONTAMINATED WOUNDS ARE SURGICAL WOUNDS IN WHICH THE RESPIRATORY, GASTROINTESTINAL,

GENITAL, OR URINARY TRACT HAS BEEN ENTERED. SUCH WOUNDS SHOW NO EVIDENCE OF INFECTION.

Contaminated wounds include open, fresh, accidental wounds and

surgical wounds involving a major break in sterile technique or a large
amount of spillage from the gastrointestinal tract. Contaminated
wounds show evidence of inflammation.

Dirty or infected wounds include wounds containing dead tissue and

wounds with evidence of a clinical infection, such as purulent drainage.
Wounds may be described according to how they are
acquired
Exudate is material, such as fluid and cells, that has
escaped from blood vessels during the inflammatory
process and is deposited in tissue or on tissue
surfaces.

The nature and amount of exudate vary according to

the tissue involved, the intensity and duration of the
inflammation, and the presence of microorganisms
TYPES OF WOUND
EXUDATE
SEROUS EXUDATE

PURULENT EXUDATE

SANGUINEOUS EXUDATE
SEROUS EXUDATE
A serous exudate consists chiefly of serum
(the clear portion of the blood) derived
from blood and the serous membranes of
the body, such as the peritoneum.
It looks watery and has few cells.
An example is the fluid in a blister from a
burn.
PURULENT EXUDATE
is thicker than serous exudate because of the
presence of pus, which consists of
leukocytes, liquefied dead tissue debris, and
dead and living bacteria.
The process of pus formation is referred to
as suppuration.
Purulent exudates vary in color, some
acquiring tinges of blue, green, or yellow.
The color may depend on the causative
organism.
 SANGUINEOUS EXUDATE
consists of large amounts of red blood cells, indicating damage
to capillaries that is severe enough to allow the escape of red
blood cells from plasma.
frequently seen in open wounds.
 MIXED TYPES OF EXUDATES OFTEN OBSERVED

1. A SEROSANGUINEOUS EXUDATE
-CONSISTING OF BOTH CLEAR AND BLOOD-
TINGED DRAINAGE,
-IS COMMONLY SEEN IN SURGICAL INCISIONS.

2. A PUROSANGUINEOUS DISCHARGE
- CONSISTING OF PUS AND BLOOD,
- IS OFTEN SEEN IN A NEW WOUND THAT IS
INFECTED