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Objectives
 At the end of this lesson, the learner will be able to:
 Review the anatomy and physiology of skin
 Define and assess wound
 Define wound drainage and its type
 Discuss the classification of wound
 Describe wound healing process and phases of wound
healing
 Discussion on factors that promote or inhibit wound healing
 Describe care of wound and irrigation of wound
 Discuss dressing and common complication of wound.
 Structure of the skin

• Skin/Integumentary system is the body’s largest

organ, 1/6th of TBW
• layers of the skin
• Epidermis
• Dermis
• Hypodermis
 Functions of the skin
• Regulates body temperature

• Prevents loss of essential body fluid

• Protection of the body from harmful effects of radiation

• Excretes toxic substances with sweat

• Mechanical support.

• Sensory organ for touch, heat and cold

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 wound
A loss of continuity of the skin or mucous
membrane which may involve soft tissues, muscles,
bone and other anatomical structure.

OR
 Any disruption to layers of the skin and underlying
tissues due to multiple causes including trauma,
surgery, or a specific disease state.
Wound assessment
 Involve examination of the entire wound
 Clinician visually assess wounds and document their findings to
monitor and evaluate the progress of wound healing
What to be assessed?
1. Location
2. Dimensions/Size
3. Tissue viability
4. Exudates/Drainage
5. Pain
6. Stage or extent of tissue damage
7. Swelling

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Wound Drainage/Exudates

 Exudates is material, such as fluid and cells, that has

escaped from blood vessels during the inflammatory
process and deposited in or on tissue surfaces.

 The nature and amount of exudates vary according to:

 Tissue involved,

 Intensity and duration of the inflammation,

 The presence of microorganisms

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 Types of Wound Drainage
1.Serous Exudates

Mostly serum

Watery, clear of cells

E.g., fluid in a blister

2. purulent Exudates
 Is thicker than serous exudates because of the presence
of pus.
 It consists of leukocytes, liquefied dead tissue debris,
dead and living bacteria.

 The Process of pus formation is referred to as

suppuration, and the bacteria that produce pus are
called pyogenic bacteria.

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3. Asanguineous (hemorrhagic) Exudates
 It consists of large amount of blood cells, indicating
damage to capillaries that allow the escape of RBCs
from plasma.

 This type of exudates is frequently seen in open

wounds.

 Nurses often need to distinguish whether the

exudates is dark or bright.
 Bright indicate fresh blood, whereas dark exudates
denotes older bleeding.
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Wound Classification
• A variety of terms are used to describe and classify
wounds.
• Wounds are usually described based on their
1. Etiology of the wound
2. The status of skin integrity
3. The extent of tissue damage,
4. Cleanliness of wounds/degree of contamination
5. Descriptive qualities of the wound such as color.
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Based on Cause of Wound
Intentional wounds
Occur during treatment or therapy.
• These wounds are usually made under aseptic
conditions.
• E.g. Surgical incisions

Unintentional wounds
• 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.
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Based on skin continuity

• Open wound:- is when there is a break in the skin or

mucous membrane.

• Closed wound:- is when there is injury to the underlying

tissue without breaking in the skin or mucous
membrane.

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Based on mechanism of injury
Incised wound:- clean cut with a sharp instrument or
object.
Ex:- operational incision(Intentional cut )
- sharp knife cut –(non intentional cut)
Contused wound:- made by blunt force.
• There is no break in the skin & characterized by hematoma
and swelling.
• Ex brucae
Lacerated wound:- are wound with jagged, irregular
edges.
• Ex:- glass, jagged cable, blunt knife.
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 Classification of…….
Abraded wound:
- Type of open wound that occurs as a result of friction.
-Example:- scraped knee from falling
Punctured wound (stab wound):-
- An open wound made by a sharp instrument that
penetrates the skin and underlying.
Penetrating wound:- is type of wound or which
an instrument penetrates deeply in to the tissue
through the skin & mucous membrane
• Example:- bullet injury
 Based on degree of contamination
1. Clean wounds
• Are intentional wounds that were created under sterile
conditions and are not entered in to respiratory,
alimentary, genitourinary, and oropharyngeal tracts.
• (expected infection rate: 1% to 5%)
2. Clean-contaminated wounds
Intentional wounds that were created by entry into the
alimentary, respiratory, genitourinary, or oropharyngeal
tract under controlled conditions.
• (infection rate: 8% to 11%)

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3. 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.
• (infection rate: 15% to 20%
4. Dirty wounds
• Traumatic wounds with retained dead tissue or
intentional wounds created in situations where purulent
drainage was present.
• (infection rate: 27% to 40%)

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 Based on descriptive qualities or color
• The RYB color code
• This concept is based on the color of the open
wound rather than the depth or size of the wound.

• R=Red Y=Yellow B= Black

 On this scheme, the goal of wound care is to

protect ( cover) red, cleanse yellow, and debrided
black.
Red wound
• Usually in the late regeneration phase of tissue repair
(i.e. developing granulation tissue) and are clean and
uniformly pink in appearance.
• They need to be protected to avoid disturbance to
regenerating tissue.
• Examples are superficial wounds, skin donor sites, and
partial- thickness or second – degree burns.

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• How to protect red wounds:
Gentle cleansing
Applying a topical antimicrobial agent.
Appling a transparent film/hydrocolloid dressing.
Changing the dressing as frequently as possible.

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Yellow wounds

• Characterized primarily by liquid to semi liquid ”slough”

that is often accompanied by purulent drainage.
• The clinician cleanses yellow wounds to absorb drainage
and remove nonviable tissue.

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 Mgt may include
 Applying dressing;
 Irrigating the wound; using absorbent dressing material
such as impregnated no adherent, hydro gel dressing, or
other exudates absorbers;
 Topical antimicrobial to minimize bacterial growth.

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Black Wound
• Covered with thick necrotic tissue or scar.
e.g. third degree burns and gangrenous ulcer.
• Required debridement.

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 Wound healing process
There are three forms of wound healing
1. Healing by first intention/primary union/
-Most surgical incisions & lacerations heal by this
process
The wound character is:
- Clean/it is clean incision/
- Straight line with little tissue damage
- Edges are well-approximated by sutures
- Rapid healing with minimal scar

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2. Healing by second intention

The wound character:

- Irregular large wounds with considerable tissue loss

- Edges cannot be approximated/big gap/

- longer healing time & more scaring

- Natural healing by granulation tissue

- High risk of infection

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3. Healing by third intention

- Occurs when delaying in suturing at time of wound

occurrence=>high interval of time

- Increased risk for infection

- Greater inflammatory rxn & more granulation tissue

formation than primary & secondary

- late suturing & large scar

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 Phase of wound healing
A. Inflammatory phase - Is initiated immediately
after injury and lasts 3 to 6 days.

• The major process occurs during this phase are

homeostasis and phagocytosis.

• Homeostasis is the cessation of bleeding results from

vasoconstriction of larger blood vessels in the affected
area.

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 Phase of wound healing
• The blood supply to the wound increase; the area
appears reddened and edematous as a result.

• During cell migration leukocytes migrate to start

phagocytes engulfing and clearing of debris.

• The microphages also produce angiogenesis factor that

stimulate development of network blood vessels and
epithelialization.
 Phase of wound healing
B. Proliferative phase

It is the second phase in healing extends from day 3 to

about day 21 post injury.

• Fibroblasts (connective tissue cells), which migrate in

to the wound began to synthesize collagen and a
substance called proteoglycan.

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 Phase of wound healing
• 5 days post injury collagen is a whitish protein
substance that adds tensile strength to the wound.

• Capillaries grow across the wound increasing the blood

supply. As capillary network develops the tissue
becomes translucent red color this tissue is called
granulation tissue.
 Phase of wound healing

• When the skin edges of a wound are not sutured, the area
must be filled with granulation tissue. When the
granulation tissue matures epithelial cells migrate it and
begin to proliferate over the connective tissue to fill the
wound.

• If the wound dose not closes by epithelialization the area

covered with dried plasma proteins and dead cells called
eschare later it will heal by forming dense scar tissue.
 Phase of wound healing
C. Maturation phase
• The maturation phase begins about 21 days and can
extend to 1 to 2 years after the injury.
• Fibroblast continues to synthesize collagen.
• The collagen fibers themselves reorganize in to more
orderly structures.
• At this time the wound is remolded and contracted the
scar become strong but the repaired is never as strong as
original tissue on some individuals an abnormal amount
of collagen is laid down.
• The results in the development of hypertrophic scar or
keloid, contracture,
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 Factors affecting wound healing

1. Developmental consideration

Age of the patient

- Children & healthy adults heal faster

- Older age-diminished fibroblastic activity this will

reduce tissue production
 Factors affecting wound healing

2. Circulation & oxygen

 Any problem that affect circulation:
-Angiopathy -problem of blood vessels
- hypoxia & hypoxemia
e.g. anemia & respiratory disease
- Obesity-
- difficult to suture
- prone to infection
 Factors affecting wound healing

3. The wound condition

- Extent of tissue damage

- Degree of contamination, foreign body & debris

- Presence of infection

- Dressing- adequate/inadequate
 Factors affecting wound healing

4. Overall patient health & condition

- Nutrition- malnutrition vs. balanced diet
- Immunosuppressive state
- Radiation therapy
- Chemotherapy
- Chronic infections/diseases
Care of wounds
• Since there are many types of wound, there are also
many ways of caring for wounds depending on the type
of wound.
• Ex:- clean wounds, septic wounds, wound with drainage
tube, wound that need irrigation.
 The care is done as an open method & closed method
Open method:- refers to the care of wound with out
dressing.
Closed method:- is the care of wound with dressing

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 Cleanse the Wound
• The goal of cleansing the wound is to remove debris
and bacteria from the wound with little trauma to
the healthy granulation tissue as possible.
• Choice of cleansing agent depends on the
physician’s prescription as well as agency protocol.
• It is recommended that isotonic solutions such as
normal saline used to preserve healthy tissue.
 Cleanse the Wound

Note-principles to keep in mind when cleansing a

wound are:

1. Use Standard Precautions at all times.

2. work from the clean area to toward the dirty area.

Example: -When cleaning a surgical incision, start over

the incision line, and swab downward from top to
bottom.
Antiseptic solutions used for wound care
• Iodine 1%:- for small, dry and clean wounds
• Hydrogen peroxide 3%:- to clean septic wound
• Normal saline 0.9% for wound irrigation
• GV 1% - for dry, clean wound
Ointments
Petroleum (Vaseline gauze):-
• Is used to protect tissue from drying
• It prevent dressing adherence to the wound
• create an air tight scar (used for burns)
Furacin gauze:-
• Antibacterial materials used for wound care. 40
 Irrigating wound

Defn:- Is the washing out of a wound.

Purpose-
• To remove excess drainage with sloughing tissue.

• To facilitate healing.

• To apply antiseptic solution.

• To cleanse and maintain free drainage of infected

wound.
 Dressing
It is covering of wound with sterile material after
cleaning with an antiseptic solution to provide the
conditions necessary for healing.
Purpose of dressing
• To provide proper environment for wound healing
• To absorb and promote drainage
• To splint or immobilize wound (prevent bleeding )
• To protect the wound & new epithelial tissue from
mechanical injury
 Purpose of dressing………

• To prevent adherence of old dressing to the wound.

• To protect the wound from contamination (Mos)

• To promote hemostasis as in pressure dressings

• Provide mental and physical comfort to the patient

• To approximate edges of wounds

• To keep in position drugs applied locally.

Bandages, Binders and Slings

• Bandages and binders are applied over wound dressing

sites: to secure, immobilize, or support a body part; to
hold a dressing in place; or to prevent or minimize
swelling of a body part

• Bandages are long rolls of material, such as gauze

designed to be wrapped around body parts.

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 Binders are bandages made for specific body parts,
usually the abdomen, perineal area, or arm (sling)
• Perineal binders, called T binders, are used to hold pads
or dressings in the perineal area.
A sling is a cloth support for an injured arm that wraps
around the back of the neck to maintain the arm in a set
position.

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 Wound complications
1. Hematoma- internal bleeding
2. Hemorrhage- external bleeding
3. Infection (wound sepsis)- invasion by MOs
4. Dehiscence and evisceration:
dehiscence- partial or total disruption of
wound edges
evisceration-protrusion of wound contents
5. Keloid-excessive growth of scar tissue
 QUESTIONS AND SUGGESTION

THANK YOU SO MUCH FOR

THE TIME YOU HAD BEEN
WITH ME!!!
THE END