WOUND CARE

NCM 103
 Learning Objectives:

After completing this topic, you will be able to:

1. Understand the concept of Wound and wound care.
2. Identify the different types of wounds and differentiate
each type.
3. Describe the different stages of Wound Healing process
4. Indentify the major factors Involving healing process.
5.Understand the Healing process
6.Identify the factors that affects wound healing
7.Increase the level of understanding in caring for patient
with wound care.
 INTRODUCTION

The skin is the largest organ in the body and

serves a variety of important functions in
maintaining health and protecting the individual
from injury. Maintaining skin integrity and
promoting wound healing is a crucial nursing
functions. In this topic you learn on how to
perform wound care.
What is a wound?
an injury that involves cutting or breaking of bodily tissue
 Types of Wounds
TYPE CAUSE DESCRIPTION &
CHARACTERISTICS
Incision Sharp instrument Open wound;
( eg. Knife or scalpel) deep or shallow
Contusion Blow from a blunt Closed wound, skin appears
instrument ecchymotic
(bruised because of damage
blood vessels
Abrasion Surface scrape , either Open wound involving the
unintentional skin
( eg. Scraped knee from a
fall) or intentional (eg.
Dermal abrasion to remove
pockmarks)
 Types of Wounds
TYPE CAUSE DESCRIPTION &
CHARACTERISTICS
Puncture Penetration of the skin and often Open wound
the underlying tissues by a sharp
instrument either intentional or
unintentional.
Laceration Tissues torn apart, often from Open wound;
accidents edges are often jagged
( eg. With machinery, primiparous
NSD birth)
Penetrating wound Penetration of the skin and the Open wound;
underlying tissues, usually
unintentional
( eg. From bullet or metal
fragments)
TYPES OF WOUNDS
Diagram of the Healing Process
Two major processes occur during this
phase:

1. Hemostasis

2. Phagocytosis
Two major processes occur during this
phase:
1. Hemostasis the cessation of bleeding results from vasoconstriction of the
larger blood vessels in the affected area, retraction drawing back of injured blood
vessels, the deposition of fibrin connective tissue, and the formation of blood clots
in the area. The blood clots provide a matrix of fibrin that becomes the framework
for cell repair.

2. Phagocytosis during cell migration, leukocytes (specifically, neutrophils) move

into the interstitial space. These are replaced about 24 hours after injury by
macrophages. These macrophages engulf microorganisms and cellular debris.
Phases of Healing Process
Wound healing can be broken
down into three phases:
Inflammatory, Proliferative, and
Maturation or Remodeling.
 INFLAMMATORY PHASE
➢The inflammatory phase begins immediately
after injury and lasts 3 to 6 days.

➢also involves vascular and cellular responses

intended to remove any foreign substances and
dead and dying tissues.
 PROLIFERATIVE PHASE
•Extends from day 3 or 4 to about day 21 post
injury. Fibroblasts (connective tissue
cells),which migrate into the wound starting
about 24 hours after injury, begin to
synthesize collagen.
 MATURATION PHASE
•The maturation phase begins on about day 21 and can extend 1
or 2 years after the injury. Fibroblasts continue to synthesize
collagen.
•The collagen fibers themselves, which were initially laid in a
hap-hazard fashion, reorganize into a more orderly structure.
•During maturation, the wound is remodeled and contracted.
•The scar becomes stronger but the repaired area is never as
strong as the original tissue.
 Factors Affecting Wound Healing
A.DEVELOPMENTAL CONSIDERATIONS
Healthy children and adults often heal more quickly
than older adults, who are more likely to have chronic
diseases that hinder healing.
For example, reduced liver function can impair the
synthesis of blood clotting factors.
 Factors Affecting Wound Healing
B. NUTRITION
Wound healing places additional demands on the body. Clients
require a diet rich in protein, carbohydrates, lipids, vitamins A
and C, and minerals, such as iron, zinc, and copper. Malnourished
clients may require time to improve their nutritional status
before surgery, if this is possible. Obese clients are at increased
risk of wound infection and slower healing because adipose
tissue usually has a minimal blood supply.
 Factors Affecting Wound Healing
C. LIFESTYLE
People who exercise regularly tend to have good
circulation and because blood brings oxygen and
nourishment to the wound, they are more likely to heal
quickly.
Smoking reduces the amount of functional
distribution, skin turgor, presence of edema, and
characteristics of any lesions that are present.
 Factors Affecting Wound Healing
D. MEDICATIONS
•Anti-inflammatory drugs (e.g., steroids and aspirin) and
anti-neoplastic agents interfere with healing.

•Prolonged use of antibiotics may make a person

susceptible to wound infection by resistant organisms.
 WOUND CARE AND APPLYING DRESSING
Assessment
•Client allergies to wound-cleaning agents
•The appearance and size of the wound
•The amount and character of exudates
•Client complaints of discomfort
•The time of the last pain medication
•Signs of systemic infection

Determine
•Any specific orders about the wound or dressing
 WOUND CARE AND APPLYING DRESSING
Assemble Equipment
EQUIPMENTS
•Both blanket(If necessary) Sterile dressing set; if none is available, gather
•Moisture proof Bag the following sterile items:
•Drape or towel
•Mask(Optional)
•Gauze squares
•Acetone or another solution(If necessary to •Container for the cleaning solution
loosen adhesive) •Cleaning solution
Two pairs of forceps
Gauze dressings
•Applicators or tongue blades, to apply
ointments
•Clean gloves •Additional supplies required for the particular
dressing
•Sterile gloves
•Tape ,Tie tapes, or binder
 WOUND CARE AND APPLYING DRESSING
Prepare the client and assemble equipment.
•Acquire assistance for changing a dressing on a restless or confused client.
•Assist the client in a comfortable position in which the wound can be readily
exposed. Expose only the wound area, using a bath blanket to cover the area
if necessary.
•Make a cuff in the moisture-proof bag for disposal of the soiled dressings,
and place the bag within reach. It can be taped on the bedclothes or on the
bedside table.
•Put on a facemask, if required.
 WOUND CARE AND APPLYING DRESSING
Procedure
•Introduce yourself and verify client’s identity. Explain to the client what you are going
to do, why it is necessary, and how the client can cooperate.
•Perform hand hygiene, and observe other appropriate infection control procedures.
•Provide client privacy.
•Remove binders and tape.
•Remove binders, if used, and place them aside. Untie tie tapes, if used.
•If adhesive tape is used, remove it by holding down the skin and pulling the tape
gently but firmly towards the wound.
•Use a solvent to loosen tape, if required.
 WOUND CARE AND APPLYING DRESSING
Procedure
•Remove and dispose of soiled dressing appropriately.
•Put on clean disposable gloves, and remove the outer abdominal dressing or surgipad.
•Lift the outer dressing so that the underside is away from the client’s face.
•Place the dressing in the moisture-proof bag without touching the outside of the bag.
•Remove the under dressings, taking care not to dislodge any drains. If the gauze sticks to
the drain, support the drain with one hand, and remove the gauze with the other.
•Assess the location, type, and odor of wound drainage, and the number of gauzes
saturated or the diameter of drainage collected on the dressings
•Discard the soiled dressings in the bag as before.
•Remove gloves, dispose in the moisture-proof bags, and wash hands.
 WOUND CARE AND APPLYING DRESSING
Procedure
•Set up the sterile supplies.
•Open the sterile dressing set, using surgical aseptic
technique.
•Place the sterile drape beside the wound.
•Open the sterile cleaning solution, and pour it over the
gauze sponges in the plastic container.
•Put on sterile gloves.
 WOUND CARE AND APPLYING DRESSING
Procedure
•Clean the wound, if indicated.
•Clean the wound, using your gloved hand or forceps and gauzed swabs moistened with cleaning
solution.
•If using forceps, keep the forceps tips lower than the handles at all times.
•Use the cleaning methods described, or one recommended by agency protocol.
•Use a separate swab each stroke, and discard each swab after use.
•If a drain is present, clean it next, taking care to avoid reaching across the cleaned incision. Clean the
skin around the drain site by swabbing in half or full circles from around the drain site outward, using
separate swabs for each wipe
•Support and hold the drain erect while cleaning around it. Clean as many times as necessary to
remove the drainage.
•Dry the surrounding skin with dry gauze swabs, as required. Do not dry the incision or wound.
Moisture facilitates healing.
 WOUND CARE AND APPLYING DRESSING
Procedure
•Apply dressing to the drain site and the incision.
•Place precut 4 x 4 gauze snugly around the drain, or open a 4 x 4 by 4 x 8, fold it lengthwise
to 2 x 8, and place the 2 x 8 gauze around the drain so that the ends overlap.
•Apply the sterile dressings one at a time over the drain and the incision. Place the bulk
dressings over the drain area and below the drain, depending on the client’s usual position.
•Apply the final surgipad, remove gloves and dispose of them. Secure the dressing with tape
or ties.

•Document the procedure and all nursing assessments.

Thank you!