WOUND CARE

● Wounds may be classified according to the

number of skin layers involved:
○ Superficial
■ Involves only the epidermis
○ Partial Thickness
Skin: structure and function ■ Involves the epidermis and
● Largest organ of the body
the dermis
● Primary function is protective
○ Full Thickness
● Composed of several layers
■ Involves the epidermis,
○ Outer epidermis
dermis, fat, fascia, and
○ Dermis, containing the capillary
exposes bone
network
○ Subcutaneous layer (hypodermis,
Classification of Wounds
adipose layer)
1. Class I (Clean) - An uninfected operative
● Thickness varies from a thin membrane at
wound in which no inflammation is
internal flexures (e.g. elbows), to thicker at
encountered and the respiratory, alimentary,
the sole of the feet which bear
genital, or uninfected urinary tract is not
considerable pressures
entered. IN addition, clean wounds are
● Hair follicles, sebaceous glands, and sweat
primarily closed and, if necessary, drained
glands pass through the epidermis, but
with closed drainage. Operative incisional
arise from the dermal layer
wounds that follow nonpenetrating (blunt)
○ To maintain skin integrity
trauma should be included in this category
if they meet the criteria.
Wound 2. Class II (Clean-contaminated) - An operative
● A wound can be defined as: “A cut or
wound in which the respiratory, alimentary,
break in the continuity of any tissue, caused
genital, or urinary tracts are entered under
by injury or operation” (Bailliere’s 23rd Ed)
controlled conditions and without unusual
contamination. Specifically, operations
Classifying wounds
involving the biliary tract, appendix, vagina,
● Wound can be classified according to their
and oropharynx are included in this
nature:
category, provided no evidence of infection
○ Abrasion - gasgas
or major break in technique is encountered.
○ Contusion
○ Hysterectomy is an example
○ Incision - clean cut
3. Class III (Contaminated) - Open, fresh,
○ Laceration - nahiwa
accidental wounds. In addition, operations
○ Open
with major breaks in sterile technique (e.g.
○ Penetrating
open cardiac massage) or gross spillage
○ Puncture
from the gastrointestinal tract, and incisions
○ Septic & etc.

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 in which acute, nonpurulent inflammation is
encountered are included in this category.
4. Class IV (Dirty-infection) - Old traumatic
wounds with retained devitalized tissue and
those that involved existing clinical infection
or perforated viscera. This definition
suggests that the organisms causing
postoperative infection were present in the
operative field before the operation.
○ Examples are DM feet and
perforated diverticulitis.

The ways in which wounds heal

● Three basic classifications exist:
○ Healing by primary intention
■ Two opposed surfaces of a ● The four (4) phases are:

clean, incised wound (no ○ Hemostasis

significant degree of tissue ○ Inflammatory phase

loss) are held together. ■ Cardinal signs of

Healing takes place from the inflammation like redness,

internal layers outwards pain, warmth, swelling, and

○ Healing by secondary intention loss of function

■ If there is significant tissue ○ Proliferative phase

loss in the formation of the ■ Regeneration happens in this

wound, healing will begin by phase

the production of granulation ○ Remodeling or natural phase

tissue wound base and walls. ■ Scar formation

○ Delayed primary healing

■ If there is high infection risk
– patient is given antibiotics
and closure is delayed for a
few days e.g. bites

Wound healing
● All wound heal following a specific
sequence of phases which may overlap
● The process of wound healing depends on
the type of tissue which has been damaged
and the nature of tissue disruption

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The Healing Process
● Day 0-5
○ The healing response starts at the
moment of injury – the clotting
cascade is initiated
○ This is a protective tissue response
to stem blood loss
○ The inflammatory phase is
characterized by heat, swelling,
redness, pain, and loss of function at
the wound site
○ Early (hemostasis)
○ Late (phagocytosis)
■ Engulf the invaders,
unwanted pathogens, or
dead cell tissues
○ This phase is short lived in the
absence of infection or
contamination
Granulation
● Day 3-14
○ Characterized by the formation of
granulation tissue in the wound
○ Granulation tissue consists of a
combination of cellular elements
including:
■ Fibroblasts, inflammatory
cells, new capillaries
embedded in a loose
extracellular collagen matrix,
fibronectin and hyaluronic
acid
Angiogenesis
● Collagen first detected at day 3 and rapidly
increased for approx. 3 weeks, then more
gradually for the next 3 months
● Fibroplasia (fibroblast proliferation and
synthetic activity) continues in parallel with
revascularization)
● Endothelial cells from the side of venules
closets to the wound begin to migrate in
response to angiogenic stimuli
(angiogenesis) forming capillary buds, then
loops
Epithelialization
● The epidermis immediately adjacent to the
wound edge begins to thicken within 24 hrs
after injury
● In approximated incised wound
re-epithelialization is usually complete within
48 hrs.
Maturation
● Can last up to 2 years
● New collagen forms, changing the shape of
the wound and increasing the tensile
strength
● Scar tissue, whoever is only ever approx.
50-80% as strong as the original tissue
● During the remodeling process there is a
gradual reduction in cellularity and
vascularity of the reparative tissue.
○ TAHBSO - Total Abdominal
Hysterectomy and BIlateral
Salpingo-Oophorectomy
Contraction
● Only undesirable where it leads to
unacceptable tissue distortion and an
unsatisfactory cosmetic result
● Wound contraction usually begins from day
5 and is complete at approx. day 12-15
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 Factors affecting healing Classifying Wound
1. Immune status Grading by tissue involved (EPUAP 1999)
2. Blood glucose levels (impaired white cell 1. Grade I - non-blanchable erythema of intact
function) skin. Discoloration of the skin, warmth,
3. Hydration (slows metabolism) oedema, induration or hardness may also be
4. Nutrition used as indicators in people with dark skin.
5. Blood albumin levels (‘building blocks’ for 2. Grade II - partial-thickness skin loss
repair, colloid osmotic pressure - oedema) involving epidermis, dermis or both. The
6. Oxygen and vascular supply ulcer is superficial and presents clinically as
7. Pain (causes vasoconstriction) an abrasion or blister
8. Corticosteroids (depress immune function) 3. Grade III - full thickness skin loss involving
damage or necrosis of subcutaneous tissue
Wound assessment that may extend down to but not through
● Lab tests underlying fascia
○ CBC (Complete blood count) - WBC 4. Grade IV - extensive destruction, tissue
is important necrosis, or damage to muscle, bone, or
○ Albumin count supporting structures with or without
● Size, depth, & location thickness skin loss.
● Wound bed (necrosis and granulation)
○ Necrotic (S-scar wound) - dark and Assessment of Clinical Appearance
means there is no blood circulation ● Slough (yellow)
○ Granulating - reddish and raised
from the wound bed
● Surrounding skin (color and moisture)
○ For example, a patient has a
colostomy and has a stoma. The skin
color surrounding is pinkish, then it
is normal. It is also important that it
is not dry and slightly moist.
● Wound edge
● Necrotic tissue (black)
● Odor or exudate
○ Normal in the wound.
○ If there is odor present, there is
already a problem.
● Signs of infection
○ Red, edematous, warm to touch,
fever

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● Infected tissue (green)
● Granulating tissue (red)
● Epithelialising (pink)
○ No pain and less exudate
Dressing choice
● What is available?
● How do we choose?
● Does the patient have a say?
● Do we consider cost?
The purpose of dressing:
● To aid debridement
● To remove excess exudate
● To control bleeding
● To protect a wound
● To support healing
The ideal dressing
● A dressing that created the optimum
environment
● Wound debridement
● Wound cleansing
● Alternative therapies
Types of dressing
Film dressing
● Semi-permeable primary or secondary
dressings
● Clear polyurethane coated with adhesive
● Conformable, resistant to shear and tear
● Do not absorb exudate
● Examples: Tegaderm, Op-site
Hydrocolloids
● Pectin, gelatin, carboxymethylcellulose and
elastomers
● Environment for autolysis to debride
sloughy or necrotic wounds
● Occlusive → hypoxic environment to
encourage angiogenesis
● Waterproof
● Different presentations e.g. Urgotul
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 Hydrogels
● Sheets or gels
● Starch and polyacrylamide (94% water)
● Low exudate, shallow wounds
● Re-hydrates necrotic tissue
● Secondary dressing needed
● May cause skin maceration
Alginates
● Seaweed dressings
● Form a gel over the wound
● Moderate to high exudate wounds
● Easily removed
● Can cause pain
● Help to debride a wound
Maceration is defined as the softening and
breaking down of skin resulting from prolonged
exposure to moisture.
Traditional Wound Dressing
1. Gauzes
○ Traditional gauzes
○ Impregnated gauzes
○ Wet-to-dry bandages
2. Transparent films
○ Bi-layer or multilayer films
3. Foams
○ Traditional foams
○ Antibacterial forms
4. Hydrogels
○ Alginate-based hydrogels
○ Collagen-based hydrogels
5. Hydrocolloids
○ Internal layer based on hydrogels
○ External layer based on synthetic
polymers
6. Hydroconductive dressings
○ Multi-layer structure
Wound Dressing Materials
● Soap and water for hand hygiene
○ Alcohol is also okay
● Face Mask
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● Clean and sterile gloves c. An exploratory laparotomy
● Forceps d. A hysterectomy
● Sterile drape e. A tummy tuck (cosmetic procedure)
● Alcohol swab / alcohol and cotton balls f. Or any surgery involving the
(used to loosen adhesive tape) abdominal area
● Povidone iodine swab / betadine, cotton tip 2. Support your surgical incision
application 3. Hold your abdominal muscles together to
● Antimicrobial ointment or cream relieve pain
● Appropriate dressing or gauze 4. Increase circulation at your surgical site to
● Medical tape / adhesive tape promote healing and decrease swelling
● Bandage scissor 5. Make physical activity more comfortable
● Plastic for contaminated materials 6. Strengthen abdominal muscles
7. Promote deep breathing
Abdominal Binder
● It is a wide compression belt that encircles
your abdomen.
● It comes in many sizes and widths.
● Most are made from elastic and have Velcro
or hook and loop closures.

Purposes of Abdominal Binder

1. An abdominal binder may be used to
speed-up the recovery process after
abdominal surgery.
a. CS
b. Bariatric surgery (surgery to patients
that have difficulties managing their
weight)

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