Outlines

Objectives

Skin integrity

Wound

wound healing process

Suturing

Stich removal

summary
04/01/2021 DT 1
 Objectives

 At the end of this session, students will be able

to:
 Define skin integrity and wound care

 Identify types of wound

 Identify wound healing process

 Identify necessary equipment for wound care

 Demonstrate suturing

04/01/2021 DT 2
Brain storming

Skin

04/01/2021 DT 3
•Skin enables us to assume our own identity and to
recognize among ourselves.

04/01/2021 DT 4
 Anatomy of Skin
 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.
04/01/2021 DT 5
 Skin Layers

Three layers of the skin:

1. Epidermis
2. Dermis
3. Subcutaneous tissue

04/01/2021 DT 6
 Diagram of the Skin

04/01/2021 DT 7
 Epidermis
 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

04/01/2021 DT 8
 Epidermis …

 Cells in the epidermis constantly change and

regenerate (research suggests 35 days)
 Injury to these cells may cause blisters &
calluses

04/01/2021 DT 9
 Dermis
 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

04/01/2021 DT 10
 Dermis…
 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

04/01/2021 DT 11
 Dermis…

 Hair follicles
 Collagen makes the skin stretchable &
elastic
 Point of attachment for smooth and
voluntary muscles

04/01/2021 DT 12
 Subcutaneous Layer
 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)

04/01/2021 DT 13
 Breakout

Describe the functions of the Skin

04/01/2021 DT 14
 Functions of the Skin
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
04/01/2021 DT 15
 Functions of the Skin
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)

04/01/2021 DT 16
Functions of the Skin cont’d
8.Psychosocial

9.Absorption

10.Elimination

04/01/2021 DT 17
 Wound
 A break in the skin or mucous membrane;
 An alteration in the integrity of the skin and
underlying tissues.

 An injury to the skin and underlying

musculature that disrupts the normal continuity
of the affected tissue, organ, or bone.

04/01/2021 DT 18
 Causes

Accidental falls
Handling of sharp objects
Gunshot
Burn
Vehicle accident
Animal bite -etc.

04/01/2021 DT 19
 Classification

• Open wound – Is a break in the skin or the mucus

membrane
• Closed wound – Is injury to underlying tissue
without a break in the skin or mucus membrane.

04/01/2021 DT 20
 Types of Open Wounds
1. Abrasion
• The surface and sometimes deeper layers of the
skin is scraped off.
• Bleeding is usually limited, but infection must be
prevented because dirt and contaminants often
enter the wound.

04/01/2021 DT 21
04/01/2021 DT 22
 Incision
• This cut is caused by a sharp object such as a knife,
scissors, or razor
• The edges are smooth and regular

• If the cut is deep, bleeding can be heavy and can

lead to excessive blood loss and shock
• Damage to muscles, tendons, and nerves may also
occur
04/01/2021 DT 23
04/01/2021 DT 24
 Lacerations
•Involves tearing of the tissues by way of
excessive force
•The wound is often has jagged or irregular
edges
•Bleeding maybe heavy and if the wound is
deep, it may lead to infection
04/01/2021 DT 25
04/01/2021 DT 26
 Puncture
• Caused by a sharp object such as a pin, nail, or
pointed instrument.
• External bleeding is limited, but internal bleeding
can be severe
• Chance of infection especially tetanus

04/01/2021 DT 27
Puncture cont’d
Are compound wounds which involve deeper
structures.

They require careful management.

04/01/2021 DT 28
04/01/2021 DT 29
 Avulsion
• Occurs when tissue is torn or ripped away from the victim’s
body

• It can result in a piece being torn and hanging from the ear,
nose, hand, or any other body part

• Bleeding is normally profuse

• It is important to preserve any body part while caring for the

patient

• Wrap the body part in sterile gauze, wet it, bag it, and ice it
make sure it goes w/pt
DT 30
04/01/2021
04/01/2021 DT 31
 Amputation
Occurs when a body part is cut off or torn off

Bleeding can be extensive

Care must be taken with the amputated object

Wrap it in a cool moist dressing (use sterile water or saline if

available). Place it in a plastic bag and then in ice water

 Never place directly on ICE

04/01/2021 DT 32
 Missile injuries

These are type of wounds which are compound

& complicated.

There is excessive tissue damage .

High degree of contamination.

 Presented with severe life threatening conditions

It should be carefully managed.

04/01/2021 DT 33
 Bites

Bites can be caused by humans or other animals.

The wounds can be puncture or lacerated

Are usually contaminated

HUMAN BITES
 Are relatively rare wound type
more heavily contaminated than those of most animals
due to polymicrobial nature.
(anaerobic organisms as a normal oral flora)
04/01/2021 DT 34
 Septic wound

A. CLEAN-CONTAMINATED:

Minor break in sterility technique causes it

Risk of contamination by bacteria 3%

Prophylactic antibiotic usage is needed.

e.g. sterility break in oropharynx ,respiratory ,GIT,GUT

Cholecystectomy procedures.
04/01/2021 DT 35
 Septic wound-----
B. CONTAMINATED WOUND :

 Risk of infection is increased

 Empiric antibiotic therapy indicated

 Leave open these wounds initially for 5days when the resistance

to infection is increased.

e.g. Gross spillage of bile , enteric content ,nearly all

traumatic wounds
04/01/2021 DT 36
 SEPTIC WOUND-----

C. DIRTY WOUND :

Heavily contaminated with bacteria .

e.g.
 Abscess
 Wound with drainage
 Irrigated wound

 Gunshot wound
04/01/2021 DT 37
What are the stages of wound healing?

Hemostasis

Inflammation

Epithelialization

Angiogenesis

Fibroplasia

Wound contracture

Scar remolding

04/01/2021 DT 38
 Phases of wound healing ------

Primary—healing with suture, staples, adhesives.

Secondary—healing by granulation.

Tertiary—delayed primary closure

04/01/2021 DT 39
 Phases of healing---
Coagulation phase:
 The first phase of healing which is induced immediately
following injury.

 Characterized by vaso-constriction, clot formation and

release of platelets.

Release other substances necessary for healing and help

as a bridge between the two edges.

04/01/2021 DT 40
 Phases of healing-----
INFLAMMATORY PHASE:

This phase takes place from time of wounding up to

three days.

 Characterized by classical inflammatory response,

vasodilatation and pouring out of fluids.

Migration of inflammatory cells and leukocytes occur.

Shows rapid epithelial growth.

04/01/2021 DT 41
 PHASES OF HEALING-----
PROLIFERATIVE PHASE:

 Known as phase of fibroplasia, starts around the 3rd day of

injury and stays for about three weeks.

This is a phase during which important events occur for

healing of the wound.

 Characterized by fibroblast, epithelial and endothelial

proliferation.

Collagen synthesis, ground substance and blood vessels

production are high in this phase.
04/01/2021 DT 42
 Question
In which phase of wound healing is new tissue built to fill
the wound space, primarily through the action of
fibroblasts?
A. Hemostasis
B. Inflammatory phase
C. Proliferation phase
D. Maturation phase

04/01/2021 DT 43
 Answer to Question
Answer: C. Proliferation phase

Rationale:
In the proliferation phase, granulation tissue is formed to fill the
wound. In hemostasis, involved blood vessels constrict and blood
clotting begins.
 In the inflammatory phase, white blood cells move to the wound.
In the maturation phase, collagen is remodeled, forming a scar.

04/01/2021 DT 44
 PHASES OF HEALING-----
MATURATION PHASE:

known as phase of remodeling.

 Remodeling takes the longest period extending for

up to one year.

Equilibrium between protein synthesis and degradation

occurs during this phase.

With cross linking of collagen bundles leading to slow and

continuous increase in tissue strength of the wound to return
to normal.
04/01/2021 DT 45
Summary of normal wound-healing process

04/01/2021 DT 46
 Types of Wound Healing

Wound healing differs according to how much tissue

has been damaged.
It occurs by first, second, and third intention.
FIRST INTENTION:
Healing occurs in wounds with minimal tissue loss,
such as surgical incisions or sutured wounds.

Edges are approximated (close to each other),thus they

seal together rapidly.

Scaring and infection rate with first intention healing

are low.
04/01/2021 DT 47
 Types of Wound Healing cont’d

SECOND INTENTION :

Healing occurs with tissue loss, such as in deep

laceration, burns, and pressure ulcers.

 Edges don’t approximate, openings fill with

granulation tissue that is soft and pinkish.

Later, epithelial cells grow over the granulation

greater than that for first intention healing.

04/01/2021 DT 48
 Types of Wound Healing cont’d
THIRD INTENTION
 Healing occurs when there is a delay in the time.

Sometimes called delayed intention or closure

It is between the injury and closure of the wound.

For example, a wound may be left open temporarily to allow for drainage
or removal of infectious materials.

surgical wounds are left open 3 - 5 days & then sutured closed.
When the wound closes later, in the mean time, wound surfaces start to
granulate.

Scaring is common.
04/01/2021 DT 49
Wound Healing Influencing Factors

Age
Nutrition
Obesity
Extent of wound
Wound stress
Circulating oxygen
Smoking
 Drugs
Chronic diseases
 Infection (local/systemic)

04/01/2021 DT 50
Wound Complications

 Hemorrhage
May be internal or external
 Shock
 Infection
 Dehiscence
Separation of wound layers, usually abdominal, caused by
wound stress (coughing, vomiting, abdominal distention)
 Evisceration
Separation of wound with protrusion of abdominal organs.
osurgical emergency
o cover with normal saline sterile dressings.

04/01/2021 DT 51
Wound Observations

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
Wound appearance
Red, swollen, area around wound warm to touch, sutures, staples -
intact or broken
4 Cs in determining muscle viability
Color
 Consistency
 Contraction and
Circulation
52
04/01/2021 DT
 Types of wound dressing
Clean wound dressing

Septic wound dressing

Dressing with drainage tube

Dressing irrigated wound

04/01/2021 DT 53
 Dressing of a clean wound

Purpose:
To keep wound clean.

To prevent the wound from injury and contamination.

To keep in position drugs applied locally on wound.

To keep edges of the wound together by immobilization.

To apply pressure.

04/01/2021 DT 54
 Equipment

Pick up forceps in a container.

Three sterile forceps.

Sterile bowl or kidney dish.

Sterile cotton balls.

Sterile gallipots.

Sterile gauze.

Rubber sheet with its cover.

04/01/2021 DT 55
 Equipment
Antiseptic solution as ordered.

Adhesive tape or bandages.

 Scissors.

Ointment or other types of drugs as needed.

Receiver, Spatula if needed.

Benzene or ether.
04/01/2021 DT 56
 Technique

Aseptic technique to prevent infection

Procedure:-
Explain procedure to the patient.

 Clean trolley or tray; assemble sterile equipment on one side,

and clean items on the other side. Make sure it is covered.
Drape and put patient in comfortable position.

Place rubber sheet and its cover under the affected side.

 Remove the outer layer of the dressing e.g. adhesive tape bandage.

04/01/2021 DT 57
 Procedure:-----

Remove the outer layer of the dressing using the first

sterile forceps and discard both the soiled dressing and
the forceps.

Take the second sterile forceps.

Clean wound with cotton balls soaked in antiseptic

solution, starting from inside to the outside then discard
it.

Use the third forceps to apply medication & gauze to the

wound. DT 58
 Method of Application

Ointment must be smeared with spatula on gauze and then

applied on the wound.

Solutions or powder can be applied direct on the wound.

 Make sure that the wound is properly covered.

 Fix dressing in place using adhesive tape or bandage.

04/01/2021 DT 59
 Method of Application
Leave patient comfortable and tidy

Record state of wound and evaluate the pt for satisfaction.

Clean and return equipment to proper place.

Document the care provided

N.B.
The above-mentioned equipment can be prepared in a
separate pack if central sterilization department is available.

04/01/2021 DT 60
 DRESSING OF SEPTIC WOUND
The purpose is to:

Absorb materials being discharged from the wound.

 Apply pressure to the area.

Apply local medication.

Prevent pain, swelling and injury.

04/01/2021 DT 61
 Equipment

Pick up forceps in a container.


Sterile forceps -3


Sterile gallipot

Sterile kidney dish/bowl.


Sterile gauze.


Sterile test tube or slide


Sterile cotton ball and - tipped application
04/01/2021 DT 62
 Equipment

Sterile pair of gloves, if needed, in case of gas

gangrene, rabies etc.

Rubber sheet and its cover.

Local medication if ordered.

 Spatula.

 Receiver with strong disinfectant to immerse used

instrument.
04/01/2021 DT 63
 Equipment


Probe and director if required

Scissors.

Benzene or ether
Bandages or adhesive tape.

Bucket to put in soiled dressing.
04/01/2021 DT 64
 Procedure

Explain procedure.

Clean trolley or tray and assemble sterile equipment on one side

and surgically clean items on the other side.

Make sure the tray or trolley is covered.

Drape patient and position comfortably.

Place rubber sheet & its cover under the affected part

First remove the outer layer of the dressing, wear gloves if

necessary.

04/01/2021 DT 65
 Procedure-------

Use, second forceps to remove the outer & inner layer

of the dressing smoothly and discard there.

 Observe wound and check if there is drainage tube.

Take specimen for culture or sensitivity if ordered

Do not cleanse wound with antiseptic before you obtain

the specimen.

04/01/2021 DT 66
 Procedure

Start cleaning wound from the cleanest part of the

wound to the most contaminated part using second
forceps with antiseptic solution.

•(H2O2 3%) is commonly used for septic wound.

Discard cotton ball used for cleaning after each

stroke over the wound.

Cleanse the skin around the wound to remove the

plaster, use cotton balls for drying the skin around the
wound properly using second forceps.
04/01/2021 DT 67
 Procedure

Dress the wound using third forceps and make sure

that the wound is covered completely.

 Fix dressing in place with adhesive tape or bandages.

 Leave patient comfortable and tidy.

Cleanse and return equipment to its proper places.

 Discard soiled dressings properly to prevent cross

infection in the ward.
04/01/2021 DT 68
 Suturing
Definition: The application of stitch on body
tissues with the surgical needle & thread.
Sutures are threads used to sew body tissue together
which can be absorbable (Chromic Cat gut) and non
absorbable (silk, clips ,wire nylon and etc. )
Purpose

 To approximate wound edges until healing occurs.

To speed up healing of wound.

To minimize the chance of infection.

For esthetic purpose

04/01/2021 DT 69
 Indication

Open intentional wound

unintentional wound

04/01/2021 DT 70
 Contraindication
1. Edema of the wound margins

2. Infection

3. Puncture(deep) wounds

4. Animal bites

5. Tendon, nerve, or vessel involvement

6. Wound more than 12 hours old .

However, such wounds have to be seen by a senior since excision of
all dead & devitalized tissue and eventually suturing may be required.

04/01/2021 DT 71
 Precautions
1. Check that the patient gets TAT before he leaves the hospital.
2. Do not suture puncture (deep) wound.
3. Before you suture any wounds make sure it is free of any
foreign body.
4. The completed knot must be tight, firm, and tied
5. To avoid wicking of bacteria, knot should not be placed in
incision lines
6. Knots should be small and the ends cut short (2-3mm)
7. Avoid using a jerking motion, which may break the suture
8. Do not tie suture too tightly as tissue ischemia may occur.

04/01/2021 DT 72
 Primary closure
Primary closure is effective in wounds presenting
within 6-8 hours & should accurately be debrided.

This is usual in civilian practice/set up.

Delayed primary closure.

Is done for traumatic or contaminated wounds

It is done to avoid the risk of wound sepsis.

 It is done within 3 days of initial treatment.

04/01/2021 DT 73
 SECONDARY CLOSURE

This is usually done in 3-7 days of initial treatment.

It is effected in contaminated or traumatic wounds.

It provides a reliable drainage.

It provides opportunity for repeated inspection

It provides chance for debridement as necessary.

04/01/2021 DT 74
Uses of different sizes of sutures

04/01/2021 DT 75
Technique for interrupted sutures

04/01/2021 DT 76
Technique for simple continuos sutures

04/01/2021 DT 77
Suture sizes and suggested indications for their use
 Wound suturing Equipment
Sterile field set
1. Tray or trolley covered with a sterile towel
2. Sterile needle holder
3. Sterile suture scissors
4. Sterile round needle (2)
5. Sterile cutting needle (2)
6. Sterile hole towel (fenestrated towel)
7. Sterile kidney dish(2)

04/01/2021 DT 79
Wound suturing Equipment cont’d
8. Sterile needle and syringe
9. Sterile gloves
10. Sterile tissue forceps(2)
11. Sterile cotton swabs in gallipots
12. Sterile gauze
13. Sterile artery forceps(3)
14. Sterile needle holder (2)

04/01/2021 DT 80
 Clean tray

1. Silk and catgut

2. Antiseptic solution with its container

3. Adhesive plaster

4. Local anesthesia

5. Light bulb

04/01/2021 DT 81
 Procedure
Check the order for suturing
Great the patient, introduce yourself and explain the
purpose of the procedure to the patient.
Adjust light
Wash your hands
Clean trolley or tray, assemble sterile equipment on one
side & clean items on the other side and make sure that the
sterile equipments are properly covered.
Clean the wound thoroughly
Wash your hands again
Put on sterile gloves , skin test with TAT & administer TAT

04/01/2021 DT 82
 Procedure-----
Drape the Wound with the hole- sheet

Infiltrate the edges of the wound to be sutured with

local anesthesia.

Approximate the edges of the fascia with the help of

the tissue forceps/pinset.

Using pinset forceps, round needle and cat- gut,

Suture the inner layer first.

04/01/2021 DT 83
 Procedure-----
Using the cutting needle and silk: suture the skin.

Approximating the edges with the help of the tissue forceps.

 Clean with iodine and cover with sterile gauze.

Remove the hole- Sheet.

 Make patient comfortable.

Remove all equipment, wash & return to its proper place or

send for sterilization.

 Wash your hands

Record the state of the wound.

04/01/2021 DT 84
Note:

Do not suture wounds that are over 12 hrs old.

How ever,such wounds have to be seen by a senior since

excision of all dead & devitalized tissue and eventual
suturing may be required.

Do not suture deep wound.

 Before you suture any wound , make sure it is free of any

foreign bodies.

04/01/2021 DT 85
 The Stitch Removal
Technique: Use aseptic technique

Principles:

Sutures may be removed all at a time or may be removed

alternatively.

Do not cut stitches in more than one place as a part of it maybe
left behind and may cause infection.

Suture is lifted slightly by the knot to allow scissors to go under

and one part of the suturing from the cleanest part of the wound to
the most contaminated part.
04/01/2021 DT 86
 Stitch removal-----
Cleanse the skin around with antiseptic solution .

Place sterile gauze to receive stitches.

Take a pair of scissors in the right hand.

Take a dissecting forceps in the left hand.

Pull-up gently the knot resting against the skin with the
forceps, pass the point of the scissors under the knot then
cut the stitch on one side and remove.

04/01/2021 DT 87
 Stitch removal-----
Receive pieces of stitches on a sterile gauze.

Inspect the scar for wound healing and apply iodine on

the skin punctures if patient is not sensitive to iodine.

Apply dressing.

 Keep patient comfortable and tidy

 Record the state of the wound

Clean and return equipment to their proper places.

04/01/2021 DT 88
Removal of suture

 Face 3-5 days

 Scalp 7-10 days

 Lip 3-5 days

 Chest 10-14 days

 Oral cavity 6-8 days

 Abdomen 10-14 days

 Neck 5-6 days

 Leg 10-14

days

04/01/2021 DT 89
DT 04/01/2021 90
DT 04/01/2021 91