Moch.

Junaidy Heriyanto
Wounds (vulnus) are a bodily injury caused by
physical means, with disruption of the normal
continuity of structures.
ACUTE: Heals in approximately 2
weeks to 6 months

CHRONIC: Takes 6 months or more

 All chronic wounds begin as acute wounds
but fail to progress through the normal
healing process and become locked in an
extended inflamatory phase.
 Common chronic wounds include :
 The diabetic foot ulcer,
 pressure ulcer
 venous static ulcer
 burn
 Clinical Presence of necrotic and unhealthy
tissue
 Lack of adequate blood supply
 Absence of healthy granulation tissue
 Lack of reepithelization
 Recurrent wound breakdown due to
superficial bridging (as seen in chronic
pilonidal sinus wound)
 Borders of a wound
 Walls of a wound
 Bottom of a wound
 Wound contents (blood,
urine, bile, intestinal
contents, foreign bodies)
Neuropathic ulcer:
• Foot pulses present +
Neuropathy (Filament or
Vibration)
Neuro-ischemic ulcer :
• Toe pressure 40-70 mmHG or
ABI<0.9 +Neuropathy
Ischemic ulcer
• Toe pressure <40 mm Hg and/or
ankle pressure < 75 mmHg
 A bed sore, a skin ulcer that comes from lying in
one position too long so that the circulation in
the skin is compromised by the pressure,
particularly over a bony prominence such as the
sacrum (sacral decubitus).

 The Latin "decubitus" (meaning lying down) is

related to "cubitum" (the elbow) reflecting the
fact the Romans habitually rested on their
elbows when they reclined.

9
 Stage 1.
Skin intact, persistent skin erythema.

Stage 2.
Skin breakdown & ulceration of subcutaneous
fat.

Stage 3.
Sores have ulceration to the level of muscle.

Stage 4.
Involvement of bone or join
Removal debris

Control of infection

Clearance of inflammation

Angiogenesis

Deposition of granulation tissue

Contraction

Remodelling of connective tissue matrix

Maturation
 No foreign
bodies
Free from
Tissue is excessive
viable bact.
infection

Normal
healing
process
 • For example: venous
Therapy of underlying disease
insufficiency, DM

Elimination of extrinsic
factors that trigger injury
• For example: Nutrition, pressure

Create physiological
wound healing conditions
• For example: moist wound healing

Next treatment program • Protection of new skin that is still fragile

Bottom wound
Edge of wound
The skin around the
wound (border)
Exudate (contain)
 Debridement:
 removes necrotic tissue or foreign matter in the
wound area

 Parts involved:
 skin, fascia, muscles, or other tissues
1.Surgical/sharp

2.Mechanical

3.Autolytic

4.Enzymatic

5.Biological
1. Use a scalpel, scissors, forceps, or curette
2. Very selective and fast
3. Only allowed by experienced doctors (skill
and knowledge)
4. Bedside can be done
5. Sometimes it requires an operating room
and GA for further procedures
6. It is recommended to control severe
infections
Contraindications:
 Injury to malignancy
 Patients with bleeding disorders
 Ischemic tissue
 Unstable
 Underneath there is a dialysis fistula,
protesis, or arterial bypass graft
 Attention to hand and face area wounds
 Attention to immunocompromised patients
1. Wet-to-dry: moist dressing is placed on the
wound  let it dry  released
› Big wound
› Nonselective
› Very painful
› Change dressings often
› Maseration and Bleeding
› Fiber dressing  puncture the wound  reaction
› Spread of bacteria when opened

Contraindication: clean wound

2. Hydrotherapy and wound irrigation
 Improve circulation
 Can cause maceration around the wound
 Long time
 Can cause trauma to the wound bed
 Contamination of the wound and the
environment
Contraindications:
 Clean wounds
 diabetic neuropathy
3. Pulsed lavage: combination of irrigation with
suction:
For Bed-bound patients

Contraindications:
Clean wounds
Using hydrocolloids and hydrogels
Rehydration of necrotic cells and remove
damaged tissue using body enzymes (present
in infected wounds).
Consideration:
 Long time
 For small to moderate debridement
 Patients have a minimal risk of infection
 Can be done anywhere
 Can be combined with other methods
 Selective
 Safe, easy to use
 No pain when dressing
 Slow
 Risk of maceration
 Removal of dressings is often painful
 Smells
 Some require secondary dressing in addition
to primary dressings
 Absorptive dressings cause dehydration of
the wound
Contraindications:
 Some dressings cannot be used for infection
wounds
 The tendons and bones are exposed
 Friable skin
 Deep wounds
 Severe neutropenia
 Immunocompromised patients
 Use streptokinase or streptodornase or bacterial-
derived collagenases.
 Streptokinase and streptodornase break down
and rehidrate necrotic tissue
Consideration:
 Patient with anticoagulant therapy
 Can be used for infection wounds
 Cost effective
 Use bedside
 Can be selective
 Inflammation around the wound in several enzymes

Contraindications:
 Clean wounds
 Allergy components of the enzyme
 = maggot therapy
 Larva Lucilia sericata (greenbottle fly) eat
necrotic tissue and pathogens.
 This technique is fast and selective
Consideration:
 Psychological stress
 Allergic reactions
 Time consuming
 Selective and less painful
 Expensive
 Decreased number of bacteria
 Bedside use
 Can be used for various types of wounds, including
infection wounds
Contraindications:
 Allergy to adhesives, fly larvae, eggs, and
soybeans
 Bleeding disorders
 Deep and tunneled wounds
 Adequate humidity level
 Normal temperature
 PH
 ulcers and open sores media for bacterial
growth
 necrotic tissue:
Excessive inflammatory response  wound
contractions are disturbed  Inhibiting wound
closurea
 21 oC  
tissue temperature at open wound
 25-27 oC 
tissue temperature when covered with
gauze
 33-35 oC 
tissue temperature when covered with
foam
Winter GD, Scales JT. Effect of airdrying and dressings on the surface of a wound. Nature 1963; 197:91.
Ovington, LG. Hanging wet-to-dry dressing out to dry. Advances in Skin and Wound Care 2002; 15(2): 79-84
 local vasoconstriction
 impaired leucocyte mobility
 increased oxygen-Hb affinity
 increased susceptibility to infection
 Prevent and overcome infections
 Clean the wound
 Lift dead tissue
 Maintain moisture
 Eliminates dead spacce
 Control odor
 Eliminate / minimize pain
 Protecting the skin around the wound
 Polyurethane
 Absorben dressing
 Moderate-heavy
exudate
 karboksimetilselulose
 Adhesif, elastomer,
gelling agent, oklusif
 Primer/skunder
dressing
 Reddish wounds/
exudative are minimal
 Absorben
 Moderate-heavy
exudate
 Retaining fluid inside
 Requires secondary
dressing
 Made from glycerin /
water
 Provide moisture
 Requires secondary
dressing
 For dry / necrotic
wounds (autolysis)
 Polyurethane film
 Semi-occlusive,
adhesive, non
absorbent
 Superficial wound, non
exudative
 Infection wound
 Silver
 Cadexomer iodine
 Non woven
 Net
 Acute wound
 Short term
 contain vaselin and
antibiotic/antiseptic
 Absorbent dressing
 Stick to wound surface
 Trauma during
removal
 Non-selective
 Osmotic effect
 Easily becomes dry
 Local tissue cooling
 Wet  absorb
 Dry  moist
 Hollow/dead space filled in
 Dirt  clean
 Multidisciplinary approach for wound
treatment, will give benefit for our patient
 Multidisciplinary approach for wound
treatment,need a strategic planning
 Multidisciplinary approach for wound
treatment,must have a good coordination
 Always tie pain medication to function!
 Safety first!
Yogyakarta, 15 Desember 2018