Kurdistan Regional Government

Ministry of Higher Education and Scientific Research

Kalar Technical Instate
Medical Lab Technology Department

Wound

Prepared by: Supervised by:

Iman Salh Husain Nihad Abas

(2019-2020)
 Introduction
A wound is an interruption to skin integrity caused by physical trauma or
disease. Everybody experiences wounds and most wounds heal uneventfully;
however, a significant minority of people have wounds that are very slow to heal
or which do not heal at all. These more complex wounds, which are mainly
managed by community nurses, were the focus of this programme of research.

The most common types of the chronic wound are leg ulcers (mainly caused
by venous and/or arterial disease), pressure ulcers (caused by unrelieved pressure
as a result of immobility) and diabetic foot ulcers (caused by vascular and
neurological complications of diabetes).

Less common chronic wounds include surgical wounds that have broken
down. The term ‘chronic wound’ implies a wound of long duration; however, from
a clinical perspective, it is often clear that a wound is complex and likely to be
longstanding at a fairly early stage. [1]

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 Wound Tissue Types
Wounds can be open or closed. Open wounds have exposed body tissue in the base
of the wound. Closed wounds have damage that occurs without exposing the
underlying body tissue. Wounds can originate from external causes such as
penetrating objects or blunt trauma, or internal causes such as immune, metabolic,
and neurologic etiologies. [2]

Open Wound Types

Penetrating wounds:
 Puncture wounds: caused by an object that punctures and penetrates the
skin (e.g. knife, splinter, needle, nail)
 Surgical wounds and Incisions: wounds caused by clean, sharp objects
such as a knife, razor, or piece of sharp glass
 Thermal, chemical, or electrical burns
 Bites and stings
 Gunshot wounds or other high velocity projectile which penetrates the
body (this may have one wound at site of entry and another at site of exit)

Blunt trauma wounds:

 Abrasions: superficial wounds due to the top layer of skin being
traumatically removed (e.g. fall or slide on a rough surface).
 Lacerations: wounds that are linear and regular in shape from sharp cuts,
to irregularly shaped tears from trauma.
 Skin tears: can be chronic like a wound in the base of a skin fissure, or
acute due to trauma and friction. [2]

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 Closed Wound Types
 Contusions: blunt trauma causing pressure damage to the skin and / or
underlying tissues (includes bruises)
 Blisters: fluid filled pockets under the skin
 Seroma: a fluid filled area that develops under the skin or body tissue
(commonly occur after blunt trauma or surgery)
 Hematoma: a blood filled area that develops under the skin or body
tissue (occur due to internal blood vessel damage to an artery or vein)
 Crush injuries: can be caused by extreme forces, or lesser forces over a
long period of time. [2]
Ulcers
Ulcers are lesions that wear down the skin or mucous membrane that can have
various causes depending on their location. Ulcers are a gradual disturbance of
tissues by an internal cause in that originate from an impaired immune system or
nervous system. Cells require blood, oxygen, and nutrients and anything that
reduces the supply of these requirements can lead to ulcer formation. The most
common types of internally originating skin ulcers are diabetic foot ulcers, venous
leg ulcers, and pressure ulcers.  

Skin ulcer types:

 Pressure ulcer: injury that causes breakdown of the skin and often the

underlying tissue as well. Pressure ulcers can range in severity from
discolored skin areas to large open wounds that expose the underlying
bone or muscle.
 Diabetic Foot Ulcer (DFU): a major complication of diabetes that
occurs when neuropathic (nerve) and vascular (blood vessel)
complications of the disease cause altered or complete loss of feeling in
the foot and/or leg. Pressure from shoes, cuts or any injury to the foot
may go unnoticed causing a DFU.

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  Venous ulcer (VLU): an open sore that develops when the skin is broken
and air or bacteria gets into the underlying tissues. VLUs are caused by
venous disease; a disease of the veins of the leg. 
 Ulcerative dermatitis: an ulcer due to a dermatological condition
 Genital ulcer: painful, non-sexually acquired genital ulceration.  [2]

Signs of Wound Infection

Wounds are not sterile and all open wounds have a certain amount of bacteria, but
this does not mean the wound is infected. Normal healing can still occur. An
infection occurs when the bacterial growth increases significantly. Call your doctor
or nurse if you have signs of an infection. [2]

Classic Signs of Infection

 Increased pain around the wound bed
 Redness or warmth
 Fever /chills or other flu-like symptoms
 Pus draining from the wound bed
 Increasing odor from the wound
 Increased firmness of skin or swelling around the wound bed [2]

Secondary Signs of Infection

Not all infections start with the classic signs of infection. There are secondary
signs and symptoms that signal a lower grade infection in the wound bed, which
delays healing and may progress if untreated1. 
 Increasing drainage from the wound bed
 Delayed wound healing
 Discoloration of the wound bed with it turning darker in color

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 Foul odor
 Increased fragility of the wound bed
 Wound breakdown /enlargement [2]

Wound Management
Guidelines for wound management: 

1. Promote a multidisciplinary approach to care.

2. Initial patient and wound assessment is important and whenever there is a
change in condition.
3. Consider the psychological implications of a wound- especially relevant
in the paediatric setting in relation to developmental understanding and
pain associated with the wound and dressing changes.
4. Determine the goal of care and expected outcomes.
5. Respect the fragile wound environment.
6. Maintain bacterial balance- use aseptic technique when performing
wound procedures.
7. Maintain a moist wound environment
8. Maintain a stable wound temperature. Avoid cold solutions or wound
exposure.
9. Maintain an acidic or neutral pH.
10.Allow a heavily draining wound to drain freely.
11.Eliminate dead space but don’t pack a wound tightly.
12.Select appropriate dressings and techniques based on assessment and
scientific evidence.
13.Instigate appropriate adjunctive wound therapies- e.g. compression,
splinting and pressure redistribution equipment, off-loading orthotics.
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 14.Follow the principles for managing acute and chronic wounds. [3]

Acute Wound Management

Wound cleansing
The goal of wound cleansing is to:

 Remove visible debris and devitalised tissue

 Remove dressing residue
 Remove excessive or dry crusting exudates
 Reduce contamination  [3]

Principles of wound cleansing:

 Use Aseptic Technique procedure- a non-touch technique is used to

protect key parts and key sites. If a key part or key site is to be touched
directly then sterile gloves must be worn. Note: when using a disinfectant
on a key site (e.g. skin) or key part (e.g. injection port) it must be allowed
to dry. 
 Cleansing should be performed in a way that minimises trauma to the
wound as new epithelial cells and vessels are fragile.
 Irrigation is the preferred method for cleansing open wounds. This may
be carried out utilising a syringe in order to produce gentle pressure and
loosen debris. Gauze swabs and cotton wool should be used with caution.
 Wounds are best cleansed with sterile isotonic saline or water, warmed to
body temperature. [3]

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Choice of dressing
A wound will require different management and treatment at various stages of
healing. No dressing is suitable for all wounds; therefore frequent assessment of
the wound is required. 

Wound healing progresses most rapidly in an environment that is clean, moist (but
not wet), protected from heat loss, trauma and bacterial invasion.

 Much research has demonstrated that moisture control is a critical aspect of

wound care.
 The appropriate dressing can have a significant effect on the rate and quality
of healing.
 The appropriate dressing will help to minimize bacterial contamination and
pain associated with wound care.

There are a multitude of dressings available to select from. Effective dressing

selection requires both accurate wound assessment and current knowledge of
available dressings. [3]

Wounds healing by Primary Intention

These wounds require little intervention other than protection and observation for
complications.
Recommended dressings include:

 Dry non-adherants
 Island dressings
 Semi-permeable films
 Hydrocolloids
 Foams [3]

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Wounds healing by secondary intention
Acute surgical or traumatic wounds may be allowed to heal by secondary
intention- for example a sinus, drained abscess, wound dehiscence, skin tear or
superficial laceration.
Dressing selection should be based on specific wound characteristics. Referral to
Stomal Therapy should be considered to promote optimal wound healing. [3]

Chronic wound management

Determine the aetiology for inhibition of wound healing. Address or control the
factors identified for example: presence of infection, poor nutritional status,
appropriate dressing selection, moist wound environment. 

Dressing selection should be based on the specific wound characteristics and

referral to Stomal Therapy should be initiated to promote optimal wound healing.
Advanced wound therapies may be required to be utilitised e.g surgical
debridement, application of a negative pressure dressing, hyperbaric therapy. [3]

Ongoing Management
Medical teams managing patients may request specific wound care and follow up
to occur at RCH via Specialist Clinics- this may also include Nurse Led Clinics or
patients may be referred to their local GP for wound follow up. [3]

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 Wound Dressing
Dressing Surgical Wounds
Most surgery can be categorised into two groups: elective ('clean') and emergency
(this is often referred to as 'dirty'). A surgical wound of the latter category has a
higher incidence of dehiscence or complications.

There are a number of well-identified risk factors that can lead to wound
dehiscence, including being overweight, increasing/advanced age, poor nutrition,
diabetes, smoking and having had radiation therapy previously in the area.

The elective case has the opportunity to correct some of these risk factors, however
the emergency case may not have such an opportunity. [4]

Suture Line
The simple, straightforward suture line is generally treated with a dressing that will
manage a small amount of anticipated, early inflammatory exudate and provide a
waterproof covering.

All surgical wounds do require support and this is an important factor both for
reducing oedema and ensuring patient comfort.

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This type of dressing is generally left intact for five to seven days and then
removed for inspection of the suture line, with the view to remove the staples or
sutures as prescribed.

Suggested dressings to achieve the aims for simple suture lines

include: Opsite™ and Mepore Pro™.

Care of this simple suture line then involves continued support and hydration. For
this, some surgeons prefer supportive adhesive flexible tape for ongoing scar
hydration, such as Fixomull™ and Mefix™.

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 Dehisced Surgical Wound

The dehisced surgical wound requires a thorough assessment of cavities or

structures involved, as well as presence of foreign bodies, infection and/or necrotic
tissue. Once these parameters have been considered, an aim can be set.

Removal of necrotic tissue and management of infection is paramount to move on

to the wound healing phase.

Surgical debridement may leave large cavities or areas of raw tissue which can
ideally be managed with a Topical Negative Pressure Device. This wound care
‘vacuum cleaner’ will remove excess exudate and contain it in a canister, away
from the wound surface.

Due to the negative pressure, the wound edges are drawn in, helping to promptly
reduce wound surface. This also reduces oedema, an important aspect to consider
in all instances of wound care. [4]

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 Dressing Abrasions
These wounds are generally acute and in most circumstances go on to heal almost
regardless of what is done. Simple abrasions in particular, if not managed by a
health professional, form a scab which eventually will drop off, revealing a healed
area beneath.

The issue here however, is that this type of healing is slow and can result in an
unacceptable scar.

The best management of an abrasion is to stop the bleeding, give the area a good
clean with an antiseptic and then apply a mesh dressing that will protect the
superficial raw area and allow new tissue to form quickly without being damaged
when the first dressing is attended. Mesh dressings for this purpose
include: Mepitel™, Urgotul™, or Hydrotul™.

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The secondary dressing on this mesh is generally a light absorbent adhesive pad,
such as Cutiplast Steril™ or Primapore™.

A secondary waterproof dressing is generally not recommended for this first

dressing due to the risk of infection – the excessive heat and moisture will create
an environment conducive to bacterial growth.

At the next dressing change, if there are no signs of infection, then a waterproof
dressing can be used as the secondary dressing, provided all environmental
considerations have been made. [4]

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 Dressing Lacerations

Simple Lacerations
After a thorough assessment, a small, simple laceration is generally managed with
antiseptic cleansing, Steri-Strips™ and either a waterproof, light, absorbent
dressing or a non-waterproof, light, absorbent, adhesive dressing, using the
principles mentioned earlier about risk of infection. [4]

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Complex Lacerations
More complex lacerations may be referred to an acute care facility or surgeon after
initial assessment.

Foreign bodies and penetrating, deep lacerations may involve tendons and nerves,
which will require specific specialised care.

The post-surgical wound will then need to be well managed to avoid infection. An
antimicrobial dressing that is also absorbent and protective would be ideal.

Dressing examples include: Aquacel Ag™ and Aquacel Foam™ non

adhesive, Acticoat Flex™ and Mesorb™, Atrauman Ag™, and Zetuvit™.

The dressings should be fixed in place with a firm crepe bandage and
appropriately-sized tubigrip. [4]

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 Specific Wound Healing Complications and Interventions
Infection
The most common cause of delayed healing in chronic wounds is infection.
Microbial contamination of wounds can progress to colonization, to localized
infection, through to systemic infection, sepsis, multi-organ dysfunction, and
subsequent life- and limb-threatening infection. The actual determination of
infection can be complicated by the presence of biofilms, not on the surface but
deep in wound tissue. [5]

Osteomyelitis
Infection in chronic wounds can spread to surrounding tissues and to underlying
bone. In patients with diabetes-related foot ulcers, infection is among the most
common reasons for hospitalization. Of those patients with diabetic foot ulcers,
20% to 60% will develop osteomyelitis, thus increasing the risk of lower extremity
amputation. [5]

Tissue Necrosis and Gangrene

Peripheral vascular disease, or PVD, is a condition caused by atherosclerosis
affecting the arteries of the extremities that leads to decreased blood supply and
arterial occlusion. This may begin as pain in the legs with walking, referred to as
intermittent claudication, and it may continue until there is occlusion of the blood
vessels, ischemia, and pain at rest, ulceration, and gangrene. [5]

Periwound Dermatitis
Periwound moisture associated dermatitis is skin damage, which is also a form of
moisture-associated skin damage, or MASD. Periwound skin damage is described

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as pale or white skin that is wrinkled or "prune-like." This is called maceration, and
it is caused by the overhydration of the stratum corneum. [5]

Edema and Periwound Edema

Another complication that impairs wound healing is periwound edema. Edema can
slow healing, bring it to a standstill, or even cause wounds. It can cause stiffness
and pain, lead to issues with mobility, increase the risk of infection, decrease blood
flow, lead to decreased elasticity of blood vessels, cause ulcerations in the affected
skin and lead to breakdown of fragile periwound skin, and add tension on wound
edges that prevents wound closure. In a situation where pressure is the primary
issue, edema can cause compression of small vessels, thus further decreasing blood
flow and potentiating the development of a pressure ulcer or injury. Also,
increased moisture associated with edema can lead to maceration, which causes the
epidermal layers of the skin to break down, further affecting healing. [5]

Hematomas
Hematomas are not usually seen in chronic non-healing wounds, but the
development of a hematoma or a seroma at a surgical site is a common
phenomenon that can lead to infection and incisional dehiscence. The risk can be
reduced with meticulous hemostasis, and if small seromas or hematomas develop
they may be evacuated by gentle manipulation or aspiration without the need for
reoperation. This process may need to be repeated once or twice, but they usually
resolve without difficulty. In the case of larger hematomas, surgical evacuation and
drainage may be required. There is a belief among some surgeons that the risk of
seroma formation increases with the use of cautery during surgery, so it is
recommended to perform surgical dissection and instead reserve cautery use for
bleeding vessels. [5]

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Dehiscence

Improved perioperative care and surgical techniques, along with advanced wound
therapy technologies, have made achieving primary closure of surgical incisions,
flaps, and grafts easier. Also, the effective management of surgical incisions, donor
sites, flaps, and grafts is important to prevent potential complications such as
surgical-site infections and wound dehiscence. Many times, however, underlying
comorbidities combined with surgical-related factors make management of
surgical incisions and primary closure challenging because of the high risk of
complications. [5]

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 References
1. Wounds research for patient benefit by: Cullum N, Buckley H and
Dumville J 2016 Aug.
https://www.ncbi.nlm.nih.gov/books/NBK379919/#:~:text=A%20wound%20is%20an
%20interruption,do%20not%20heal%20at%20all.

2. Wound Types from JOBST USA

http://www.jobst-usa.com/healthy-living/wound-care/wound-types/

3. Wound Assessment and Management by Edwards H, Gibb M, Finlayson

K, Jensen R 2013.
https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Wound_assessment_and_m
anagement/

4. Wound Care by: Jan Rice November 2019.

https://www.ausmed.com/cpd/guides/wound-care

5. WoundSource Practice Accelerator's blog by WoundSource Practice

Accelerator March, 2018. https://www.woundsource.com/blog/complications-in-chronic-
wound-healing-and-associated-interventions

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