Wound Care

Wound – an abnormal break in the skin tissues of the skin or in the underlying surface. Include
cuts, scrapes, scratches, and punctured skin. They often happen because of an accident, but
surgery, sutures, and stitches also cause wounds.
Classification of wound
1. Open wound
 Skin is split, cut or cracked open in some way. Leaves underlying tissues and
sometimes bone and muscle exposed to the air, as well as to dirt and bacteria.
2. Closed wound
 Skin is not broken. Includes simple injuries like basic bruises, where you bump
into something and later experience redness, bleeding and/or discoloration
underneath the surface of the skin at the site.
 More serious closed wounds take place when someone is violently hit by an
object. A direct blow can cause more severe internal bleeding, tissue damage
and even muscle damage.
Types of Wound
 Incised wound
– clean cut wound result from a surgical procedures or from the skin being cut with a
sharp object like a scalpel, knife or scissors.
 Laceration
– is a deep cut or tearing of your skin. Accidents with knives, tools, and machinery are
frequent causes of lacerations. In the case of deep lacerations, bleeding can be rapid
and extensive.
 Abrasion
– occurs when your skin rubs or scrapes against a rough or hard surface. Road rash is
an example of an abrasion. There’s usually not a lot of bleeding, but the wound
needs to be scrubbed and cleaned to avoid infection.
 Contusion/Bruise
– a blunt blow or punch that rupture capillaries beneath the skin.
 Puncture
– a wound with small entry site but a deep track of internal damage usually round
caused by long, pointy object, such as a nail or needle.
   Penetration
– an object or force breaks through the skin and damages underlying tissue, muscle or
organs. Have different sizes, shapes and levels of severity depending on the cause,
and can be life-threatening.
  Avulsion
– is a partial or complete tearing away of skin and the tissue beneath. Usually occur
during violent accidents, such as body-crushing accidents and explosions. They bleed
heavily and rapidly.
 Bed sores, pressure sores or decubitus ulcers
– are caused by pressure and/or shearing force on the skin. These generally occur in
people who have limited mobility due to illness and/or frailty and are unable to
regularly move part or all of their body to a different position.  The skin on the points
of the body with the greatest pressure breaks down and the resultant wounds range
from small superficial wounds to large deep wounds the depth of which may extend
down to bone.
First Aid for Minor Wounds
1. Stop Bleeding

 Wash hands.

 Apply direct pressure on the cut or wound with a clean cloth, tissue, or piece of gauze
until bleeding stops.

 If blood soaks through the material, don’t remove it. Put more cloth or gauze on top of
it and continue to apply pressure.

 If the wound is on the arm or leg, raise limb above the heart, if possible, to help slow
bleeding.

 Wash your hands again after giving first aid and before cleaning and dressing the
wound.

 Do not apply a tourniquet unless the bleeding is severe and not stopped with direct
pressure.
2. Clean Cut or Wound

 Gently clean with soap and warm water. Try to rinse soap out of wound to prevent
irritation.

 Don’t use hydrogen peroxide or iodine, which can damage tissue.

3. Protect the Wound

 Apply antibiotic cream to reduce risk of infection and cover with a sterile bandage.

 Change the bandage daily to keep the wound clean and dry.
4. When to Call a Doctor

 The wound is deep or the edges are jagged or gaping open.

 The wound is on the person’s face.

 The wound has dirt or debris that won’t come out.

 The wound shows signs of infection, such as redness, tenderness, or a thick discharge,
or if the person runs a fever.

 The area around the wound feels numb.

 Red streaks form around the wound.

 The wound is a result of an animal or human bite.

 The person has a puncture wound or deep cut and hasn’t had a tetanus shot in the past
five years, or anyone who hasn’t had a tetanus shot in the past 10 years.
Stages of wound healing
The stages include:

 preventing too much blood loss

 defending and cleaning the area

 repairing and healing

Keeping the wound clean and covered can help your body repair the area.
Stage 1: Stop the bleeding (hemostasis)
 When you get a cut, scratch, or other wound in your skin, it usually starts bleeding. The
first stage of wound healing is to stop the bleeding.
 Blood begins to clot seconds to minutes after you get a wound. This is the good kind
of blood clot that helps to prevent too much blood loss. Clotting also helps to close and
heal the wound, making a scab.
Stage 2: Scabbing over (clotting)
Clotting and scabbing phase has three main steps:
1. Blood vessels around the wound narrow. This helps to stop the bleeding.
2. Platelets, which are the clotting cells in blood, clump together to make a “plug” in the
wound.
3. Clotting or coagulation includes a protein called fibrin. It’s “blood glue” that makes a net
to hold the platelet plug in place. Your wound now has a scab over it.
 4. Inflammation, which involves cleaning and healing
 Once your wound isn’t bleeding any more, the body can begin cleaning and healing it.
 First, the blood vessels around the wound open a bit to allow more blood flow to it.
 This might make the area look inflamed, or a little red and swollen. It might feel a bit
warm too. Don’t worry. This means help has arrived.
 Fresh blood brings more oxygen and nutrients to the wound — just the right balance to
help it heal. White blood cells, called macrophages, arrive on the scene of the wound.
 Macrophages help clean the wound by fighting any infection. They also send out
chemical messengers called growth factors that help repair the area.
 You might see clear fluid in or around the wound. This means white blood cells are at
work defending and rebuilding.
Stage 3: Rebuilding (growth and proliferative)
 Once the wound is clean and stable, your body can begin rebuilding the site. Oxygen-
rich red blood cells come to the site to create new tissue. It’s like a construction site,
except your body makes its own building materials.
 Chemical signals in the body tell cells around the wound to make elastic tissues called
collagen. This helps to repair the skin and tissues in the wound. Collagen is like a scaffold
that other cells can be built on.
 At this stage in healing, you might see a fresh, raised, red scar. The scar will slowly fade
in color and look flatter.
Stage 4: Maturation (strengthening)
 Even after your wound looks closed and repaired, it’s still healing. It might look pink and
stretched or puckered. You may feel itching or tightness over the area. Your body
continues to repair and strengthen the area.
Signs of infection
A wound may heal slowly if it’s infected. This is because your body is busy cleaning and
protecting the wound, and can’t get to the rebuilding stage properly.
An infection happens when bacteria, fungi, and other germs get into the wound before it fully
heals. Signs of an infection include:

 slow healing or doesn’t seem to be healing at all

 swelling

 redness

 pain or tenderness

 hot or warm to touch

  oozing pus or liquid
Treatment for an infected wound includes:

 cleaning the wound

 removing dead or damaged tissue around the wound

 antibiotic medications

 antibiotic skin ointments for the wound

Wound Care
Assessment
Assess for:
 level of comfort
 external appearance of the dressing
 appearance of the wound and drains
 understanding about change dressing and wound care
 healing response to previous treatments
 risk of delayed or poor wound healing
 need for pain medication
Nursing Diagnosis
 impaired skin integrity
 impaired tissue integrity
 risk for infection
Planning/Expected outcome
1. The site will be inspected.
2. The site will have the appropriate dressing applied.
3. The client/family member will be able to verbalize understanding and demonstrate
wound dressing change and wound care.
Implementation
1. Wash hands.
2. Prepare needed equipment and bring it to the bed side.
3. Introduce yourself, explain the procedure to the patient and verify the name of the
patient.
4. Provide privacy.
5. Put on clean gloves.
 6. Slowly remove the dressing (if the dressing is dry pour a small amount of normal saline
solution for it to loosen).
7. Observe the wound for healing, signs of infection and drainage.
8. Clean the skin around the wound if necessary.
9. Remove gloves, wash hands and set up the sterile pack.
10. Put on sterile gloves.
11. Using a working forceps clean the wound with betadine solution in a circular motion
from center to outer.
12. Apply sterile dressing/gauze and secure it with a plaster.
13. Remove gloves and wash hands.
14. Conduct client/family health teaching about wound care.
Evaluation
1. The site was inspected.
2. The site had the appropriate dressing applied.
3. The client/family member was able to verbalized understanding and demonstrated
wound dressing change and wound care.