Skin integrity and wound healing

Definition
Wound is an injury to body that dis-integrate the skin and the
rest tissue
Wound is a disruption in the integrity of body tissue which may be intentional or
unintentional

1 Cause
A. Intentional wound :- involves surgical procedure
– Usually done under aseptic technique w/c minimize infection
– Wound edges usually smooth & clean
B . Un intentional wound :- Traumatic injury
– It create risk of infection
2. Based on integrity of skin

1. OPEN WOUND - a wound characterized by a

break in continuity of skin & tissues
The cause of open wound is the external
physical force that have tendency to cut the skin
E.g. incision wound
2. CLOSED WOUND - a wound that occurs with
out skin opening. E.g. contusion or bruised
wound
3. Based on appearance of wound open wound can be
A. Abrasion - a wound with only the outer protective tissue (skin) is injured
- Bleeding is limited
- Danger of infection exist but minimum
B. Incision/cut/ wound - occur when body is injured with sharp objects
- Bleeding is heavy and rapid
- If deep enough can cause internal organ damage
- The danger for infection is existing
C. Laceration wound - wound with irregular or blunt breaking or tearing of
the soft tissue
- It occurs when great force is exerted against the body
- Bleeding may be rapid & extensive
- Because of high disruption of tissue there is greater chance for
latter infection
D. Puncture wound - the act of piercing or penetration with pointed objects
- Create small whole on the skin but there may be greater internal organ damage

- External bleeding is limited ,so that , the skin of internal infection is increase
- Tetanus & gas gangrene may develop
E Amputation wound - complete cut of the part
= High risk of infection
= Severe bleeding
= Needs immediate referral & treatment Eg. leg cut at knee by blast injury
F Avulsion - occurs when there is cut/tearing away from the structure
- There may be formation of both incision and laceration wound at the same time
- It is occurred when there is:-Animal bite
-motor vehicle injury
Risk of infection is high
-bleeding is high
 Wound classified According to bacterial
invasion
• Septic wound ( Infected wound ) – contain
bacteria
• Aseptic wound ( clean wound )
– not contain pathogenic microbes
• Surgical wound based on presumed magnitude of
bacterial load at the time of surgery
1, clean wound -
2, clean contaminated wound ,wound at GI, RT,
GUS with out significant spillage of contents.
3, contaminated wound –accidental wound
extensive introduction of bacteria in to normal
sterile area and gross spillage of contents
4, dirty wound – traumatic wound in which
significant delay over in treatment over infection
evidenced by presence of purulent puse
 PHASE OF WOUND HEALING.
• Wound healing generally divided into 3 phase.
1 inflammatory phase:
- begin at the time of injury with formation of blood
clot.
- the migration of phagocytic WBC into the wound
site.
- Neutrophil arrive at the site ,ingest and remove
bacteria and cellular derbies
- Macrophages continue to ingest cellular derbies
and play essential role in production of growth
factor
 Con…
• 2. proliferative phase :
- process building of new tissue to fill the wound
space
- the key cell during this phase is fibroblast that
produce family of growth factors ,angiogenesis,
endothelia cell proliferation, connective tissue(
secret collagen ,glycoprotien).
-the final component of the proliferative phase is
epithelialization to form new surface layer that is
similar to previous
 Con…
• 3. Remodeling phase:
- begin 3 weeks after injury with the
development of fibrous scar
- there is decrease in vascularity and
continued remodeling of scar tissue with
simultaneous synthesis of collagen by
fibroblast and lysis by collagenase enzymes
 Factor influence wound healing
1. Age
- risk & infection
- Slow in cell growth
- Slow in blood supply
- Slow in clotting process
2. Nutrition
- helps for tissue repair
- helps for resistance
3. Extent & wound
4. Smoking
- decrease level & functional hemoglobin
5. Immunity
- ed immunity lead to poor haling process
- chronic illness, eg, DM
- Immuno suppressant drug lead to poor healing
6. Wound stress
 Complication & wound
• hemorrhage – bleeding from the site
• Infection
• fistulas = an opening b/n two organs
• Evisceration = protruding of the visceral organ
• Dehiscence = is the partial or total separation
of the layers of the skin & tissue in properly
healing wound
 Nursing responsibility
– P/Exam of the wound
– Inspection
• Promoting Assessment
– note on the drainage
– amount
– color
– odor
– consistency
• The drainage varies from
– Serous – clear, water plasma
– Sanguineous – fresh bleeding
– Sero sanguineous – pale more watery ( plasma red cell )
– Purulent – thick, yellow
- green or brown
- ( dead, living bacteria & WBC
 TASK-1 DRESSING OF A WOUND
Purpose = to keep wound clean
= to prevent the wound from injury and
contamination
= to keep in position drugs applied locally
= to keep edges of the wound together by
immobilization
= to apply pressure
= to promote healing
= to absorb discharge from the wound
• Principles of wound dressing
• If big ward give priority for clean wound
• Not pack too tightly and loosely
• Be sure the wound is completely covered
• Avoid skin irritation and excoriation
• If not have sterile forceps use sterile glove
• Immerse used instrument on disinfection