TYPES OF WOUNDS
It occurs commonly when a client assumes a sitting
• Clean wounds are uninfected wounds in which there is minimal
inflammation and the respiratory, gastrointestinal, genital, and urinary
tracts are not entered. Clean wounds are primarily closed wounds.
• Clean-contaminated wounds are surgical wounds in which the
respiratory, gastrointestinal, genital, or urinary tract has been entered.
Such wounds show no evidence of infection.
• Contaminated wounds include open, fresh, accidental wounds and
surgical wounds involving a major break in sterile technique or a
large amount of spillage from the gastrointestinal tract. Contaminated
wounds show evidence of inflammation.
• Dirty or infected wounds include wounds containing dead tissue
and wounds with evidence of a clinical infection, such as purulent
drainage.
Types of Wounds
Incision
● Sharp instrument (e.g., knife or scalpel)
● Open wound; deep or shallow; once the edges have
been sealed together as a part of treatment or healing,
the incision becomes a closed wound.
Contusion
● Blow from a blunt instrument
● Closed wound, skin appears ecchymotic (bruised)
because of damaged blood vessels.
Abrasion
● Surface scrape, either unintentional (e.g., scraped knee
from a fall) or intentional (e.g., dermal abrasion to remove
pockmarks)
● Open wound involving the skin
Puncture
● Penetration of the skin and often the underlying tissues
by a sharp instrument, either intentional or unintentional
● Open wound
Laceration
● Tissues torn apart, often from accidents (e.g., with
machinery)
● Open wound; edges are often jagged
Penetrating wound
● Penetration of the skin and the underlying tissues,
usually unintentional (e.g., from a bullet or metal
fragments)
● Open wound
PRESSURE ULCERS
Pressure ulcers consist of injury to the skin and/or underlying tissue,
usually over a bony prominence, as a result of force alone or in
combination with movement. Pressure ulcers were previously called
decubitus ulcers, pressure sores, or bedsores
● Pressure ulcers are due to localized ischemia, a
deficiency in the blood supply to the tissue.
● When pressure is relieved, the skin takes on a bright red flush,
called reactive hyperemia.
● The flush is due to vasodilation, a process in which extra blood
floods to the area to compensate for the preceding period of
impeded blood flow.
Risk Factors
FRICTION AND SHEARING
● Friction is a force acting parallel to the skin surface. For
example, sheets rubbing against skin create friction.
Friction can abrade the skin, that is, remove the
superficial layers, making it more prone to breakdown.
● Shearing force is a combination of friction and pressure.
position in bed.
IMMOBILITY
● Immobility refers to a reduction in the amount and control of
movement a person has.
FECAL AND URINARY INCONTINENCE
● Moisture from incontinence promotes skin maceration (tissue
softened by prolonged wetting or soaking) and makes the
epidermis
● Digestive enzymes in feces, urea in urine, and gastric tube
drainage also contribute to skin excoriation (area of loss of the
superficial layers of the skin; also known as denuded area)
Stages of Pressure Ulcers
1.) Stage 1- non-blanchable, erythema, skin is intact
2.) partial-thickness skin loss
3.) full-thickness skin loss, not involving underlying fascia
4.) full-thickness skin loss with extensive destruction
Unstagable- base of ulcer covered by slough or eschar in wound be
WOUND HEALING
● Healing is a quality of living tissue; it is also referred to as
regeneration (renewal) of tissues.
Types of Wound Healing
Primary intention healing occurs where the tissue surfaces have
been approximated (closed) and there is minimal or no tissue loss; it
is characterized by the formation of minimal granulation tissue and
scarring. It is also called primary union or first intention healing.
A wound that is extensive and involves considerable tissue loss, and
in which the edges cannot or should not be approximated, heals by
secondary intention healing. An example of wound healing by
secondary intention is a pressure ulcer
Wounds that are left open for 3 to 5 days to allow edema or infection
to resolve or exudate to drain and are then closed with sutures,
staples, or adhesive skin closures heal by tertiary intention. This is
also called delayed primary intention.
PHASES OF WOUND HEALING
INFLAMMATORY PHASE
The inflammatory phase begins immediately after injury and lasts 3
to 6 days. Two major processes occur during this phase: hemostasis
and phagocytosis.
Hemostasis (the cessation of bleeding) results from vasoconstriction
of the larger blood vessels in the affected area, retraction (drawing
back) of injured blood vessels, the deposition of fibrin (connective
tissue), and the formation of blood clots in the area.
These macrophages engulf microorganisms and cellular debris by a
process known as phagocytosis.
PROLIFERATIVE PHASE
The proliferative phase, the second phase in healing, extends from
day 3 or 4 to about day 21 postinjury. Fibroblasts (connective tissue
cells), which migrate into the wound starting about 24 hours after
injury, begin to synthesize collagen.
● Collagen is a whitish protein substance that adds tensile strength
to the wound. As the amount of collagen increases, so does the
strength of the wound
● As the capillary network develops, the tissue becomes a
translucent red color. This tissue, called granulation tissue, is
fragile and bleeds easily.
 ● If the wound does not close by epithelialization, the area becomes
covered with dried plasma proteins and dead cells. This is called
eschar.
● Initially, wounds healing by secondary intention seep blood-tinged
(serosanguineous) drainage
MATURATION PHASE
● The maturation phase begins on about day 21 and can
extend 1 or 2 years after the injury. Fibroblasts continue to
synthesize collagen.
● In some individuals, particularly dark-skinned individuals,
an abnormal amount of collagen is laid down. This can
result in a hypertrophic scar, or keloid.
TYPES OF WOUND EXUDATE
● Exudate is material, such as fluid and cells, that has
escaped from blood vessels during the inflammatory
process and is deposited in tissue or on tissue surfaces.
● A serous exudate consists chiefly of serum (the clear
portion of the blood) derived from blood and the serous
membranes of the body, such as the peritoneum.
● A purulent exudate is thicker than serous exudate
because of the presence of pus, which consists of
leukocytes, liquefied dead tissue debris, and dead and
living bacteria.
● The process of pus formation is referred to as
suppuration.
● A sanguineous exudate consists of large amounts of red
blood cells, indicating damage to capillaries that is severe
enough to allow the escape of red blood cells from
plasma. This type of exudate is frequently seen in open
wounds
Complications of Wound Healing
HEMORRHAGE
● Hemorrhage (massive bleeding), however, is abnormal.
A dislodged clot, a slipped stitch, or erosion of a blood
vessel may cause severe bleeding.
● Some clients will have a hematoma, a localized
collection of blood underneath the skin that may appear
as a reddish blue swelling (bruise).
INFECTION
DEHISCENCE WITH POSSIBLE EVISCERATION
● Dehiscence is the partial or total rupturing of a sutured
wound. Dehiscence usually involves an abdominal wound
in which the layers below the skin also separate.
● Evisceration is the protrusion of the internal viscera
through an incision
Transparent Dressings
● Transparent dressings are often applied to wounds
including ulcerated or burned skin areas.
● • They act as temporary skin.
● • They are nonporous, nonabsorbent,
Hydrocolloid Dressings
● Hydrocolloid dressings are frequently used over pressure
ulcers.
● They last 3 to 7 days
● . They do not need a “cover” dressing and are water
resistant, so the client can shower or bathe
Securing Dressings
● The nurse tapes the dressing over the wound, ensuring
that the dressing covers the entire wound and does not
become dislodged.
Wound Irrigation and Packing
● An irrigation (lavage) is the washing or flushing out of
an area. Sterile technique is required for a wound
irrigation because there is a break in the skin integrity.
Irrigation pressures should range from 4 to 15 pounds per
square inch
● Gauze packing using the damp-to-damp technique has
been used to pack wounds that require debridement.
Bandages
● is a strip of cloth used to wrap some part of the body
Basic Turns for Roller Bandages
● Circular turns are used to anchor bandages and to
terminate them.
● Spiral turns are used to bandage parts of the body that
are fairly uniform in circumference
● Spiral reverse turns are used to bandage cylindrical parts
of the body that are not uniform in circumference
● Recurrent turns are used to cover distal parts of the body,
● Figure-eight turns are used to bandage an elbow, knee,
or ankle, because they permit some movement after
application.
A binder is a type of bandage designed for a specific body part;
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Selected Types of Wound Dressings

Transparent film
● Adhesive plastic, semipermeable, nonabsorbent
dressings allow exchange of oxygen
● To provide protection against contamination and friction;
to maintain a clean moist surface that facilitates cellular
migration;
● IV dressing Central line dressing

Impregnated nonadherent
● Woven or nonwoven cotton or synthetic materials
● To cover, soothe, and protect partial- and full-thickness
wounds without exudate.
● Postoperative dressing

Black wounds are covered with thick necrotic tissue, or eschar. Black
wounds require debridement (removal of the necrotic material).