STUDENT MODULE 5:

WOUND CARE

BY: GOOGLE

BY: BITMOJI

JOANNE FAITH N. ABRINA,

RN, MSN
Edited by:

ESTRELLITA OCAMPO, RN, MSN

PALAWAN STATE UNIVERSITY

August 2020
 PRE-ACTIVITY

I. SEQUENCING. Arrange the wound dressing procedure in chronological order.

_____Explain procedure to client. Ask clarification from client.

_____Open the OB bag. Set up a clean field with a paper lining inside the plastic lining field.
_____ Introduce self and verified client’s identity.
_____Locate the wound site. Remove the outer dressing. Lift the outer dressing so the underside
was away from the client’s face.
_____Place the soiled dressing in the YELLOW waste bag.
_____Perform hand hygiene.
_____Perform hand hygiene again.
_____Set up the cleaning and dressing supplies.
_____Assess the type, wound appearance, size, discharges (color and volume), and odor of
wound drainage.
_____Apply clean gloves.
_____Clean wound using forceps (or gloved hands) with gauze swabs moistened with cleaning
solution
_____Evaluate client’s comfort.
_____Remove gloves and plastic drape. Do after care.
_____Cover the wound site with sterile gauze and place snugly around the wound.
_____Document the wound location, appearance, odor and discharges.
 FOREWORD
Dear Students,

Welcome to our Community Health Nursing class!

Since we cannot see each other face to face, I hope this module will somewhat make up
for it!

This module is the sum of all the references that I have found all rolled into one.

I hope you will learn a lot from this module and you will appreciate our complex subject
as we go through it together.

I hope you will enjoy learning from this module as I have enjoyed making it for you!

TO GOD BE THE GLORY!

Truly yours,

Teacher Jay

DISCLAMER: THIS MODULE IS FOR LEARNING PURPOSES ONLY.

This module is never for sale. Photocopying this module without my permission is
also prohibited. I do not own the pictures here; it is copyrighted to the respective
owners. Thanks, BITMOJI for my avatars.
 WHY DO YOU HAVE TO READ THIS &
ANSWER THIS MODULE?

It will teach you all the important things you need to know
about basic wound care.

It will help you remember what you’ve learned.

It will make you smile as it enhances your knowledge

and skills.

Overview on Basic Wound Care

Skin is the body’s largest organ. It also acts as the body’s

first defense. When we break, cut, hurt or traumatized our skin
then we are making wounds. We have different kinds of wounds and
we will explain each in this module. Wound care is giving a certain
treatment to the wound.
explain the basic woundcare.

Identify the different types of wounds.

demonstrate the basic woundcare.

 Types of Wounds
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.

Open Wound Types

Penetrating wounds:
• Puncture wounds: caused by an object that punctures and

penetrates the skin (e.g. knife, splinter, needle, nail)

By: Wikipedia.com This Photo by Unknown Author is licensed under CC BY-NC-ND

• Surgical wounds and Incisions: wounds caused by clean, sharp
objects such as a knife, razor, or piece of sharp glass

This Photo by Unknown Author is licensed under CC BY

• Thermal wounds, chemical, or electrical burns - including

wounds caused by extreme temperatures that result in
thermal injuries such as burns, sunburns, and frostbite.

By: google.com
• Bites and stings - injury by the bites and stings of
many kinds of insects and animals.

• 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).

https://journals.rcni.com/nursing-standard bonestopprepperstop
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.

By: ahebd.com
• Skin tears: can be chronic like a wound in the base of a skin
fissure, or acute due to trauma and friction.

by:magonlinelibrary.com
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

This Photo by Unknown Author is licensed under CC BY-NC

By: sciencedirect.com
• Seroma: a fluid filled area that develops under the skin or
body tissue (commonly occur after blunt trauma or surgery)

By:tuasaude.com
• 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.

By: Hippoed.com
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.
By: https://www.lvlawny.com/
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.

www.wmar2news.com

By: southwestwouncare.com
• 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.

3 Images By: azuravascularcare.com

• Ulcerative dermatitis: an ulcer due to a dermatological
condition

By: National Eczema Association

By: wdfree.com

• Genital ulcer: be caused by infectious or noninfectious

etiologies

By: std-hiv-clinic.hk

TEXT SOURCE: Garner SE, Frantz RA et al, The validity of the clinical signs and symptoms used to identify localized chronic wound infection. Wound
Repair Regen. 2001, May-June; 9(3): 178-86.
Signs of Wound Infection
Wounds are not sterile and all open wounds have a certain number 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. ((https://www.jobst-usa.com/healthy-living/wound-care/wound-types/)

By: https://www.steadyhealth.com/
 WOUND DRESSING
(Community Setting)

WOUND DRESSING PROCEDURE

(PSU CNHS CHECKLIST)
1. Introduce self and verified client’s identity.
2. Explain procedure to client. Ask clarification from client.
3. Open the OB bag. Set up a clean field with a paper lining inside the plastic
lining field.
Gather the following:
In the paper lining: Apron, plastic drape, gloves, kidney basin with gauze
swab/sponges (cherries), irrigating solution, forceps, micropore, sterile
gauze.
In the plastic lining: yellow & black plastic waste bag
4. Perform hand hygiene.
5. Provide for client privacy.
6. Locate the wound site. Remove the outer dressing. Lift the outer dressing so
the underside was away from the client’s face.
7. Place the soiled dressing in the YELLOW waste bag.
8. Assess the type, wound appearance, size, discharges (color and volume),
and odor of wound drainage.
9. Remove and discard gloves in yellow waste bag.
10. Perform hand hygiene.
11. Set up the cleaning and dressing supplies.
Place the plastic drape beside or under the body part with wound. Observe
sterile technique avoid to touch the client’ skin.
Open the cleaning solution and poured it over the gauze swab in the sterile
kidney basin.
12. Apply clean gloves.
13. Clean wound using forceps (or gloved hands) with gauze swabs
moistened with cleaning solution
a.. Clean from “clean to dirty” and “top to bottom”.
- Clean wound first going from top to bottom
- Clean along each side of wound with a separate gauze, going from top
to bottom.
b. Use separate swab for each stroke and discarded each swab after use.
14. Allow the wound site to air dry or use dry gauze and gently dab to dry
15. Cover the wound site with sterile gauze and place snugly around the
wound.
16. Evaluate client’s comfort.
17. Remove gloves and plastic drape. Do after care.
18. Document the wound location, appearance, odor and discharges.
19. Observe effective body mechanics throughout the procedure.
 EXIT PASS

WHAT ARE THE 3 MOST IMPORTANT THINGS

THAT I HAVE LEARNED FROM THIS MODULE?
AND WHY IS IT IMPORTANT?
1.________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
2._______________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
3._______________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
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 OUTPUTS

Make a video of you performing

wound dressing procedure.

The deadline will be the same day next week.

RUBRICS FOR THE VIDEO PRESENTATION

Criteria Exemplary (6) Met Expectation (4) Needs Guidance (3)
Content Excellent Provided the The information is
knowledge of the complete and wrong or not
topic/s. More in- correct information. complete.
depth information
was given.
Creativity and Originality The ideas in the Provided what was The video may or
video asked in the video. It may not be good but
presentation are maybe original but it looks like it was
new, fresh, not creative enough. copied from
catchy and someone else’s
unique. video or idea.
Audible The voice of the The voice of the The voice cannot be
presenter is loud presenter was good heard.
and clear. enough to be heard.
Video Clarity The video is very The video is clear The video is not
clear and the enough to be seen. clear at all.
angles were really
good to perfect.
Confidence The presenter is The presenter was The presenter is
enjoying what she not camera shy. camera shy.
is doing and is
not camera shy.
SUBTOTAL
OVER ALL TOTAL /30 PERCENTAGE:
SCORE:
 REFERENCES
• Garner SE, Frantz RA et al, The validity of the clinical signs and symptoms used to identify
localized chronic wound infection. Wound Repair Regen. 2001, May-June; 9(3): 178-86.

• PSU – CNHS CHECKLIST

• www.jobst-usa.com/healthy-living/wound-care/wound-types/)

• www.steadyhealth.com

• Bitmoji Application

• Google Images

“…Whatever you do,

do it all for the glory of
GOD!”
- 1 CORINTHIANS 10:31-