WOUND CARE

Skin/Integumentary system is the bodys largest

organ, 16% of TBW

Protects against disease causing organisms.

Sensory organ.

Synthesizes Vitamin D.

Thermal regulation

SKIN INTEGRITY
 2 principle layers in
relation to wound
healing
Epidermis: Outer most
layer...
Dermis: Inner layer of
skin..
Hypodermis
(subcutaneous layer)...
NORMAL INTEGUMENT
Any disruption to layers of the skin and underlying
tissues..
Due to multiple causes including trauma, surgery,
or a specific disease state

WOUND-DEFINITIONS
SPECIFIC TYPES OF WOUNDS
Abrasions:
Top layer of skin rubbed or scraped
away. Little or no blood loss.
Puncture:
Deep and narrow. Object pierces
through skin;
 Incision:
Smooth cut or slice through one or more
layers of skin .
Laceration:
Skin tissue and skin layers torn leaving
rough or uneven edges.

SPECIFIC WOUNDS CONT

 SPECIFIC WOUNDS CONT

Avulsion
Piece of skin is torn or left hanging from the body.
1. Determine how severe the wound is

Wounds requiring medical attention (Doctor)

Uncontrolled bleeding...
Deep incision (cuts), laceration, or avulsion that;

Goes into the muscle or bone

Tends to gape widely
A large or deep puncture wound

CARE FOR WOUNDS

 Wounds requiring medical attention (Doctor)
A large embedded object or a deeply
embedded object of any size
Foreign matter left in the wound
Animal or human bite...
Eyelid cut
Split lip
Internal bleeding
Uncertainty about how to treat

CARE FOR WOUNDS CONT

 CARE FOR WOUNDS

2. Control bleeding.
CONTROLLING EXTERNAL BLEEDING
Direct Pressure
with clean cloth, tissue or piece or piece
of gauze..
Elevate Body Part
Pressure Bandage.
Apply Ice Pack
INTERNAL BLEEDING
Care
for shock and call EMS (Emergency
Medical Service)
Bruises and contusions
Painful, tender, rigid, bruised abdomen
Vomiting or coughing up blood
Stool that is black or contains blood.
3. Wash hands..

4. Clean the wound...

5. Apply anitbiotics..

6. Cover the wound..

CARE FOR WOUNDS

 To protect the wound from mechanical injuries
To
protect the wound from microbial
contamination
To
provide or maintain high humidity of the
wound
To absorb drainage and /or debride a wound
Toprevent hemorrhage (when applied as a
pressure dressing or with elastic bandages).
Tosplint or immobilize the wound site and thereby
facilitate healing and prevent injury.

PURPOSES OF WOUND DRESSING

7. Change dressing..

8. Get stitches for deep wound.

9. Watch out for signs of infection.

CARE FOR WOUNDS

SIGNS & SYMPTOMS OF PRESENCE OF
INFECTION

Wound is swollen.
Wound is deep red in color.
Wound feels hot on palpation.
Drainage is increased and possibly purulent.
Foul odor may be noted.
Wound edges may be separated with dehiscence present.
.
11. Manage pain...

CARE FOR WOUNDS

 Cold- decreases pain by vasoconstriction
Decreased blood flow to the area decreases
inflammation and edema
Raises the threshold of pain receptors thereby
decreasing pain
Decreases muscle tension

HEAT & COLD THERAPY

 Heat- reduces pain & promotes healing through
vasodilation
Increases oxygen and nutrients to aid in
inflammatory response
Reduces edema by promoting removal of
excessive interstitial fluid
Promotes muscle relaxation

HEAT & COLD THERAPY

IMPALED OBJECTS
Usually
extend into the fat, muscle,
and other tissue
Cancause severe bleeding if object
penetrates a major blood vessel or
organ
Do not remove the object...
AMPUTATIONS

Cutting or tearing off of a body part

Usually bleed heavily
Activate EMS immediately
Wrapped severed tissue...
1. Hold the burn under cooling running water, soak
in a basin of coll water
2. Clean the wound with mild soap and tap water
3. If blister develops, do not break the blister
4. For more serous burn, put antibiotic ointment and
a sterile bandage/ clean cloth
5. Do not put butter, oil, ice or any household
remedy to a burn.

FOR MINOR BURNS

 Infection- S/S malodorous purulent drainage, pain,
redness around wound, edema, increased temp,
elevated WBC

Hemorrhage S/S large amts sanquineous drainage

+ other symptoms of hypovolemic shock.(Restlessness,
and altered mental status, pale, cold, or clammy skin, rapid
breathing and heart rate, changes in responsiveness)

Dehiscence- S/S wound edges pulling away; not

well-approximated. Early sign = increasing
serosanquineous drainage

Evisceration- S/S wound opens revealing internal

organs. Emergency rx = sterile NS gauze to cover;
prepare for OR

WOUND COMPLICATIONS
 A pressure ulcer is a localized injury to the skin
and/or underlying tissue usually over a bony
prominence, as a result of pressure, or pressure in
combination with shear and/or friction.

PRESSURE ULCERS
 Tissues receive oxygen and nutrients and
eliminates metabolic wastes via the blood
Any factor that interferes with this affects cellular
metabolism and cell life
Pressure affects cellular metabolism by
decreasing or stopping tissue circulation resulting
in tissue ischemia

PRESSURE ULCERS
 Friction
Poor Nutrition
Incontinence
Moisture
Co-existing Medical Conditions
Impaired Sensory Input
Impaired Motor Function

PRESSURE ULCER CONTRIBUTING

FACTORS
STAGE 1 PRESSURE ULCER

Intact skin with non-

blanchable redness of a
localized area usually over a
bony prominence.
Reversible
Stage I Treatment
Off-load pressure
Moisture barrier
 Involves the epidermis
(break) and/or dermis.
The ulcer is superficial and
presents clinically as an
abrasion, blister, or shallow
open ulcer

STAGE II
 Damage or necrosis to
subcutaneous tissue
Ulcer presents as a deep
crater

STAGE III
STAGE III
 Extensive destruction, tissue
necrosis or damage to
muscle, bone , or
supporting structures
(tendons, joint)

STAGE IV
STAGE III
 Preventing pressure ulcers-early identification of those at risk
Positioning: Turn every 2 hours when in bed & at least every
hour in wheel chair or chair
Hygiene and skin care (incontinence care)
Support surfaces
Nutritional support
Prevent friction and shear
Education

PREVENTION & TREATMENT

 Age:children aged 1 year and under, and
people aged 65 years and over
Malnutrition
Obesity
Poor circulation and oxygenation
Immunosuppression
Smoking
Medications (steroids )
Co-morbidities (Diabetes, blood disorders)
Wound Stress

FACTORS THAT IMPAIR WOUND

HEALING
 Protein fibroplasia, neogenesis, collagen formation,
remodeling.
Carbohydrates energy and protein sparing
Fat - cell walls
Vitamins A, B, C, D, E, K
Copper, Iron, Magnesium, Zinc

NUTRIENTS
 An acute medical emergency caused by failure
of the heat-regulating mechanisms of the body.
Common to elderly and very young people

HEAT STROKE
 Hot dry skin
Weakness
Anhydrosis
Polydipsia
Hyperthermia
CNS dysfunction: confusion, delirium, coma

MANIFESTATIONS
 Maintain ABC
Reduce the high temperature
Remove the patient's clothing
Sponging with cool water
Ice applient tot he neck, groin, chest and axilla
Immersion of the patient in a cold water bath

MANAGEMENT
 Venomous snake bites are medical emergency

SNAKE BITES
 Have the patient lie down
Clean the wound and cover with sterile dressing
Immobilized the wound below the level of the
heart
Bring the patient to the nearest emergency
department

MANAGEMENT