MORNING PRAYER

Dear God,
On this day I ask You to grant this request,
May I know who I am and what I am,
Every moment of every day.
May I be a catalyst for light and love,
And bring inspiration to those whose eyes I meet.
May I have the strength to stand tall in the face of conflict,
And the courage to speak my voice, even when I'm scared.
May I have the humility to follow my heart,
And the passion to live my soul's desires.
May I seek to know the highest truth,
And dismiss the gravitational pull of my lower self.
May I embrace and love the totality of myself,
My darkness as well as my light.
May I be brave enough to hear my heart,
 MORNING PRAYER
To let it soften so that I may gracefully
Choose faith over fear.
Today is my day to surrender anything that stands
Between the sacredness of my humanity and my divinity.
May I be drenched in my Holiness
And engulfed by Your love.
May all else melt away.
And so it is.
Father, during this time may your Church be a sign of hope,
comfort and love to all.
Grant peace.
Grant comfort.
Grant healing.
Be with us, Lord.
May we honor you today in all we say and do. In Jesus name
we pray. AMEN 
WOUND CARE
 WOUND AND HEALING
 A wound is a break in the skin (the outer layer
of skin is called the epidermis). Wounds are
usually caused by cuts or scrapes. Different
kinds of wounds may be treated differently from
one another, depending upon how they
happened and how serious they are.
 Healing is a response to the injury that sets
into motion a sequence of events. With the
exception of bone, all tissues heal with some
scarring. The object of proper care is to
minimize the possibility of infection and scarring.
 Phases of Wound Healing
I. Inflammatory Phase
 A) Immediate to 2-5 days
 B) Hemostasis
Vasoconstriction
Platelet aggregation
Thromboplastin forms clot
 C) Inflammation
Vasodilation
Phagocytosis
II. Proliferative Phase
 A) 2 days to 3 weeks
 B) Granulation
Fibroblasts lay bed of collagen
Fills defect and produces new capillaries
 C) Contraction
Wound edges pull together to reduce defect
 D) Epithelialization
Crosses moist surface
Cell travel about 3 cm from point of origin in all

directions
III. Remodeling Phase
 A) 3 weeks to 2 years
 B) New collagen forms which increases tensile
strength to wounds
 C) Scar tissue is only 80 percent as strong as
original tissue
 Classification of
Wounds

1. Acute wound: is traumatic or surgical and moves

through the stages of the healing process in a
predictable time frame.
2. Chronic wound: does not progress through the stages
of healing and is not resolved over an expected period
of time regardless of the cause.
 Methods of Wound Healing

 Wound healing is the

process by which damaged
tissue is restored to normal
function.
 Healing may occur by:
1. Primary Intention
2. Secondary Intention
3. Tertiary Intention
 Primary Intention Healing
 Involves the union of the edges of a wound under aseptic
conditions, for example, a laceration or incision that is closed
with sutures or skin adhesive.
 The wound edges are sharp and completely clean and free of
microbes as is the case with a wound produced via surgical
incision (in a sterile environment).
 It is also possible to close some cuts caused by trauma via
primary intention but they need to be sutured within 4 to 6
hours after the incident in order for the wound edges not to
have become too inflamed, colonised or necrotic.
 The advantage of primary healing is that the time to closure is
short which reduces the risk of infection and, furthermore, the
scarring is limited. If the wound edges cannot be approximated,
the wound will need to heal by second intention.
 Secondary Intention
Healing
 It occurs when the wound’s edges cannot be brought
together.
 The wound is left open and allowed to heal by contraction
and epithelialization.
 Epithelialization encourages restoration of the skin’s integrity.
 Wounds that heal by secondary intention include surgical or
traumatic wounds where a large amount of tissue has been
lost, heavily infected wounds, chronic wounds or, in some
cases, where a better cosmetic or functional result will be
achieved.
 Tertiary Intention
Healing

 Refers delayed primary closure, occurs when a wound has been left open
and is then closed primarily after a few days’ delay, usually once swelling,
infection or bleeding has decreased.
 Delayed primary closure is a combination of healing by primary and
secondary intention and is usually instigated by the wound care specialist
to reduce the risk of infection.
 In delayed primary closure, the wound is first cleaned and observed for a
few days to ensure no infection is apparent before it is surgically closed.
 Examples of wounds that are closed in this way include traumatic injuries
such as dog bites or lacerations involving foreign bodies.
FOUR STAGES OF WOUND HEALING

1. Haemostasis
2. Inflammation Phase
3. Proliferation Phase
4. Maturation Phase
 New Trends
 Major trend is to use moisture retentive
dressing rather than drying the wound.
( this allows the tissue to granulate)
 Moisture enhances cellular activity in all
phases of wound repair, facilitates autolytic
wound debridement of necrotic tissues, enables
epithelial cells to migrate into the wound bed,
insulates and protects nerve endings
 Clinical notes
 Document how long client has had wound
 Determine previous treatment if any and
treatment results
 Check for allergies
 WOUND
ASSESSMENT
 EQUIPMENTS NEEDED

1. Pliable disposable measuring device

2. Cotton-tip applicator stick
3. Plastic disposable bag
4. Clean gloves
5. Sterile gloves
 Wound Assessment
Assessment
1. Assess wound for moisture, debridement,
infection and cleanliness Rationale: To
assess wound appropiately
2. Make sure drainage from wound site is
contained and adjacent skin is protected
Rationale: To prevent microorganisms from
entering wounds
3. Make sure skin sealant is used
appropriately Rationale: To maintain sterility
during dressing changes
 Wound Assessment
4. Check that dressing is dry on air-exposed
site Rationale: To prevent bacterial
proliferationtion
5. Make sure drainage system is operating
Rationale: To maintain drainage if a drainage
system is used
 WOUND ASSESSMENT
PROCEDURE
1. Wear sterile
gloves
2. Examine wound.
Note appearance of
wound bed
 Check for exudate,
drainage, necrotic
tissue or sign of
infection
3.Assess surrounding
area for problems
in skin nutrition
 Atrophy, loss of hair,
thickening of nails
 Edema of skin or scaly
skin
 Skin hydration
 Skin integrity or
maceration
 Skin color (red
[inflammation], white
[arterial
insufficiency],black
[necrosis],
brown[venous
insufficiency])
 Skin temperature (cool,
cold,warm,normal)
4.Assess extent of
wound
 Measure length and width
of wound using
disposable measuring
device
 Measure depth of wound
by using cotton-tipped
applicator stick
 Check for tunneling or
sinus tract by placing
cotton-tipped
applicator stick into
suspected area advancing
until resistance is met
5. Observe color of
wound :
A. black (necrotic
tissue),
B. yellow
(pus,fibrin,debris),
C. red (wound ready
to heal)
6. Assess for wound
drainage:
A. Type (dry or moist),
B. Amount ( minimum,
moderate, maximum),
C. Color of drainage
-clear[serous],
-brown, brown-yellow
[slough],
-yellow,yellow-green[pus
from strep or staph],
blue-green
[pseudomonas])
7. Assess for level of
moisture in wound.
A moist environment
allows wound to heal
without forming a
scab
8. Assess odor of
wound:
A. foul
(infected[necrotic
tissue has an odor
even if not
infected])
B. sweet
(pseudomonas
infection)
LABORATORY ASSESSMENT

Laboratory values need to be assessed

routinely while the wound is healing:
1. Increased WBC count indicates infection

2. Low hemoglobin and hematocrit indicate

anemia, which can decrease oxygen
transport to the wound
3. Altered serum glucose level
 WOUND
CLEANING
 Principles of Wound
Cleansing
 The aim of wound cleansing is to help create the optimum local
conditions for wound healing.
1. Sodium chloride (0.9%) is a physiologically balanced solution
that has a similar osmotic pressure to that already present in
living cells and is therefore compatible with human tissue.
 Although sodium chloride has no antiseptic properties, it

dilutes bacteria and is non-toxic to tissue.

2. Use of tap water for irrigating chronic wounds; no significant
difference has been shown in the healing and infection rates in
wounds irrigated with tap water or 0.9% sodium chloride.
 Wound Cleaning
Equipment
1. Sterile normal saline or any non-cytotoxic wound
cleanser
2. Sterile dressing
3. Tape
4. Sterile round bowl
5. Sterile emesis basin
6. Sterile gloves
7. Absorbent pads
8. Disposable bags
9. Googles
 Clinical note
 If a wound is clean and has
granulation tissue present, cleaning
is contraindicated
Rationale: Wound healing can be delayed
by destroying newly produced tissue. It
can also remove exudate that may have
bactericidal properties.
 WOUND CLEANING
PROCEDURE
Check physician’s order
for wound cleaning
solution. Sterile saline
or noncytotoxic solution
should be used.
 Rationale: other products

such as hydrogen
peroxide should be
avoided as they are toxic
to cells
2. Pour cleaning solution
over gauze pads.
 Do not use products
that shed cotton
fibers.(this can lead
to foreign body
reaction, thus
delaying the healing
process prolonging
the inflammatory
phase.
 If antimicrobial
solutions are used, be
sure to dilute it.
 Warm solution to
body
temperature( this
prevents lowering of
wound temperature
delaying the healing
process)
3. Wear sterile gloves
 Pick up several gauze
pads, pulling edges
together to form a ball
( prevents glove from
touching the wound)
 Sterile cleansing
solutions can be poured
directly over wound
before gauze pads are
use for cleaning. Place
emesis basin on side of
patient to catch excess
cleansing solution.
 Clean wound from
cleanest to dirtiest
 Clean from top to
bottom using new gauze
with each stroke
 WOUND
IRRIGATION
 Wound Irrigation
Equipment:
1. Same as in wound cleaning
2. Warm irrigation solution
3. Syringe: 30 to 60 ml syringe
4. Clean and sterile gloves (2 pairs)
 WOUND IRIGATION
PROCEDURE
1. Check orders for type and amount of
irrigating solution to be used.
2. Don sterile gloves and remove dressing.
discard dressing and gloves in disposable
bag
3. Open sterile supplies, pour warmed
irrigating solution into sterile basin
 WOUND IRIGATION
PROCEDURE
4. Don sterile gloves. Draw up solution into
syringe
5. Instill solution into wound
6. Place sterile emesis basin next to wound
to catch irrigation solution as it drains
from wound
7. Repeat irrigation process until returns are
clear and free from debris
 WOUND IRIGATION
PROCEDURE
8. Cleanse around wound with moist gauze
pads; dry thoroughly with dry gauze
pads
9. Remove gloves and place in disposable
bag
10. Don sterile gloves and apply dressing
11. Remove gloves and place in disposable
bag
Dressings
 Principles of Dressing a
Wound
1. Allows gaseous exchange.
2. Maintains optimum temperature and pH in the wound.
3. Forms an effective barrier to bacteria (contains cellular debris or
exudate to prevent the transmission of micro-organisms into and out
of the wound).
4. Allows removal of the dressing without pain or skin stripping.
5. Is acceptable to the patient.
6. Is highly absorbent (for heavily exuding wounds).
7. Is cost-effective.
8. Requires minimal replacement or disturbance.
9. Appropriate to the wound; debridement activity, hemostatic
properties, odour absorbing.
 A. Wet to Damp Dressing
Equipment
1. 4x4 gauze
2. ABD pads
3. Sterile solutions
4. Sterile gloves
5. Clean gloves
6. Tape
7. Disposable bag
 Wet to Damp Dressing
Procedure:
1. Identify type
and number of
dressings and
type of solution
needed.
 Wet to Damp Dressing
Procedure:
2.Clean over-bed table;
open sterile packages
and place on over-
bed table. Arrange
packages making sure
you do not cross
sterile field.
 Cut tape strips and
place on over-bed
table.
 Wet to Damp Dressing
Procedure:
3.Ensure that two packages
of 4 x 4 gauze pads are
open for use in outer
dressing.
 Fanfold top linen to

foot of bed. Provide

patient’s privacy
 Place bag for soiled

dressing near the table

 Wet to Damp Dressing
Procedure:
4. Pour sterile solution
into 4 x 4 gauze
dressing container
 Wet to Damp Dressing
Procedure:
5. Wear clean gloves
and remove dressing.
Place in disposable
bag
 Wet to Damp Dressing
Procedure:
6. Obtain wound
specimen for culture if
ordered.
 Remove clean

gloves and dispose

in appropriate
container
Collecting Wound Specimen
 Rinse wound with sterile NSS
 Use non-cotton tipped swab
 Rotate swab while obtaining specimen
 Swab wound edges starting from top; crisscross
wound to bottom
 Do not take specimen from exudate
 Remove gloves and place in disposable bag
 Wash your hands
Collecting Wound Specimen
7. Don sterile gloves
and have materials
needed for dressing
change available
Collecting Wound Specimen
8. Wring out several gauze pads
until slightly moist.( if
dressing is too moist risk of
infection and maceration of
surrounding skin is increased.
 Fluff moistened dressing and
lightly packed them in all
crevices and depressions in
wound.
 Necrotic tissues are usually in
deep crevices (tightly packed
wound dressing inhibit
wound edges from
contracting and may
compress capillaries)
 Irrigate wound if grossly
contaminated.
Collecting Wound Specimen
9.Apply dry sterile
gauze over moist
dressing
Rationale:
This will absorb excess
exudates
Collecting Wound Specimen
10.Place sterile ABD
pads over wound site.
Rationale:
Pads protects wound
from trauma and
external
contamination
Collecting Wound Specimen
11.Tape wound
securely.
Tape wound dressing
lengthwise , top and
bottom of dressing
 B. Dry Dressing for Open
Wound Drainage
Equipments:
1. Dressings (4 x 4 gauze, ABD pads)
2. Precut sterile 4 x 4 gauze pads (2)
3. Forceps and cotton balls
4. Sterile cleansing solution and sterile container
5. Sterile safety pin
6. Sterile scissors
7. Sterile gloves
8. Clean gloves
9. Disposable bag
 Dry Dressing
Procedure:
1. Wear clean gloves
2. Remove soiled dressing
and place in disposable
bag
 Remove clean gloves
 Open sterile
packages;place on over-
bed table
 Pour sterile cleansing
solution into container
 Observe wound closely
for sign of infection or
healing.
 Dry Dressing
Procedure:
3.Don sterile gloves and
closely observe pin in
Penrose drain.
 If pin is crusted

replace with new

sterile pin. Be careful
not to dislodge pin
 Penrose Cleaning
 To advance Penrose drain, complete the
following steps:
1. Using sterile forceps, pull drain out of wound
number of centimeters ordered
2. Reposition safety pin so it is at level of skin.
Pin prevents drain from slipping back into
wound.
3. Cut off excess tubing with sterile
scissors.Leave at least 2 inches of tubing on
outside. This prevents drain from being drawn
back into wound opening.
4. Clean drain site with
sterile solution. Use
forceps with cotton balls
soaked in cleansing
solution. Start cleansing
at drain site, moving in
circular motion towards
periphery.
 Rationale: this

prevents infection of
the drain site.
 Discard cottons balls in

disposable bag
 Advance drain if

ordered
5.Place precut 4 x 4
gauze under Penrose
drain
 Place several 4 x 4

gauze pads under

drain site
 Apply 4 x 4 gauze

pads over drain (Pads

absorbs drainage and
prevents drainage
from accumulating
into skin.)
6. Place ABD pads over
sterile gauze pads.
Remove gloves and
place in disposable
bag.
7. Tape ABD pads
securely to skin.
Montgomery tie tape
should be use if
frequent dressing
changes are recquired
or client have
sensitive skin.
Wound Drainage
 Drainage Bag for Wounds
Purpose:
 Collecting drainage specially if it is
excessive
 Measuring drainage
 Protecting skin from drainage
 Containing drainage
 Containing microorganisms to decrease
their spread to other areas
 Decreasing frequency of dressing changes
 Care for the Client with
Drainage Bags:
PROCEDURE:
1. Don clean gloves
2. Remove dressing
and place in
disposable bag
3. Measure drainage
from pouches, as
ordered
 Care for the Client with
Drainage Bags:
4. Remove clean gloves and wear sterile
gloves.
5. Clean drain site with sterile cleansing
solution and forceps and cotton balls. New
cotton balls for each site.
6. Apply sterile dressing as ordered,
drainage pouches may be left open for
assessment.
 Closed Wound Drainage
System
Equipments:
1. Specimen cup for measuring drainage
2. Input & Output bedside record
3. Absorbent pad
4. Clean gloves
 Closed Wound Drainage
Procedure:
1. Wear clean gloves.
Expose catheter
insertion site while
keeping client draped
 Place drainage system
on absorbent pad or
towel(to protect bed
from being soiled)
 Examine Jackson Pratt
or hemovac catheter
for patency, seal and
stability. If occluded
notify physician
 Closed Wound Drainage
Procedure:
2. Empty hemovac
drainage system by
removing Hemovac
plus from pouring
spout.
 Pour drainage into
specimen bottle.
 Safety alert:

To maintain patency, compress

Jackson Pratt or Hemovac
container every 4 hrs
 Closed Wound Drainage
Procedure:
3. Compress hemovac
by pressing top and
bottom together with
your hands. Keep
pump tightly
compressed while you
reinsert plug
 Closed Wound Drainage
Procedure:
4. Disconnect tubing
from Jackson Pratt
system. Pour
drainage into
specimen container
 Closed Wound Drainage
Procedure:
5. Compress bulb on
Jackson-Pratt system.
 Hold bulb tightly

compressed and
connect to tubing
 Closed Wound Drainage
Procedure:
6. Place drainage
system on bed. (this
facilitates observation
and drainage of
wound)
 Measure and record

amount of drainage
 Observe color,

consistency and odor

Decubitus Ulcer
 Pressure Ulcer Staging
 Stage I- Non-blanching erythema of
intact skin, the heralding lesion of
skin ulceration

 Stage II- Partial thickness skin loss

involving epidermis and dermis. The
ulcer is superficial and presents
clinically as an abrasion, blister or
shallow crater
 Stage III- Full-thickness skin loss
involving damage or necrosis of
subcutaneous tissue that may extend
down to, but not through the
underlying fascia. Presents as deep
crater with or without the
undermining of he adjacent tissue

 Stage IV- Full-thickness skin loss

with extensive destruction, necrosis,
damage to bone, muscle and
surrounding structures
Treatment protocol
The End