Module five

Wound care and dressing

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THE SKIN

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 FUNCTIONS OF THE SKIN
Defense against
Synthesis of microorganisms
Maintenance of hydration Vitamin D

Waste removal
Immune function Healthy Skin

Protection against Sensation

injury
Thermoregulation

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Wound-definitions
(Manley, Bellman, 2000)
A loss of continuity of the skin or
mucous membrane which may
involve soft tissues, muscles,
bone and other anatomical
structure.
• Any disruption to layers of the skin
and underlying tissues

• Due to multiple causes including

trauma, surgery, or a specific
disease state 4
 WOUND HEALING
Classification of wound healing
(According to the amount of tissue loss)

 Primary intention healing

 Secondary intention healing
 Tertiary intention healing
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 Wound Classification
 Intentional wounds and Unintentional
wounds
 Open wounds and closed wounds
 Acute and chronic wounds

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 PHASES OF WOUND HEALING
Healing is a quality of living tissue; it is also
referred to as regeneration (renewal) of tissue.

A. The inflammatory phase

B. The regenerative (Proliferative) phase

C. The Maturative (Remodeling) phase

(Manley, Bellman, 2000)

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 The inflammatory phase (Initiated
immediately after injury and last 3-4-6 days
Injury /damage Cells

Histamine Blood Clot

Vasodilation Dry
Permeability
Uniting the
wound edges
&Neutrophils
Monocytes
Dilated blood vessels-
Oedema& -Microcirculation slow
Engorgement down 8
0-3 days
 The Regenerative (Proliferative) phase
Blood vessels near the edge of the Begins 2-3 days of injury
wound become porous
Lasting up to 2-3 weeks

Allowing excess moisture

to escape - Resultant tissue filling is referred
To as granulation tissue
- process of wound contraction begins
Macrophage
activity
& Traps other blood cells
Stimulates damaged blood vessels
Begin to regenerate within
the wound margins
Formation& multiplication
of fibroblasts
This fibrous network
Which - Laying down of a ground
Resulting

substance
migrate along fibrin - Beginning the synthesis of
threads collagen fibers (granulation 9

tissue )
 The Regenerative phase
cont’d
This phase of healing:
Last from 0-24 days
Signs of inflammation should
subside although the wound will
often remain red in colour and
to some degree raised in
relation to its surrounding
tissue . 10
 The Maturative phase
 Begins about day 21 and can extend up to
6 months up to one or two years after the
injury.
 Fibroblasts continue to synthesize
collagen
 The collagen fibers recognized into a more
orderly structure
 The scar become a thin ,less elastic, white
line
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 Factors affecting wound healing
(Manley.K, Bellman. L,2000)
 Developmental consideration/Age
 Nutrition
 Life-style
 Medication
 Infection
 Wound perfusion
 PH of the wound interface
 Foreign bodies
Contamination
Bacteria present on surface

Colonization
Bacteria attach to tissue and multiply

Infection
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Bacteria invade healthy tissue and overwhelm immune
defenses
 Types of Wound
(Hahn,Olsen,Tomaselli, Goldberg ,2004)
Description and Cause Type
Characteristics
Open wound; painful Sharp instrument eg. Knife Incision
Close wound, skin Blow from a blunt instrument Contusion
appears ecchymotic
(bruised) because of
damaged blood vessels
Open wound; involving Surface scrape, either unintentional Abrasion
the skin ; painful (eg, scraped knee from fall) or
intentional (eg, dermal abrasion to
remove pockmarks)
Open wound; can be Penetration of the skin and, often the Puncture
intentional or underlying tissues from a sharp
unintentional instrument
Open wound; edges are Tissues torn apart, often from Laceration
often jagged accidents (eg, machinery)
Open wound; usually Penetration of the skin and the Penetrating
accidental ( bullet or underlying tissues wound 13
metal fragments)
 Classification of surgical wounds
(Altmeire 1999, Ayliffe & Lowbury 1992, NAS 1996)

Clean wounds: Operations in which a viscus is

not opened. This category includes non-
traumatic, uninfected wounds where no
inflammation is encountered and no break in
technique has occurred.
Clean-contaminated: A viscus is entered but
without spillage of contents. This category
included non- traumatic wounds where a minor
break in technique has occurred.

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 Classification of surgical wounds cont’d
(Altmeire 1997, Ayliffe & Lowbury 1992, NAS 1996)

Contaminated: Gross spillage has occurred or a

fresh traumatic wound from a relatively clean
source. Acute non-purulent inflammation may
also be encountered.
Dirty or infected : Old traumatic wounds from
a dirty source, with delayed treatment,
devitalised tissue, clinical infection, faecal
contamination or a foreign body.

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 Classification of wounds by depth

I. Partial-thickness: Confined to the skin, the

dermis and epidermis.
II. Full-thickness : Involve the dermis,
epidermis, subcutaneous tissue, and possibly
muscle and bone
Partial Thickness Full Thickness

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 Wound assessment
A complex process
Involve examination of the entire wound
Nurses visually assess wounds and
document their findings to monitor and
evaluate the progress of wound healing

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 Wound assessment cont’d
(Hahn,Olsen,Tomaselli, Goldberg ,2004)
What to assess?
1.Location
2.Dimensions/Size
3.Tissue viability
4.Exudate/Drainage
5.Periwound condition
6.Pain
7.Stage or extent of tissue damage , dictates how
often a wound is reassessed
8.Swelling
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Risk Factors Which Increase Patient
Susceptibility to infection
(Manley.K, Bellman. L,2000)
A- Intrinsic risk factors:
1. Extremes age: Defined as “ Children aged 1
year and under, and people aged 65 years and
over’.
2. Underling Conditions/Disorders
A. Diabetes
B. Respiratory disorders
C. Blood disorders
3. Smoking
4. Nutrition and build 19
 Risk Factors Which Increase Patient
Susceptibility to infection cont’d
(Manley.K, Bellman. L,2000)

B- Extrinsic risk factors:

1. Drug therapy as a risk factor: e.g.
Cytotoxic
2. Breach in the integrity of the skin
3. Items as foreign bodies
4. Bypass of defence mechanism
through devices e.g. Intubations
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 S&S 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.
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 Kinds of Wound Drainage
1.Exudate is material, such as fluid and
cells, that has escaped from blood vessels
during the inflammatory process and
deposited in or on tissue surfaces. The
Nature and amount of exudate vary according
to:
A. Tissue involved
B. Intensity and duration of the inflammation
C. The presence of microorganisms
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 Kinds of Wound Drainage cont’d
2.A purulent Exudate
 Is thicker than serous exudate because of the presence of
pus.
 It consists of leukocytes, liquefied dead tissue debris, dead
and living bacteria.
 The Process of pus formation is referred to as suppuration,
and the bacteria that produce pus are called pyogenic
bacteria.
 Purulent exudate vary in color, some acquiring tinges of blue,
green, or yellow. The color may depend on the causative
organism.

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 Kinds of Wound Drainage cont’d
3. A sanguineous (hemorrhagic) Exudate
 It consists of large amount or blood cells, indicating
damage to capillaries that is very severe enough to
allow the escape of RBCs from plasma
 This type of exudate is frequently seen in open
wounds.
 Nurses often need to distinguish whether the
exudate is dark or bright. Bright indicate fresh blood,
whereas dark exudate denotes older bleeding

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 Wound Complications
 Infection
 Hemorrhage
 Dehiscence and evisceration
 Fistula formation

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 The RYB color code
(Stotts,1999)
 Thisconcept is based on the color of
the open wound rather than the depth or
size of a wound.
R=Red Y=Yellow B= Black
 On this scheme, the goal of wound care are
to protect ( cover) red, cleanse yellow,
and debride black.
 The RYB code can be applied to any wound
allowed to heal by secondary intention.
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 The RYB color code cont’d
(Stotts,1999)
Red wounds
 Usually in the late regeneration phase of tissue repair (ie,
developing granulation tissue) and are clean and
uniformly pink in appearance
 They need to be protected to avoid disturbance to
regenerating tissue. Examples are superficial wounds,
skin donor sites, and partial- thickness or second –
degree burns.

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 The RYB color code cont’d
(Stotts,1999)
Red wounds cont’d
 How to protect red wounds:

Gentle cleansing
Avoid the use of dry gauze or wet- to-dry saline
dressings
Appling a topical antimicrobial agent
Appling a transparent film or hydrocolloid dressing
Changing the dressing as infrequently as possible
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 The RYB color code cont’d
(Stotts,1999)
Yellow wounds
 Characterized primarily by liquid to semiliquid ”slough” that
is often accompanied by purulent drainage.
 The nurse cleanses yellow wounds to absorb drainage and
remove nonviable tissue. Methods used may include .
 Applying wet-to-wet dressing; irrigating the wound; using
absorbent dressing material such as impregnated nonadherent,
hydrogel dressing, or other exudate absorbers; and consulting
with the physician about the need for a topical antimicrobial to
minimize bacterial growth.

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 The RYB color code cont’d
(Stotts,1999)
B – Black Wound
 Covered with thick necrotic tissue or
Eschar.
 e.g.. third degree burns and gangrenous
ulcer.
 Required debridement .
 When the eschar is removed, the wound
is treated as yellow, then red. 30
 Purposes of wound dressing
To protect the wound from mechanical injuries
To protect the wound from microbial
contamination
To provide or maintain high humidity of the
wound
To provide thermal insulation
To absorb drainage and /or debride a wound

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Purposes of wound dressing cont’d
To prevent hemorrhage (when applied as a
pressure dressing or with elastic
bandages).
To splint or immobilize the wound site and
thereby facilitate healing and prevent injury.
To provide psychologic (aesthetic) comfort.

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 Principles of asepsis
The aim:
 Guarantee the safety of the equipment
used (cleaning/disinfection/sterilisation).
 Reduce the level of microbial
contamination of the site requiring
manipulation (antisepsis).
 Ensure that no microorganisms are
introduced (asepsis).
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 Principles of asepsis cont’d
Cleaning : Is the removal of dirt, debris and
organic material.
Disinfection: Removes or destroys harmful
microorganisms but not bacterial spores or
slow viruses.
Sterilisation: is the complete destruction or
removal of all living microorganisms
including bacterial spores.
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 Principles of asepsis cont’d
Antisepsis: is the reduction of the number
of microorganisms already present on the
body site prior to a procedure.
Asepsis: Procedure designed to prevent
any introduction of microorganisms to the
site achieved by a non-touching
technique and use of sterile gloves
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delines for cleaning wounds
N, 1999)
1. Use physiologic solution, such as
isotonic saline or lactated ranger solution
2. When possible , warm the solution to body
temperature before use
3. If the wound is grossly contaminated by foreign
material , bacteria, slough, or necrotic tissue clean
the wound at every dressing change
4. If a wound is clean , has little exudate , and
reveals healthy granulation tissue , avoid repeated
cleaning 36
 uidelines for cleaning wounds
ont’d (AJN, 1999)
5. Use gauze squares .
Avoid using cotton bolls
6. Consider cleaning superficial
noninfected wound by irrigating them
with normal saline rather than using
mechanical means
7. To retain wound moisture , avoid drying
a wound after cleaning it
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Topics for Home Care Teaching
 Supplies
 Infection prevention
 Wound healing
 Appearance of the skin/recent changes
 Activity/mobility
 Nutrition
 Pain
 Elimination
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 Sutures and staples
Types of sutures:
 Plain interrupted
 Mattress interrupted
 Plain continuous
 Mattress continuous
 Blanket continuous
 Retention 39
 Sutures and staples

 Removing interrupted suture

Suture removal set

 Removing staples

Staple removal

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