WOUND CARE

Lopar
 INTRODUCTION
 A wound is a bodily injury caused by physical
means, with disruption of the normal continuity
of structures.
 This can be identified as an acute or a chronic

wound.

 ACUTE: Heals in approximately 2 weeks to 6

months

 CHRONIC: Takes 6 months or more

 Types of Wounds
A – Intentional – therapeutic
1.Surgical operations
2.Venipuncture
B – Unintentional – accidental; caused by trauma
3. Open – skin or mucous membranes surface is
broken
4. closed – tissues are traumatized without a
break in the skin
 Classification of Wounds
1) Clean Wound:
– Operative incisional wounds that follow no penetrating
(blunt) trauma.
2) Clean/Contaminated Wound:
– uninfected wounds in which no inflammation is
encountered but the respiratory, gastrointestinal, genital,
and/or urinary tract have been entered.
3) Contaminated Wound:
– open, traumatic wounds or surgical wounds involving a
major break in sterile technique that show evidence of
inflammation.
4) Infected Wound:
– old, traumatic wounds containing dead tissue and wounds
with evidence of a clinical infection (e.g., purulent
drainage).
 Wound healing
Primary intention healing occurs when a wound
has little or no tissue loss

Delayed primary intention healing occurs when

significant tissue loss can be repaired surgically
with a skin or muscle graft

Second intention describes the process of healing

a wound without the benefit of surgical closure
The process of wound healing begins at the
moment of injury and may continue for years

No matter how trivial or extensive the wound,

healing always includes three overlapping
phases: inflammation, proliferation, and
differentiation
 Inflammatory Phase
The main function is to initiate the wound-
healing cascade, remove the debris, and
prepare the wound for the regeneration of new
tissue
The inflammatory phase is characterized by
local erythema, edema, and tenderness
 Proliferative Phase
The proliferative phase of wound healing
overlaps the inflammatory phase
It begins 2-4 days after wounding and lasts for
approximately 15 or 16 days
The main events during this phase are deposition
of connective tissue and collagen cross-linking
which fills the wound with collagen and provides
strength
 Granulation
During collagen production, new capillaries are
forming as budlike structures. Capillaries penetrate
the wound and carry nutrients to the newly
generating tissue

Granulation tissue, when kept moist, provides good

tissue for advancing epithelial cells

As matures, the synthesis of collagen decreases, the

new vascular channels regress, the wound transforms
to a comparatively avascular, and cell-free scar tissue
composed of dense collagen bundles
 Epithelization
Epithelial cells migrate from the wound margins
across the wound surface to create a watertight
seal over the wound
Fibrin strands functions as a scaffolding over which
the cells creep
Sheets of new epithelial cells continue to grow until
they come into contact with others moving across
the wound from other directions
• Primary healing —fibrin closes the wound
within a few hours and epithelization begins
in 1-2 days
• Secondary healing —migration of cells is
rapid at first but gradually slows—days or
weeks may elapse before epithelization is
complete
• If a scab is covering the wound surface, the
epithelial cells must migrate underneath the
scab
 Contraction
The scar in a wound that has healed by
secondary intention shrinks by a process
called wound contraction

It begins on about the fifth day

Secondary intention healing continues for

months or even years
 Differentiation Phase
The wound matures and the collagen in the scar
undergoes repeated degradation and re-synthesis
This is the longest phase of wound healing
The tensile strength of the scar increases
Between the 1st and the 14th day, tissues regain
approximately 30% to 50% of their original strength
Tensile strength continues to increase to
approximately 80% of normal tissue strength
Wounds never completely regain the tensile
strength of unwounded tissue
Phases of Wound Healing
WOUND CARE
WOUND DRESSING
 Purpose of wound dressing
To promote wound healing by primary
intention .
To prevent infection .
To assess the healing process
To protect the wound from mechanical trauma
To absorb drainage.
To prevent contamination from bodily
discharge.
Holding medication in place
 Types of wound dressing

Dry - to – dry :
Used primarily for wounds closing by primary
intention.
Layer of wide mesh cotton gauze lies next to
the wound surface , second layer of dry
absorbent cotton to protect the wound
Wet – to – dry :

These are particularly useful for untidy or

infected wounds that must be debrided
and closed by secondary intention
Layer of wide mesh cotton gauze
saturated with saline next to wound
surface ,second layer of moist absorbent
with same solution to debride the wound
Wet –to – damp :
Variation of wet to dry dressing .

Wet – to wet :
Used in clean open wounds.
Layer of wide mesh gauze saturated with
antibacterial solution next to the wound
surface, second layer of absorbent material
saturated with the same solution to dilutes
viscous exudates .
 Assessment
Client allergies to wound cleaning agents.
The appearance and size of the wound .
The amount and character of exudates.
Client complaints of discomfort.
The time of last pain medication .
Signs of systemic infection ( e.g. .elevated
in body temp , diaphoresis, malaise …) .
 Equipment
Moisture proof bag .
Mask .
Acetone solution to loosen adhesive .
Clean gloves.
Sterile gloves .
Sterile dressing set .
Additional supplies ( extra gauze dressing , and
ointment if ordered .
Tie tapes, tape or binder .
Normal saline or antiseptic solution
 Implementation
Before changing a dressing , determine any specific
order about dressing or wound.
Preparation
Acquire assistance for changing a dressing on restless
or confused client .
Put the client to comfortable position in which the
wound can be readily exposed ( expose only wound
area ).
Make cuff on the moisture proof bag for disposal of
the soiled dressings and place the bag within reach .
Put on face mask .
 Performance
Explain procedure to the client .

wash hands.

provide for client privacy .

Remove binder and
tape
remove binder if used
and place them aside .
If adhesive tape used ,
remove it by holding
down the skin and
pulling the tape
toward the wound .
Use solvent to loose
Remove and dispose of soiled
dressing
Put on clean gloves to remove
outer dressing
Place outer dressing away from
client .
Place the soiled dressing in
moisture proof bag without touch
the outside the bag .
Remove the under dressing , taking
care not to dislodge any drains , if
the gauze sticks to the drains ,
support the drain with one hand
and remove
Assess the location , type
and odor of the wound
drainage and number of
gauzes saturated

Discard the soiled dressing in

the bag as before .

Remove clean gloves .

- Wash hands or clean with

antiseptic solution .
Setup sterile supplies
Open the sterile dressing
set using aseptic technique
Place the sterile drape
beside the wound
Open the sterile cleaning
solution pour it over the
gauze sponges
Irrigate the wound :
Instill a steady stream of
irrigating solution into the
wound
Position the basin below the
wound to receive the irrigating
Use either a syringe with a
catheter attached or with
irrigating tip to flush the wound
Continue irrigating until the
solution becomes clear.
Dry the area around the wound.
Clean the wound .
Clean the wound using your
gloved hands or forceps and
gauze swabs moisture with
cleaning solutions.
Use the cleaning method
Use a separate swab for each
stroke and discard each swab
after use .
Support and hold the drain erect
while cleaning around .
Dry the surrounding skin with
gauze swab as required .do not
dry wound or incision itself .
Apply dressing to the drain site
and incision.
Place a precut 4 in 4 gauze
around drain .
Apply the sterile dressing one at a
time over the drain and incision .
Apply surgipad , remove gloves
and dispose of them .
Secure the dressing with tape or
tie.
Wash your hands.
Document the procedure and all
nursing assessment .
 Bandages & Binders
 Secures dressings in place

 Determine size needed

 Outer covering must cover entire wound

 Tape to secure (initial, date time)

 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
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
 Other Therapies
Wound V.A.C. – negative pressure vacuum
assisted closure system. Removes drainage and
helps wounds close.
Hydrotherapy – Pulse lavage, Whirlpool
Aids in debridement and cleansing, warm water
vasodilation.
Hyperbaric Oxygen
Electrical Stimulation
 Factors Affecting Healing
Healing is influenced by systemic conditions or
by local conditions in the wound

Tissue oxygenation
Stress
Advanced age
Nutrition
Infection
 Tissue Oxygenation
Oxygen is essential for wound healing
Blood flow supplies the wound with oxygen and
nutrients
Blood flow removes carbon dioxide and metabolic
by-products
Any condition that reduces blood flow to a wound,
such as arterial occlusion, vasoconstriction, or
external pressure impedes healing
 stress
Sympathetic nervous system and adrenal responses to
stress (i.e. neural, hormonal, or metabolic changes)
can impair wound healing
A plan that provides sleep and rest for the patient with
a pressure ulcer will promote wound healing
 Advanced age
Aging affects almost all aspects of the healing
response
Slowing epidermal turnover and increasing skin
fragility together reduce wound healing by a
factor of four
The repair rate declines with: falling rates of cell
proliferation, lack of development of wound
tensile strength, impaired collagen deposition
and wound contraction
Aging affects almost all aspects of the
healing response
Slowing epidermal turnover and
increasing skin fragility together reduce
wound healing by a factor of four
The repair rate declines with: falling rates
of cell proliferation, lack of development
of wound tensile strength, impaired
collagen deposition and wound
contraction
 Malnutrition
Wound healing and the immune response both
require an adequate supply of various nutrients,
including protein, vitamins, and minerals
Loss of more than 15% of lean body mass
interferes with wound healing
Individuals with chronic wounds may need more
protein and calories than the recommended
daily allowances and may require dietary
supplements
Protein
Low serum albumin levels are a late
manifestation of protein deficiency
Serum concentrations below 3.0 g/dl are an
indicator of poor nutritional status
Serum concentrations below 2.5 g/dl reflect
severe protein depletion
Vitamins & Minerals
Vitamin C
Deficiency is associated with impaired
fibroblastic function and decreased collagen
synthesis which delay healing and contribute
to breakdown of old wounds
Deficiency causes loss of resistance to infection
Is water-soluble and cannot be stored in the
body
Vitamin A
Associated with retarded epithelialization and
decreased collagen synthesis
Deficiency is uncommon because it is fat-soluble
and is stored in the liver

Other vitamins, such as thiamine and riboflavin,

are also necessary for collagen organization and
the resultant tensile strength of the wound
Various minerals, such as iron, copper,
manganese, and magnesium play a role in
wound healing
 Barriers to Healing
Corticosteroids—
Suppress the inflammatory response;
inflammation is necessary to trigger the
wound-healing cascade

Steroid therapy begun after the

inflammatory phase of healing (usually 4-5
days after wounding) has a minimal effect
on wound healing
Smoking

Nicotine interferes with blood flow:

Is a vasoconstrictor
It increases platelet adhesiveness—causing
clot formation
Cigarette smoke is a vasoconstrictor, and
contains carbon monoxide and hydrogen
cyanide
Diabetes
High levels of glucose compete with transport of
ascorbic acid, which is necessary for the deposition
of collagen, into cells
Tensile strength and connective tissue production
are significantly lower in diabetics
Arterial occlusive disease can impair healing
Reduced sensation may leave wounds undetected
Patients with diabetes have more difficulty
resisting infection and their wounds heal more
slowly than non-diabetic patients
 Wound Complications
 Infection- S/S purulent drainage, pain, redness around wound,
edema, increased temp, elevated WBC
 Hemorrhage – S/S large amts sanquineous drainage + other
symptoms of hypovolemic shock. Check UNDER clients
 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
 Psychosocial impact – Encourage verbalization of feelings;
encourage self-care as tolerated by client