Wound care

P.K.C.DAMAYANTHI
SPECIAL GRADE NURSING TUTOR
MANEGER CLINICAL TRAINING
LANKA HOSPITALS CORPORATION
PLC
wound
• A disruption in the
integrity of body tissue is
called a wound.
•
 skin?

The skin is the body’s

largest organ and is the
primary defense against
infection
There are other function
also there eg; thermos
regulation of the body
PRINCIPALS
OF WOUND
CARE
• Five Principals use for wound
care

• wound assessment,

• wound cleansing

• timely dressing change

• selection of appropriate dressings

• and antibiotic use

 depending on the underlying disease process.

Wound
cause of the wound

the status of skin integrity

Classification the extent of tissue damage

cleanliness of wounds

descriptive qualities of the wound such as color.

 Clean-

Cleanliness Clean wounds contaminated

wounds

of Wound
Dirty and
Contaminated
infected
wounds
wounds
Classification of wounds
ØClean wounds are intentional wounds that were created under conditions
in which no inflammation was encountered, and the respiratory, alimentary,
genitourinary, and oropharyngeal tracts were not entered.
ØClean-contaminated wounds are intentional wounds that were created by
entry into the alimentary, respiratory, genitourinary, or oropharyngeal tract
under controlled conditions
ØContaminated wounds are open, traumatic wounds or intentional wounds
in which there was a major break in aseptic technique, spillage from the
gastrointestinal tract, or incision into infected urinary or biliary tracts.
These wounds have acute non-purulent inflammation present
ØDirty and infected wounds
are traumatic wounds with retained dead tissue or intentional wounds
created in situations where purulent drainage was present
Classification by Thickness of Skin Loss
The thickness classification system is based on the depth of the wound
commonly use for the burn wound classification
• Superficial epidermal (first degree) are confined to the epidermis layer,
which comprises the four outermost layers of skin.
• Partial-thickness (first to second degree) involves the epidermis and
upper dermis, which is the layer of skin beneath the epidermis.
• Deep (second degree) involves the epidermis and deep dermis.
• Full thickness (third degree) refers to skin loss that extends through
the epidermis and the dermis, and into subcutaneous fat and deeper
structures.
ctd
• Fourth degree are deeper than full-thickness loss, extending into
the muscle and bone.
Superficial epidermal
(first degree burn)
• Injury to the epidermis; skin is red, dry, and
painful Superficial epidermal (Injury to the
epidermis; skin is red, dry, and painful.)
Deep (second degree burn):

• Injury to the epidermis and upper layers of the dermis, skin is red, moist or dry blisters, and
extremely painful; exudate and swelling usually occur.
Full-thickness (third
degree burn)

• Injury is to the
epidermis, dermis, and
subcutaneous tissue;
skin is dry, pearly white
to charred, inelastic,
and leathery
4th degree Burns Fourth degree burns are the highest level of burns and
have the potential to be life-threatening. They are the
most severe and deepest injury; affecting all layers of
the skin, muscles, tendons and bones.
The rule of nines gives

• The rule of nines gives an idea of how much of your total body's surface area a
burn takes up. This informs treatments based on the size and intensity of the burn
injury. Emergency medical responders are some of the medical workers who use
the rule of nines most.

• The rule of nines can also relay to a medical team receiving the patient how serious
the injury is. Providers also know that burns that exceed 30 percent of a person's
body can be potentially fatal, according to the National Institutes of Health

• In the modern burn care setting, adults with over 40% total body surface area
burned and children with over 60% total body surface area burned are at high risk
for morbidity and mortality, even in highly specialized centers.
Rule of nines for burns (Measure the burn)
Type of
Injury
1. Amputation

2. Avulsion

3. Curish Injury

4. Puncture

5. Abration

6. Laceration
Bruise Injury

• Bruise, also known as a

contusion, results from
damage to the soft tissues and
blood vessels, which causes
bleeding beneath the skin
surface
Abrasion injury
• Abrasion, also known as a scrape or rug
burn, results when the outer layer of skin
is scraped or rubbed away. Exposure of
nerve endings makes this type of wound
painful, and the presence of debris from
the scraped surface (rug fibers, gravel,
sand) makes abrasions highly susceptible
to infection.
Laceration injury
• Laceration, cut, or incision, is caused by
sharp objects such as knives or glass: or
from trauma due to a strike from a blunt
object that opens the skin, such as a
baseball bat. If the wound is deep, the
cut may bleed profusely; if nerve endings
are exposed, it may also be painful
Avulsion injury

• Avulsion, results when the skin or tissue

is torn away from the body, either
partially or completely. The bleeding and
pain will depend on the depth of tissue
affected
Puncture wounds

• Puncture results when the skin is

pierced by a sharp object such as a
pencil, nail, or bullet. If a piece of
the object remains in the skin, or if
there is little bleeding due to the
depth and location of the puncture,
infection is likely
Wound
Assessment
Ø The appearance of the wound (wound bed and
surrounding skin are assessed for sinus tracts,
undermining, tunneling, exudate, drainage, necrotic
tissue, and signs of infection)

Ø Identify the wound location.

Ø Determine the cause of the wound:

Ø Evaluate for foreign bodies or neoplastic processes. .

Ø Determine the stage of the wound:

Ø Stage of the wound ( stage 1 ; Superficial, involving

only the epidermal layer. )

Ø Evaluate and measure the depth, length, and width

of the wound

Ø Document the amount, color, location, odor,

and consistency of any drainage
 Assess the level
of pain
Ø Document and notify the
physician of any pain or
tenderness at the wound site.
Ø Pain may indicate infection or
bleeding. It is normal to
experience pain at the
incision site of a surgical
wound for approximately 3
days.
Ø If there is any sudden
increase in pain accompanied
by changes in the appearance
of the wound, be sure to
notify the physician
immediately
Wound healing
Ø Wound healing, as a normal biological
process in the human body, is achieved
through four precisely and highly
programmed phases: hemostasis,
inflammation, proliferation, and
remodeling. For a wound to heal
successfully, all four phases must occur in
the proper sequence and time frame.
Factors Affecting Wound Healing
WOUND
MANAGEMENT
• Basic wound management technique

1) Washing your hands.

2) Cleaning the wound and around

the wound.

3) Protecting the wound.

4) Changing the dressing.

5) Monitor for infection.

•
Cleanse the Wound
ØThe goal of cleansing the wound is to remove
debris and bacteria from the wound bed with as
little trauma to the healthy granulation tissue as
possible.
ØChoice of cleansing agent depends on the
physician’s prescription as well as agency
protocol.
ØIt is recommended that isotonic solutions such
as normal saline or lactated Ringers be used to
preserve healthy tissue.
ØProper use of antiseptic solutions in open
wounds.
 The major principles to keep in mind
when cleansing
ØUse Standard Precautions at all times.

ØWhen using a swab or gauze to cleanse a wound, work from the clean area out toward the
dirtier area.

Ø When irrigating a wound, warm the solution to room temperature, preferably to body
temperature, to prevent lowering of the tissue temperature
ØBe sure to allow the irritant to flow from the cleanest area to the contaminated area to avoid
spreading pathogens
•
Dressings

Purpose of Dressings
1. To protect the wound from mechanical injury
2. To splint or immobilize the wound
3. To absorb drainage
4. To prevent contamination from bodily
discharges (feces, urine)
5. To promote hemostasis, as in pressure dressings
6. To debride the wound by combining capillary action
and the entwining of necrotic tissue within its mesh
7. To inhibit or kill microorganisms by using
dressings with antiseptic or antimicrobial
properties
8. To provide a physiologic environment conducive to healing
9. To provide mental and physical comfort for the patient
Type of dressing
• Dry-to-dry dressings

– Used primarily for wounds closing by primary

intention
– Offers good wound protection, absorption of
drainage, and esthetics for the patient and provides
pressure (if needed) for hemostasis
– Disadvantage they adhere to the wound surface when
drainage dries (Removal can cause pain and disruption of
granulation tissue.)

• Wet-to-wet dressings
– Used on clean open wounds or on granulating surfaces. Sterile
saline or an antimicrobial agent may be used to saturate the
dressings.
– Provide a more physiologic environment (warmth, moisture),
which can enhance the local healing processes as well as ensure
greater patient comfort. Thick exudate is more easily removed.
– Disadvantage surrounding tissues can become macerated, the
risk of infection may rise, and bed linens become damp.
 Drains
• Drains are placed in wounds only when abnormal fluid
collections are present or expected.
• Drains are placed near the incision site:
– Usually in compartments (eg, joints and pleural space)
that are intolerant to fluid accumulation
– In areas with a large blood supply (eg, the neck and
kidney)
– In infected draining wounds
– In areas that have sustained large superficial tissue
dissection (eg, the breast)

• Collection of body fluids in wounds can be

harmful in the following ways:
– Provides culture media for bacterial growth
– Causes increased pressure at surgical site, interfering
with blood flow to area
– Causes pressure on adjacent areas
– Causes local tissue irritation and necrosis (due to
fluids such as bile, pus, pancreatic juice, and urine)
THANK YOU