Care of wound

1. CARE OF WOUNDS
‫بالجروح‬ ‫العناية‬

2. Out Line:
1. Function of skin
2. Body reaction to trauma
3. Wound classification
4. Wound healing process
5. Complication of wound healing
6. Factors influence wound healing
7. First aid for wound.
8. Change dressing, cleansing skin & drain site.
9. Applying bandages & binders.
10. Removing staples, & sutures.
11. Collecting a wound culture.
12. Irrigation for sterile wound
13. Applying external heating device.
14. Applying external cold device.
15. Documentation of wound care.

3. DEFINITION of WOUND
The wound is a disruption in the normal integrity of the skin.
Functions of The Skin:
1. The skin protects the body (how?)
mechanism, invasion of the body by bacteria is prevented by intact skin; injury to underlying
tissues & organs is decreased by intact skin.
2. The skin helps to regulate body temperature, (how?)
a- The production of perspiration & its loss by evaporation help to cool the body. Much heat
is lost from the body by radiation & by conduction when blood supply to skin is
increased by vasodilation.
b- Lack of perspiration & vasoconstriction help the body to retain temperature.
3. The skin is a sense organ: there are receptors for pain, touch, pressure & temperature in
the skin that help the body to receive stimuli from the environment.
4. The skin is an excretory organ: water, salts & nitrogenous wastes are lost from the skin
although in much smaller quantities than are lost from the kidneys.
5. The skin helps to maintain water & electrolyte balance and prevent the escape of excess
water and electrolytes from the body.
6. The skin produces & absorbs vitamin D: a precursor for vit. D is present in the skin,
which in conjunction with ultra violet rays from the sun, then produces vit. D.

4. Trauma
Body Reaction to Trauma:
Local physical responses to an injury cannot be separated from an over all body
reaction.
An injured foot or hand or an abdominal incision can cause a variety of systematic
reaction which include the followings:
1. Increase body temperature.
2. Increase heart rate & respiratory rate.
3. Anorexia.
4. Nausea & vomiting.
5. Skeletal muscle tension.
6. Harmful hormonal change.
Trauma: it is a general term meaning an injury.
To a person undergoing a response to a trauma, there are important things must be
Taken into consideration:
1. Adequate rest.
2. Relief of emotional stress.
3. Sufficient nutrient & fluid.

5. WOUNDS CLASSIFICATIONS ‫تصنيفات‬
‫الجروح‬
1- An intentional wound. ‫الجرح‬
‫المقصود‬
2- Unintentional wound. ‫الجرح‬
‫غير‬
‫المقصود‬
‫المفاجئ‬
3- An open wound.
4- A closed wound.
5- A clean wound.
6- Contaminated wound. ‫الجرح‬
‫الملوث‬
7- Superficial wound. ‫الجرح‬
‫السطحي‬
8- Deep wound. ‫الجرح‬
‫العميق‬

6. WOUNDS CLASSIFICATIONS:
- An Intentional Wound:
Is the result of planned therapy or treatment that
requires invasive measures.
The intentional wounds include those wounds that
result from (surgery, I.V therapy, & lumbar
puncture).
The wound edges are clean, bleeding is controlled,
because the wound was made under sterile
conditions with sterile supplies & skin
preparation, the risk for infection is decreased &
healing is facilitated

7. WOUNDS CLASSIFICATIONS:
Un Intentional Wounds:
They occur from UN expected trauma as the following:
A- Accidents.
B- Forcible injury such as; stabbing wound, gun shot
wounds.
C- Burns.
Because the wounds occur in an UN sterile environment,
contamination is likely, multiple trauma is common,
bleeding is UN controlled, these factors create a high risk
for infection & longer healing time.

8. WOUNDS CLASSIFICATIONS
An Open Wound:
They occur from intentional or UN intentional trauma, the
skin surface is broken, providing a portal of entry for
microorganisms.
Open wounds may be accompanied by bleeding, tissue
damage & increase risk for infection.
Closed Wounds:
They result from a blow, force, or strain caused by trauma
as a fall, an assault or motor vehicle accident.
The skin surface is not broken but soft tissue is damaged
& internal injury & hemorrhage may occur.

9. WOUNDS CLASSIFICATIONS
Clean or Contaminated.
Intentional wound to remove appendix = clean
open wound and open laceration considered to be
contaminated, this after an automobile accident.
Superficial or Deep.
Superficial wound: one layer of the skin
Deep: Many layers of the skin.

10. WOUND HEALING:
Definition: It is a process of tissue repair involving
tissue response to injury.
Aspects of body’s healing process are:
a- Increase blood supply to damaged area.
b- Walling off & removing of cellular & foreign
debris.
c- Initiating cellular development. ‫تحفيز‬
‫عملية‬
‫تطور‬
‫وبناء‬
‫الخاليا‬
.

11. Principles of wound healing
1-The body’s ability to handle altered skin integrity depends on the extent of
damage & person’s general state of health.
2-The body’s response to a wound is more effective if proper nutrition has been
maintained, under nourished patient is at greater risk for developing a wound
infection.
Vitamins & minerals are needed for efficient wound healing:
A- Vit. A: is necessary for collagen synthesis & epithelialization.
B- Vit. B complex (Vit B1, B6, B12): serves as a factor of enzyme needed
for wound healing.
C- Vit. C: is needed for collagen synthesis, capillary formation & resistance
to Infection.
D- Vit. K: for synthesis of prothrombin.
E- Mg+2: serves as enzyme activator.

12. cont…
3-The body responds systematically to trauma in any of its parts, for
example, surgical incision can cause a variety of systematic reactions
such as increase temperature, increase H.R & R.R, anorexia, nausea, &
vomiting.
4- An adequate blood supply is essential for the body’s normal response
to any injury; the blood brings increased number of WBCs, RBCs &
platelets to the site of injury.
a- Intact skin & mucous membranes are the first line of defense
mechanism against microorganisms. A break in the integrity of the
skin or mucous membranes increases the risk for infection.
b- Normal healing is promoted when the wound is free from foreign
material as excessive exudates, dead or damaged tissue cells,
pathogenic organisms, metal , glass or others.
Note: Abscess: localized collection of puss.

13. PHASES OF WOUND HEALING:
inflammation, fibroplasias & maturation, these phases are
controlled & regulated by substances called growth
factors, these hormones like substances interact with
specific surface receptors to control the wound healing
process.
1-Inflammatory phase:
it begins with incision for surgery & lasts through 3 or 4
post-Operative days, two major physiologic activities are
homeostasis & phagocytosis, the inflammatory response
is mediated & prepares the tissues for healing, during this
phase the patient has generalized body response include;
mild increase in the temperature, & increase WBCs
(Leukocytosis) & generalized malaise.
3 phases

14. Cont…
2- Fibroplasias (proliferation phase):
It begins on about day to 3 or 4 days & can last up to day 21,
fibroblasts rapidly synthesize collagen & ground substance,
and these tow substances form the scaffold for the final repair
of the wound. Fibroblasts also migrate from the blood stream
into the wound, depositing fibrin that stretches through the
clot.
The granulation tissue: is the new tissue is highly vascular &
reddish & bleeds easily.
The systemic symptoms now typically disappear. During this
phase:
A- Adequate nutrition.
B- Oxygenation.
C- Prevention of strain on the suture line.
All of the above are important patient’s care that must be
taken into considerations.

15. Cont…
3- Maturation phase: (remodeling phase)
The final stage of healing begins about 3 weeks
after injury & can continue for as long as 1 to 2
years. The collagen that was haphazardly
deposited in the wound is remodeled, making the
healed wound stronger & more like adjacent
tissue. New collagen continues to be deposited,
which compresses the blood vessels in the
healing wound, so that the scar eventually
becomes a flat, thin white line.
The scar: is a vascular collagen tissue that does
not sweat, grow hair, or tan in sun light.

16. WOUND HEALING PROCESS
Factors Affecting Healing Process:
1- Age: children & healthy adults heal more rapidly than older
adults.
2- Circulation & oxygenation; circulation may be impaired in older
adults & in people with peripheral vascular disorders, cardio-
vascular diseases, increase BP (Hypertension) or D.M.
Oxygenation of tissues is decreased in people with anemia or
chronic respiratory disorders like asthma & in those who smoke
much.
3- Wound condition: in a specific condition of the wound affects
how quickly & effectively it heals.
For example; large, contaminated, infected wound that retained
foreign bodies heal slowly, some wounds may fail to heal.

17. Continue:
4- Over all patient health status: patients who have:
A- Inadequate nutrition.
B- Are taking steroid drugs.
C- Require postoperative radiation therapy.
Those are at high risk for delayed healing & wound
complications.
The presence of a chronic physical illness as cardio
vascular disease or D.M can negatively affect wound
healing.

18. The wound heals by one of 3
processes: ‫الجروح‬ ‫التئام‬ ‫أنواع‬
A- Primary intention. ‫األول‬ ‫بالمقصد‬ ‫اإللتئام‬
B- Secondary intention. ‫الثاني‬ ‫بالمقصد‬ ‫اإللتئام‬
C- Tertiary intention. ‫الثالث‬ ‫بالمقصد‬ ‫اإللتئام‬

19. Continue:
1- Primary intention characteristics:
A- Wound is clean, in a straight line with little
loss of tissues.
B- All wound edges are well approximated with
sutures.
C- Usually rapid healing with minimal scaring.
‫األول‬ ‫بالمقصد‬ ‫االلتئام‬
:
‫األسرع‬ ‫الطريقة‬ ‫هذه‬ ‫وتعد‬ ،‫األولي‬ ‫الجرح‬ ‫إغالق‬ ‫أو‬
‫نسبة‬ ‫فيها‬ ‫وتقل‬ ‫ونظيفة‬ ‫صغيرة‬ ‫ندبة‬ ‫وتترك‬ ،‫الجروح‬ ‫مع‬ ‫للتعامل‬
‫وقد‬ ،‫التئامها‬ ‫سرعة‬ ‫بسبب‬ ‫والعدوى‬ ‫لإللتهاب‬ ‫التعرض‬
‫الشقوق‬ ‫أمثلتها‬ ‫ومن‬ ،‫صغيرة‬ ‫مساحة‬ ‫لتغطية‬ ‫جديدة‬ ‫دموية‬ ‫أوعية‬ ‫تتطلب‬
‫الجراحية‬
.

20. Continue:
2- Secondary intention characteristics:
A- Large wound with considerable tissue loss.
B- Natural healing by formation of granulation tissue. Granulation tissue is a new connective tissue
and microscopic blood vessels that form on the surfaces of a wound during the healing process.
Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any
size.
C- Healing takes longer time & results in more scaring.
‫اإللتئام‬
‫الثاني‬ ‫بالمقصد‬
:
‫ويتمثل‬ ‫الثانوي‬ ‫اإلغالق‬ ‫أو‬
‫في‬
‫ي‬ ‫ال‬ ‫التي‬ ‫الجروح‬ ‫التئام‬
‫مكن‬
،‫أطرافها‬ ‫تحديد‬
‫هناك‬ ‫يوجد‬ ‫وال‬
‫الحواف‬ ‫لسحب‬ ‫الجلد‬ ‫من‬ ‫يكفي‬ ‫ما‬
‫وإذا‬ ،ً‫ا‬‫مع‬
‫كان‬
‫المثال‬ ‫سبيل‬ ‫على‬ ‫جديد‬ ‫نسيج‬ ‫تكوين‬ ‫إلى‬ ‫الحاجة‬ ‫مع‬ ‫النطاق‬ ‫واسع‬ ‫األنسجة‬ ‫فقدان‬
‫الرابعة‬ ‫الدرجة‬ ‫من‬ ‫الحروق‬ ‫في‬
.
‫هذا‬ ‫ويتطلب‬
‫اإللتئام‬
‫نسيح‬ ‫مصفوفة‬ ‫بناء‬ ‫يتم‬ ‫أن‬
‫الجرح‬ ‫لملء‬ ‫حبيبي‬
.
‫ظهور‬ ‫إلى‬ ‫ويؤدي‬ ‫أطول‬ ‫وقت‬ ‫إلى‬ ‫اإلغالق‬ ‫هذا‬ ‫ويحتاج‬
ً‫ا‬‫وضوح‬ ‫أكثر‬ ‫ندوب‬

21. Continue:
3- Tertiary intention characteristics:
A- Time delay before wound is sutured.
B-Greater granulation, greater risk for infection,
greater inflammatory rather than primary
intention.
C- Late suturing & more scaring.
‫اإللتئام‬
‫الوقت‬ ‫من‬ ‫لمدة‬ ‫مفتوحة‬ ‫تركها‬ ‫يتم‬ ‫التي‬ ‫الجروح‬ ‫مع‬ ‫بالتعامل‬ ‫يهتم‬ ‫الثالث‬ ‫بالمقصد‬
‫قبل‬
ً‫ا‬‫تمام‬ ‫وإغالقها‬ ‫تقطيبها‬ ‫يتم‬ ‫أن‬
.
‫ويمكن‬
ً‫ا‬‫أيض‬ ‫يسمى‬ ‫أن‬
‫المؤجل‬ ‫بااللتئام‬
‫الت‬ ‫الجروح‬ ‫مثل‬ ،
‫ي‬
‫منها‬ ‫واإلفرازات‬ ‫الخراجات‬ ‫من‬ ‫بالتخلص‬ ‫للسماح‬ ‫مفتوحة‬ ‫تترك‬
.
‫كما‬
‫من‬ ‫النوع‬ ‫هذا‬ ‫يستخدم‬
‫على‬ ‫السيطرة‬ ‫أو‬ ‫الجرح‬ ‫تلوث‬ ‫على‬ ‫للسيطرة‬ ‫الجروح‬ ‫التئام‬
‫اإللتهاب‬
‫الجرح‬ ‫فترك‬ ،‫فيه‬
‫الجرح‬ ‫مراقبة‬ ‫على‬ ‫يساعد‬ ً‫ا‬‫مفتوح‬
‫صحيح‬ ‫بشكل‬
.
‫ا‬ ‫بالمقصد‬ ‫تلتئم‬ ‫التي‬ ‫الجروح‬ ‫وتحتاج‬
‫لثالث‬
‫الضامة‬ ‫األنسجة‬ ‫من‬ ‫المزيد‬ ‫إلى‬
(
‫الندبي‬ ‫النسيج‬
)
‫من‬ ‫أكثر‬
‫اإللتئام‬
‫بالمقصد‬
‫الثاني‬
.

22. WOUND COMPLICATIONS:
1- Infection:
symptoms become apparent within 2-7 days
after injury or surgery.
Symptoms of infection:
A- Purulent drainage.
B- Increases drainage, pain, redness & swelling
in & around wound.
C- Increase body temperature.
D- Increase WBCs (Leukocytosis).

23. Cont…
2- Hemorrhage: may occur from:
A- Slipped suture.
B- Dislodged clot from stress at the suture line or operative site.
C- Infection.
D- Erosion of blood vessels by a foreign body (as drain).
** Dressing should be checked frequently during the first 48
hours after surgery & not less than every 8 hours thereafter.
3- Dehiscence & Evisceration: (most serious post op wound
complication).
Dehiscence: is partial or total disruption of wound layers.
Evisceration: is the protrusion of viscera through the incision area.

25. Patients at risk for this complications
are:
A- Obese.
B- Malnourished.
C- Have infected wounds.
E- Excessive coughing.
F- Vomiting or straining.

26. Psychological Effects of Wounds:
1- Pain: although it is considered a physical
complication, it has a large psychological
component as well.
2- Anxiety & fear (common responses to a wound).
3- Alterations in body image.

27. First Aid For Wounds:
General guidelines for the first aid of wound:
1-Assess general condition for the patient according to ABC (Airway, breathing,
Circulation) after ensuring that the client is stable, assess the wound.
2- Assess the severity of wound.
3- Control of bleeding by applying direct pressure over the wound.
4- Apply ice to control swelling & reduce pain.
5- Assess for injuries associated with trauma. E.g. fractures, internal bleeding,
spinal cord injuries & head trauma.
6- Clean & cover the wound with clean dressing.
7- Refer to ER (Emergency Room) to reduce the risk of infection & allows
healing with less scar formation.
(Anti Tetanus Toxoid (ATS) injection also be necessary).
8-Teach client to immediately report any redness, swelling, increased drainage,
and continuous pain.

28. Change Dressing, Cleansing Skin &
Drain Site:
Dressing: it is used as a protective cover over the
wound.
The goal of wound care is to promote tissue
repair & regeneration, so that skin integrity is
restored.

30. Most dressing consist of 3 layers:
1- Contact layer: dressing applied directly over the wound, it
allows drainage to pass into the middle layer.
2- Middle layer: dressing absorbs the drainage.
3- Outer layer: keeps the two inner layers in place.
There are many different types of dressing, but all have
essentially the same purpose:
1- Provide physical, psychological & aesthetic comfort.
2- Remove necrotic tissues.
3- Prevent, eliminate or control infection.
4- Absorb drainage.
5- Maintain a moist wound environment.
6- Protect the wound from further injuries.
7- Protect the skin surrounding the wound.

32. Types of Dressing:
It depends on the location & the size of the wound & on the amount & type of
drainage.
1- Gauze dressing used to cover the wound; various sizes (2*2,
4*4 inches or 4*8) are packaged as single units or in packs.
2- Special gauze dressing (soft- wick) to fit around drains or tubes.
3- Larger dressing (8*10 bandages, abdominal pads (ABDs),
surgical pads are placed over smaller gauze dressing & absorb
drainage & protect the wound from contamination or injury.
4-Transparent dressings (op-site), applied directly over a small
wound or tube. This type is often used over I.V site, subclavian
catheter insertion site & healing wounds, these dressings are
occlusive, so the possibility of contamination is limited while
allowing visualization of wounds.
Tape: it ranges from 2 to 4 inches in width but the 1- inch tape
is most commonly used.

33. Types of Tape or plaster:
1- Adhesive Plaster: can cause occlusion, allergy, skin
maceration & shearing.
Purposes: Used for strength, support & economy.
A- To secure dressing & splints ‫الجبائر‬ .
B- To strap joints to prevent athletic injuries.
C- To immobilizes or stabilizes body parts.
D- To provides pressure.
E- To approximate wound edges.
2- Paper, plastic, acetate:
Purpose:
A- To increase comfort, decrease allergy & skin problems.
B- To close small wounds.
C- To secure dressings.

34. APPLYING EXTERNAL COLD DEVICE:
• Cold constricts peripheral blood vessels,
reducing blood flow to tissue & decrease the
local release of pain producing substances as
histamine, serotinin & bradykinin.
• Decrease formation of edema & inflammation
also decrease muscle spasm, alters tissue
sensitivity (producing numbness) & promotes
comfort by slowing the transmission of pain
stimuli.
• Extensive cold produces systemic effects of
increase BP, shivering & tissue injury.

35. DOCUMENTING WOUND CARE:
The nurse documents assessments & interventions
each time wound care is given. If drainage is
present, the kind & amount are described. If the
patient has a complicated dressing, details for
caring for wound should be described in the care
plan.
Many patients have preferences for when dressings
are changed & how the dressings are best
arranged, they may become distressed if one
nurse uses one method & another nurse uses a
different one, even if both nurses use proper
technique.

36. CHANGING A DRESSING FOR
DRAINING AWOUND:
By using following techniques:
A- Promoting comfort, by giving analgesic or
sedatives 30 to 45 minutes before changing a
dressing.
B- Maintaining skin integrity, by using a protective
ointment or paste may be applied to clean skin
surrounding the draining wound.
C- Preventing infection & promoting healing, nurses
uses principles of both medical & surgical
asepsis, precautions should be taken to prevent
infection of wound by following centers for
disease control & prevention (CDC) guidelines.

38. Cleaning a wound & applying a clean
dressing:
The nurse prepares the patient for dressing change before starting
the procedure by explain
what will be done, also proper screening is needed to provide
privacy.
APPLYING BANDAGES & BINDERS:
Uses: 1- to secure dressing.
2- To apply pressure.
3- To support the wound
Bandages: are strips of gauze (roll gauze) or elasticized material
(bandages) used to wrap a body part. They come packaged in
rolls & vary in width from 1 to 6 inches.
Binders: Designed for a specific body parts & include slings,
abdominal binders, and chest binders. They may be made of cloth
or of an elasticized material that fastens together with Velcro.

39. GUIDE LINES FOR APPLYING BANDAGES &
BINDERS:
1- Prolonged heat & moisture on the skin may cause skin break
down. The area to be covered should be cleaned & dried
thoroughly before applying a bandage or binder.
2- Bandaging the body part in the normal functioning position
prevents deformities & discomfort.
3- The bandage or binder is applied with sufficient pressure to
provide the amount of immobilization or support desired.
Note: pressure should not be so great because circulation in the
body part involved is impeded.
4-The tension of all bandage turns should be equal & unnecessary
& uneven overlapping of turns should be avoided.
5- After application, circulation & comfort are assessed at regular
intervals.

40. Continue:
Applying Roll Bandages:
Roller Bandage: is a continuous stripping of material wound on it
self to form a cylinder or roll.
Removing staples & suture:
Skin sutures which may be black silk, synthetic material, metal
staples, fine wire or metal skin clips are used to hold tissue &
skin together. Retention sutures are used to provide extra
support for obese patients & for wounds with increased risk for
dehiscence.
Collecting a wound culture:
If assessment of the wound indicates a possible infection, a
specimen of the drainage is obtained & sent to laboratory for
C&S.

41. Irrigation for a sterile wound:
Definition: It is a directed flow of solution over tissues.
Purposes:
1- Cleaning the area from pathogens & other debris.
2- Applying local heat or antiseptic solution to the area.
Note: Non-sterile solutions are used if the wound is closed.
** Sterile equipment & solutions are required for open
wound; N/S 0.9 or sterile H2O (Hydrogen Pyroxide), an
antiseptic or AB (Antibiotic) solution may be used. Sterile
and large volume syringe is used; packing is some time
placed in wounds after irrigation to allow granulation
tissue & healing by secondary intention to take place.

42. Effects of applying heat: (external
heating device)
Heat dilates peripheral blood vessels .
Vasodilatation also increases local blood flow & increases
the supply of O2 & nutrients to the area, also venous
congestion is decreased.
Systemic effects of extensive prolonged heat are: (increase
the cardiac output, sweating, increase pulse rate &
decrease BP).
Heat may be dry & moist methods:
Dry heat (by radiation) is provided by heat lamps or heat
cradles. Moist heat (by conduction) is provided by hot
compresses or packs or sits baths or soaks