Wounds can be intentional from medical procedures or unintentional from accidents. There are four main types based on mechanism of injury: incised, contused, lacerated, and puncture wounds. Wound healing involves three phases: inflammatory, proliferative, and maturation. The inflammatory phase begins healing and the proliferation phase involves new tissue growth. Eventually the maturation phase strengthens the scar tissue. Proper wound management includes cleaning, antibiotics, tetanus shots, and dressings. Abnormal healing can involve excessive scarring like keloids or poor healing with dehiscence. Many factors can influence the healing process.

1. Wounds
By:-
Logman Mohammed Alshaikh
Msc:- med-surg nursing

2. Introduction
A wound is a disruption in the continuity and
regulatory processes of tissue cells;
wound healing is the restoration of that
continuity. Wound healing, may not restore
normal cellular function

3. Types of wounds
• Intentional Occur during therapy ( operations,
venipunctures, or radiation burns).
• Unintentional wounds (accidental)
An arm fracture in a car accident. And it may be
either closed or open

4. Wound description
1. Mechanism of Injury -4-
2. Degree of Contamination -4 -

5. Mechanism of Injury -4-
1. Incised wounds ”made by a clean cut of a
sharp instrument, such as a surgical
incision with a scalpel

6. Cont..
2. Contused wounds ”made by blunt force
that typically does not break the skin but
causes considerable tissue damage with
bruising and swelling

7. Cont..
3. Lacerated wounds ”made by an object
that tears tissues producing jagged,
irregular edges; examples include glass,
jagged wire, and blunt knife

8. Cont..
4. Puncture wounds ”made by a pointed
instrument, such as an ice pick, bullet, or
nail

9. Degree of Contamination -4-
1. Clean ”an aseptically made wound, as in
surgery, that does not enter the alimentary,
respiratory, or genitourinary tracts.

10. Cont..
2. Clean-contaminated ”an aseptically made
wound that enters the respiratory,
alimentary, or genitourinary tracts.
These wounds have slightly higher probability
of wound infection than do clean wounds.

11. Cont..3. Contaminated ”wounds exposed to
excessive amounts of bacteria.
These wounds may be open and accidentally
made, or may be the result of surgical operations
in which there are major breaks in sterile
techniques or gross spillage from the
gastrointestinal tract.

12. Cont..
4. Infected ”a wound that retains dead tissue
or involves preoperatively existing
infection or perforated viscera. Such
wounds are often left open to drain

13. Wound healing

14. Wound healing
• Regeneration : new cells (same type) and
normal function
• Replacement : new cells (new type) and
loss some function or scar

15. Wound healing
• Regeneration or Replacement depend on
Tissue involvement
– Labile cell ; mucous membrane, lymphoid tissue
– Stable cell ; connective tissue, liver, endocrine
– Permanent cell ; neuron
Nature or extent of the wound

16. Types of wounds healing
• Primary intention healing Occurs when
tissues surfaces have been approximated
and there is minimal or no tissue loss ( that
is; minimal granulation tissue and scarring).
• Secondary intention Occurs when the
tissue surfaces are not approximated and
there is extensive tissue loss.

17. Wound healing phases
1. Inflammatory Phase (lasts 1 to 5 days)
2. Proliferative Phase (lasts 2 to 20 days)
3. Maturation Phase (21 days to months
or years)

18. Inflammatory Phase (lasts 1 to 5
days)
1. Vascular and cellular responses
2. Transient vasoconstriction occurs
3. Subsequent dilation of small venules occurs
causing edema, redness, warmth, and pain
4. Localized vasodilation is the result of direct
action by histamine, serotonin, and prostaglandins
5. leukocytes (neutrophils) and monocytes enter the
wound
6. Basal cells at the wound edges undergo mitosis

19. Vascular phase of acute
inflammation

20. Proliferative Phase (lasts 2 to 20
days)
1. Fibroblasts (connective tissue cells) multiply and
migrate to serve as a matrix.
2. forming new capillaries that penetrate and nourish
the injured tissue.
3. The combination of capillaries and proliferating
fibroblasts is called granulation tissue.
4. Active collagen synthesis by fibroblasts begins by
the fifth to seventh day, and the wound gains
tensile strength
5. By 3 weeks, skin obtains 30% of its preinjury
tensile strength, the intestinal tissue about 65%,
and fascia 20%

21. Maturation Phase (21 days to
months or years)
1. Scar tissue is composed primarily of
collagen
2. increasing in tensile strength
3. the scar continue to change
4. collagen production drops off
5. Normal maturation of the wound is
clinically observed

22. Wound management
• 1/Wounds inflicted less than 6hours are
cleaned and sutured but wound of more than
6hors duration before arrival to hospital
should be cleaned thoroughly and dressed
without suture .
• 2/Antibiotic from penicillin family if there
is no allergy to penicillin other wise use
Erythromycin if there is hyper sensitivity to
penicillin .

23. Wound management
• Ask about about status of tetanus
immunization and treat as follows:
• a/ if he was immunized within less than five
years there is no need for further
immunization.
• b/ if he was immunized within 5-10years a
booster dose of tetanus vaccine is given
(tetanus toxoid)

24. Wound management
• c/ if he is immunized more than 10years ago
give him asingle dose of human anti tetanus
serum(human immunoglobulin ATS)to give
passive immunity and booster dose of
vaccine.
• d/ if he is not immunized at all give him
immediate dose of human anti tetanus
serum(ATS) and start program of tetanus
vaccination.

25. Wound management
• 4/ later when wound gap is big but with
good granulation tissue split graft is applied.
• 5/ tendons,nerves,arteies ,veins bone,
cartilages, brain and intestine should not be
left exposed otherwise they will dry up and
suffer necrosis . Skin flaps are advised to
cover these structures .

26. Wound management
• 6/ Strong disinfectant material like alcohol
,hydrogen peroxide and tincture iodine
should not be use in all types of wound at
all because they damage the cells , however
providone iodine is found to be good for
disinfecting wounds.

27. Disturbances in Wound Healing
• problems of wound healing occurs either
due to poor healing or excessive healing

28. Factorsaffectingwoundhealing
Systemic
• Age
• Nutrition
• Trauma
• Metabolic disease
• Immunosuppression
• Connective tissue dis.
• Smoking
Local
• Mechanical injury
• Infection
• Edema, hematoma
• Ischemia
• Topical agent
• Radiation
• Low oxygen tension
• Foreign body

29. ABNORMALWOUNDHEALING
Excessive wound heal ing
• 1/ Hypertrophic scar
• 2/ Keloid
Etiology
• Unknown
• Immune system
• Increase collagen synthe and matrix than normal

30. Excessive healing
HYPERTROPHIC SCAR
• Stay within and confine of
origin wound
• Above skin level 4 mm
• 4 week & regression
• Pain, itching, burning
sensation
ABNORMALWOUND HEALING

31. Excessive healing
Keloid
• Extend from origin wound
• Occur 3 mo-1 yr
• No regression
• Black people
• Earlobe, presternal,
deltoid
• ttt: steroid inj
• Big keloid excision and
skin graft
ABNORMALWOUND HEALING

32. Poor healing
• Dehiscence:
• a/ This occur in wound infection when pus
collected in subcutaneous tissue and burst
though the skin resulting in skin gap.
• The wound should be exposed on third post
operative day .if there is pain, redness and
positive blanching sign the cellulites will be
diagnosed an antibiotic should be given.

33. cont
• If patient developed fever pain or
serangeous discharge from wound in the 5th
to 7th post-operative day then the patient is
either developing proper wound infection
i.e. pus in subcutaneous tissue which should
be treated by removal of few stitches to
drain out the pus or the patient may be
developing the alarming sign of burst
abdomen .

34. cont
• b/ Dehiscence may occur in the deep layers
while skin remain intact . This result in
inscional hernia.
• c/ compleete seperation of all layer lead to
exposeure of abdominal contens is called burst
abdomen .this is treated by immediate
covering of the intestine by sterile gauze
soaked in normal saline to prevent evaporation
,drying up of the intestine and to reduce
infection .

35. cont
• The patient should be taken to the
operation room for closure with tension
sutures(sutures passing through all layers
including skin).

36. cont
• Causes of dehiscence:
• a/infection
• b/suture with absorbable suture material.
• c/poor technique i.e tight suture that cutt the
blood supply off the healing edges resulting
in necrosis and failure of healing.

37. cont
• d/ increasing intra abdominal pressure by
cough ,straining during defecation and
urination, carrying heavy weight, pregnancy
,malignancy steroid chemotherapy and
radiotherapy.

38. Takerest