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Learning outcomes
At the end of this lecture the students will be able to :
1. Discuss the anatomy of human skin in
2.
3.
4.
5.
relation to wound management.
Brain storm terms commonly used to
describe wounds.
Describe the process of normal wound
healing.
Identify strategies to promote wound
healing.
Demonstrate an understanding of the
factors that may delay or interfere
with healing.
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Learning outcomes cont’d
6. Classify wounds according to how they
are acquired, degree of wound
contamination, and depth.
7. Describe assessment parameters
necessary to monitor and evaluate the
progress of wound healing.
8. Discuss current technology/advances
in management of wounds.
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Introduction:
 The skin is the largest organ in the body
and serves as variety of important function
in maintaining health and protect from
injury (discussed in chapter three).
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Skin integrity:
 Intact skin: refer to the presence of
normal skin and skin layers uninterrupted
by wound.
 Wound: is disruption of normal skin
integrity.
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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.
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Factors effect on skin integrity:
 Age.
 Chronic illness (impaired peripheral
circulation).
 Medication such as corticosteroid.
 Poor nutrition.
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FUNCTIONS OF THE SKIN
Synthesis of
Maintenance of hydration
Vitamin D
Immune function
Defense against
microorganisms
Waste removal
Healthy Skin
Sensation
Protection against injury
Thermoregulation
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Skin consist of:
 Epidermis
 Dermis
 Subcutaneous
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THE SKIN
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ONE CUBIC CENTIMETER OF
SKIN CONTAINS
 10 hairs
 15 sebaceous glands
 3 yards of blood vessels
 4 yards of nerves
 100 sweat glands
 3,000 sensory cells
 300,000 epidermal cells
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Wound classification as:

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

Intentional or unintentional.
Open or closed.
Acute or chronic.
Partial thickness, full thickness and
Complex.
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Types of wound:
 Incision may cause of sharp instrument
such as knife.
 Contusion closed wound that is result
from blow from blunt instrument.
 Abrasion open wound result from
friction.
 .
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Incisional wound
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Contusion wound
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CONT:
 Puncture wound: open wound made by
sharp instrument that penetrates the skin
and under lying tissue.
 Laceration: open wound when tissues are
torn apart may occur in RTA.
 Penetrating wound when instrument is
inserted in to the tissues such as bullets
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Wounds may describe according
degree of wound contamination:
 Clean wound: uninfected (no
inflammation).
 Clean – contaminated wound: surgical
wound in which the respiratory,
alimentary and genital has been entered,
no evidence of infection.
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CONT:
 Contaminated wound: open, fresh,
accidental wound and surgical wound
involving a major break in sterile
technique, show evidence of
inflammation.
 Dirty or infected wound: old, accidental
wound containing dead tissue with
evidence a clinical infection
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Types of wound healing:

1)Primary intention healing:
occur where the tissue surfaces
has been approximated (closed)
and there minimal or no tissue
loss.
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 2) Secondary intention healing: is
extensive and involves considerable tissue
loss and in which the edges cannot be
approximated and the repair time is longer,
scarring is greater and susceptibility to
infection is greater.
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Phases of wound healing:
 1) Inflammatory phase: initiated
immediately after injury and lasts 3 to 6
days two major processes occur during
this phase are homeostasis and
Phagocytosis.
A) homeostasis: result from vaso
constriction in the large vessels in affected
area, deposition of fibrin and formation of
blood clot in the area.
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Inflammatory phase
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CONT
 B) Phagocytosis: the macrophage engulf
microorganism and cellular debris.
 Prolilifrative phase: extend 4 to 21 days
and start of synthesize collagen, capillary
grow across wound and granulation
tissue forms foundation for scar tissue
development.
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Proliferative phase
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CONT
 Maturation phase: begins about 21 days
and can extend to 1- 2 years after injury,
the collagen fiber haphazardly arranged
and the scar formation.
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Maturation phase
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Factors affecting on wound healing:
1. Vasculature: good blood supply promote
healing because it provides nutrients for
tissue repair.
2. Compromised host: client at risk for
additional reasons such as infection,
diabetes and patient who receiving
radiation therapy.
3. Nutrition: wound healing requires
additional demand to promote healing.
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Factors affecting on wound healing:
4. Obesity: adipose tissue has limited blood
supply.
5. Medication such as immuno suppression agent
and
anti inflammatory drugs may make
mask on the symptom.
6. Smoking: reduce functional of hemoglubulin
resultant reduce circulating oxygen.
7. Stress: stimulate body hormone which reduce
blood supply.
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PRESSURE ULCER
 Is any lesion caused by un relieved
pressure.
 The etiology of pressure ulcer is due to
ischemia ( deficiency of blood supply).
 usually occur over bony promenance.
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PRESSURE ULCER
 Is any lesion caused by un relieved
pressure.
 The etiology of pressure ulcer is due to
ischemia ( deficiency of blood supply).
 usually occur over bony promenance.
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PRESSURE ULCER
 Is any lesion caused by un relieved
pressure.
 The etiology of pressure ulcer is due to
ischemia ( deficiency of blood supply).
 usually occur over bony promenance.
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PRESSURE ULCER
 Is any lesion caused by un relieved
pressure.
 The etiology of pressure ulcer is due to
ischemia ( deficiency of blood supply).
 usually occur over bony promenance.
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PRESSURE ULCER
 Is any lesion caused by un relieved
pressure.
 The etiology of pressure ulcer is due to
ischemia ( deficiency of blood supply).
 usually occur over bony promenance.
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Stages of pressure ulcer
1) stage one:
Erythema of intact skin.
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STAGE ONE
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 2) Stage Two: partial
thickness skin loss involving
epidermis, dermis or both.

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STAGE TWO
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 Stage three: thickness skin loss
involving damage or necrotic of
subcutaneous that may extend
down.
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Stage three
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 Stage four: full thickness skin loss
with extensive destruction, tissue
necrosis or damage to the muscle,
bone or tendon
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STAGE FOUR
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Risk factors (ulcer)
 Immobility.
 Inadequate nutrition.
 Decreased mental status ( unconscious
patient).
 Diminished sensation.
 Excessive body heat.
 Advanced age.
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Kinds of wound drainage:
 Serous exudates: compromised chiefly of
serum and serous membrane of the
body.
 Purulent: presence of pus, consist of
leukocyte, dead tissue debris and dead
bacteria.
 Sanguineous: large amount of RBC.
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Complication of wound healing:
 hemorrhage
 Infection.
 Dehiscence with possible evisceration.
 Dehiscence: partial or total rupturing of a
wound.
 Evisceration: protrusion of the internal
viscera through an incision.
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Sign and symptom of infection:
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Wound is swollen.
Redness.
Feels hot on palpated.
Foul odor may be noted.
Pain
Drainage is increase and possibility purulent.
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Psychological effect of wounds:
 Pain.
 Anxiety.
 Change in body image.
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Assessment of wound:
Untreated wound usually seen shortly after injury
 a) Assess the size and severity of the wound
 Control bleeding by applies direct pressure over
the wound and elevating involved extremity.
 Preventing infection by cleaning or flushing with
water covering the wound with a clean dressing
and tightly enough to apply pressure.
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 Control swelling and pain by applying ice
over the wound.
 If bleeding is sever or if internal bleeding
is suspected, assess the client for sign of
shock (rapid thready pulse, cold clammy
skin, pallor and lowered blood pressure.
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CONT
 Assess the wound for contamination with
foreign material and had lest tetanus
toxiod injection.
 Assess vital sign.
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CONT:
 Treated wound:
 Usually assessed to determine the
progress of healing involves observation
for appearance, pain, size, drainage,
swelling, redness and tubes.
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Lapratory result:
 Decreased WBC may delay healing
because it increase possibility of infection.
 Coagulation study.
 Serum protein analysis may indicate body
nutrition
 Wound culture to confirm or rule out the
presence of infection.
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Caring for open and closed wound
Dressing has following advantage:
 Absorb drainage and depride the wound when
remove.
 Protect the wound from external microbial
contamination.
 Approximate wound edge.
 Supporting and splinting the wound site, thus
reduce mobility and trauma to the wound it self.
 Covering unpleasant disfrugments.
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CONT:
 Open methods (no dressing is used)
exposing wound to the air promote drying
and discourage the growth of
microorganism such as burns.
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Color classification of open wound:
 R= Red – proliferative stage of healing,
reflect color of normal granulation.
 Y= Yellow – characterized by oozing, need
to cleansed.
 B=Black – covered with thicker eschar,
requires debridment.
 Mixed wound contain component or RY&B
wounds.
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RED WOUND
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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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YELLOW WOUND
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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
non adherent, hydrogel dressing, or other exudates
absorbers.
 consulting with the physician about the need for a topical
antimicrobial to minimize bacterial growth.
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BLACK WOUND
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B – Black Wound
 Covered with thick necrotic tissue or
Eschar.
 e.g.. third degree burns and gangrenous
ulcer.
 Required debridment .
 When the eschar is removed, the wound is
treated as yellow, then red.
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Debridment
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 Cleaning agent:
1. Povidine .
2. 70% alcohol.
3. Sterile normal saline.
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Guidelines for cleaning
wounds (AJN, 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
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CONT:
5. Use gauze squares .
Avoid using cotton bolls
6. Consider cleaning superficial non
infected 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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