Wound lecture
D. Ali M Al-Gurmi
WOUND
DEFINITION
A wound is a break in the integrity of the skin (or) tissues often, which
may be associated with disruption of the structure and function.
• Wound is simply a disruption of any tissues — soft tissue (or) bone
(or) internal organs.
Classification of Wound
• There is no standard classification of wound. The classification used in this
guideline is based on:
A. Timing:
• Acute: sudden disruption of skin integrity; usually due to trauma or surgery
• Chronic: wound that failed to proceed through an orderly and timely
process to produce anatomic and functional integrity
• Non‐healing wound: Any wound that has no signs of healing process
within 2 to 4 weeks after appropriate intervention.
1. Tissues Involved
• Simple wounds – Only skin / tissue is involved
• Combined/Complex wounds – Involving mixed tissues
(vessels/nerves/tendons/bones)
2. Neatness Of wound
Tidy wounds – Surgical incisions & Sharp objects – Clean / no tissue
loss – Primary suturing
Untidy wounds – Crushing, Tearing, Avulsion & Devitalized injury – #
of bone + / - Infection – common – Suturing after excision & cleaning
Types of wound
1. Incision: open wound, painful, deep or
shallow, due to sharp instrument.
Incision
2.Abrasion: open wound involving skin only,
painful, due to surface scrape.
3. Puncture: open wound, penetrating of the skin
and often the underlying tissues by a sharp
instrument.
Abrasion
Puncture
Types of wound
4. Contusion: closed wound, skin appears
ecchymosis because of damaged blood vessels, due
to blow from blunt instrument.
5.Laceration: open wound edges are often jagged,
tissues torn apart. Often from accidents.
6. Stab wound: open wound, penetration of the skin
and the underlying tissues, usually unintentional.
Types of wound
7. Penetration wound: caused by an object
i.e. a knife entering and coming out from
the skin. Gunshots: caused by a bullet.
• Hematoma – It is a localized collection of
blood after blunt trauma.
Time Elapsed
• Acute wounds – Are those that progress through the normal healing
phases and typically show signs of healing in less than 4 weeks.
• Chronic wounds – Are those that do not follow the normal healing
process and show no signs of healing
Chronic wound
Pressure Ulcer Staging
6. Type Of Surgical Wound
Class 1 - Clean wound – It is a non-traumatic, uninfected operative
wound. Elective & primarily closed. – E.g.: Excision / Thyroid &
Hernia surgeries – Infection rate is < 2%
Class 2 - Clean contaminated wound – Gastrointestinal, respiratory
or Genito - urinary tracts entered without significant spillage or wounds
which are mechanically drained. – E.g.: appendicectomy, gallbladder,
biliary, pancreatic surgeries – Infection rate is < 10%
6. Type of surgical Wound
• Class 3 - Contaminated wound
Acute abdominal conditions. – Spillage from hollow organs. – Break in
sterile technique. – Chronic open wounds. – Infection rate is 15 - 30%
• Class 4 - Dirty Infected wound
Abscess drainage. – Pyocele. – Faucal peritonitis. – Empyema
gallbladder. – Infection rate is 40 - 70%
Wound Healing:
• Itis biological process that restores tissue continuity after the injury.
• It is a combination of physical, chemical and cellular events that restore
wounded tissue or replace it with collagen which may start immediately
after injury or incision.
• There are four phases of wound healing as inflammation, debridement,
repair and maturation
• During 1st 3 to 5 days are the lag phase of wound healing because
inflammation and debridement predominate in this duration.
phases of wound healing
There are four phases of normal wound healing. They are:
1. Hemostasis
2. Inflammatory Phase
3. Proliferative Phase (comprised of granulation and epithelialization)
4. Maturation Phase (also called reconstruction or remodeling phase)
Hemostasis
• Hemostasis begins immediately upon wounding. The body's natural
defenses try to control bleeding first by constricting the local blood
vessels, and then by creating a plug with circulating platelets. This
temporary plug is later replaced by a more durable fibrin clot. This
process is quick, occurring over several hours.
Inflammatory Phase
Inflammation is commonly referred to as the
clean-up period. White blood cells (neutrophils
and macrophages) invade the wound. Dead
tissue, debris, and bacteria are first digested by
these cells. Growth factors and other chemical
messengers are then released. This starts the
healing process.
Proliferative Phase
• The process of "new" tissue growth or proliferation is subdivided into
two
• phases depending upon the depth of injury: Granulation and
Epithelialization
Granulation
All partial and full thickness wounds heal by
the process of granulation. The epidermal layer
has been destroyed so the natural healing
process originates from dermal cells
(Fibroblasts) in the wound bed and peri wound
margins.
A new layer of protein (Collagen) is deposited
in the wound space.
Epithelialization
Superficial wounds heal by Epithelial Regeneration.
The natural process of epidermal cell keratinocytes
growth and differentiation will result in the resurfacing
of the wound with natural skin. The growth originates
from keratinocytes in the wound bed, peri wound
margins, and from islets of epidermal cells (e.g. hair
follicles, sweat glands)
Conti…
Healing is influenced by Host factors, wound characteristics, and other external
factors.
Inflammatory phase: it is protective tissue response initiated by damage,
characterized by
1. Increased vascular permeability.
2. Chemotaxis of circulatory cells.
3. Release of cytokines and growth factors
4. Cells activation(macrophages, lymphocytes, neutrophils and fibroblasts.
Factors affecting healing
• Immune status
• Blood glucose levels (impaired white cell function)
• Hydration (slows metabolism)
• Nutrition
• Blood albumin levels (‘building blocks’ for repair, colloid osmotic pressure - oedema)
• Oxygen and vascular supply
• Pain (causes vasoconstriction)
• Corticosteroids (depress immune function)
Complications of wound healing
• Hemorrhage
• Infection
• Dehiscence
• Evisceration
• Fistula
• Abscess
• Gangrene
• Keloid
How to assess wound
• Exudate (drainage), a liquid produced by the body in response to tissue
damage, is present in wounds as they heal.
• It consists of fluid that has leaked out of blood vessels and closely
resembles blood plasma.
• Exudates can result also from conditions that cause edema, such as
inflammation, immobility, limb dependence, and venous and
lymphatic insufficiency.
How to assess wound
• Accurate assessment of exudate is important throughout the healing
process because the color, consistency, odor, and amount change as a
result of various physiologic processes and underlying complications
Type of exudate Serous
• Thin, clear, watery plasma, seen in partial-thickness wounds and
venous ulceration.
• A mod er ate to heavy amount may indicate heavy bio-burden or
chronicity from a subclinical infection.
• • Serous exudate in the acute inflammatory stage is normal
Nursing actions:
•Anything that touches the wound should be sterile e.g. Dressings,
instruments, solutions
• Emphasize on hand washing before and after the procedure.
• Observe strictly the principles of surgical asepsis.
• The wound and the surrounding skin should be cleaned thoroughly to
reduce the number of bacterial.
Nursing actions:
• The wounds should be protected always with clean and sterile dressings.
• Removal and replacement of the dressings should be done when the air
movement us at minimum.
• No sweeping should be done when the dressings are opened).
• The soiled dressings should be carefully collected and burned to prevent
the spread of infection
Nursing actions:
• The contaminated articles should be disinfected before it is used again
• Keep the environment free form dust and flies
• Practice barrier nursing.
• Isolate patients with clean wounds form those patients with
contaminated wounds.
• Use of gloves, masks and gowns in creases the barriers to the
organisms.
Principles
• Bacterial travel along with the dust particles
• Sweepings and dusting should not be done when the dressings are in
progress.
It should be done at least one hour before the expected time of the
dressing.
Nursing actions
• Flapping of the bed cloths and dresses should be avoided to prevent dust
particles entering the wound.
• Sterile articles must be kept covered until it is time for use.
• Prolonged exposure to the air makes them contaminated
• Cleaning an area where there is less number of organisms.
• Before cleaning an area where there are more organisms, minimize the
spread of organisms to the clean area.
Nursing action
• Consider the wound area cleaner than the skin around even if the wound is
infected.
• Keeping this principle in mind, clean the wound from the center to the
periphery, discarding the used swab after each stroke.
• Skin and mucus membranes normally harbor pathogens.
• If the wound is clean first before the cleaning of the skin around the wound,
there is less chance of introduction the skin pathogens into the wound.
Principles
• A break in the skin and mucus membrane acts as the portal of entry for
the pathogenic organisms
• Open wounds are to be sealed or dressed as early as possible to
prevent the entrance of pathogenic organisms into the body.
Nursing
• All precautions are to be taken to prevent further tissue damage and promote the
healing process.
• Use antiseptic solutions of correction strength which are safe form the skin and
mucus membranes.
• Using the antiseptics of high concentration can cause tissue damage.
• When using the heat in the form of hot fomentation or surgical soak, the
temperature should be controlled between 37 to 40.50 C (98 to 1050 F) to prevent
tissue burns.
• Respiratory tract harbors microorganisms that can enter the wound.
Nursing action
When dressing large open wounds, masks may be worn by the nurses to
prevent the organisms entering the wounds through the droplets.
• Avoid talking, coughing, coughing and sneezing while attending to a
wound.
• Respiratory tract harbors microorganisms that can enter the wound.
• Moisture facilitates growth and movement of micro- organisms
Nursing actions
• Microbes can neither live nor travel without moisture.
There fore keep the sterile field dry.
• Replace the soild dressings with dry dressings as soon as they are wet
otherwise the
• Microbes can enter the wound by traveling through the wet dressings.
Nursing actions
• Maintain the privacy of the patient and avoid unnecessary exposure.
• Do not expose the wound in front of the patient.
• Turn the patient’s head to one side to avoid unpleasant sight.
• Diversion is provided by conversation or by other means.
• The nurse should try to control the reactions to the sight of the wound
or dressing.
Nursing actions
• The patient frequently studies the face of the person changing the dressing
in order to evaluate the extent of injury or healing process.
• Systematic ways of working saves time, energy and material
• Place the bed and the patient at working height
• Prepare the patient; articles and the environment before the dressing are
opened.
• Assemble and arrange the articles on the beside locker conveniently to
avoid leaving the patient in between the procedure.
Nursing Care Principles
• Assessment: Regularly evaluate wound appearance, size, depth, drainage
(amount/color/odor), and surrounding skin.
• Infection Prevention: Wash hands before/after care; use aseptic or sterile
technique for dressing changes.
• Cleaning: Use normal saline or mild, pH-neutral soap and water to cleanse,
avoiding harsh antiseptics like hydrogen peroxide.
• Protect the personal clothing and the bed linen with a waterproof covering.
• Get assistance if needed.
Nursing Care Principles
• Debridement: Remove necrotic tissue, debris, or slough to encourage
healing.
• Dressing Selection: Maintain a moist environment with appropriate
dressings (e.g., hydrocolloids, foams, alginates) based on exudate
level.
• Monitoring & Documentation: Document progress and watch for
complications like increased pain, swelling, or heat
Basic Elements of Wound Care
• Cleanse Debris from the Wound
• Possible Debridement
• Absorb Excess Exudate
• Promote Granulation and Epithelialization When Appropriate
• Possibly Treat Infections
• Minimize Discomfort
Interventions Stage 1:
• Maintain skin integrity
• Skin to remain clean and odor free
• Protect and moisturize skin TREATMENTS: Preferred agents (dry
skin)
• Aloe Vesta skin cream Preferred agents (at risk for breakdown due to
incontinence/pressure)
• Aloe Vesta protective ointment
• Dermarite Perigaurd barrier ointment
Interventions Stage 1:
• Maintain skin integrity
• Skin to remain clean and odor free
• Protect and moisturize skin Treatments: Preferred agents (dry skin)
• Aloe Vesta skin cream Preferred agents (at risk for breakdown due to
incontinence/pressure)
• Aloe vesta protective ointment
• Derma rite Perigaurd barrier ointment
Interventions Stage II, III,IV
Dry to Minimal Exudate goals:
• Minimize dressing changes
• Maintain moist environment
• Prevent infection
• Prevent additional skin breakdown
Treatments:
Preferred agents:
• Hydrofiber (Aquacel)
• Viscopaste
• Hydrocolloid (DuoDERM Extra Thin)
Follow product guidelines for frequency of
dressing change