WOUND CARE
The skin ; ( integument) is the largest organ of the body and considered
the first line of defense. It consist of the following layers ;
1- Subcutaneous layer ; directly under the skin &its appendages
includes, glands ,hair & nails .
2- Dermis ,the second layer consist of frame work of elastic
connective tissue nerves ,hair follicles ,glands of blood vessels
3- Subcutaneous tissue,the under lying layer which fixing the skin to
the body tissue,it consist of adipose tissue (fat cells).
FUNCTION OF THE SKIN
protection
 Protection against infection
 Injury to underlying tissue and
organs is decreased by intact skin
 Prevents loss of moisture from the
surface and underlying structures.
WOUND CARE
Temperature
regulation
psychosocial
sensation
Vitamin D
production
immunological
 The evaporation of perspiration
draws heat from the skin
 Blood vessels in the skin dilate to
dissipate heat
 In cold conditions,blood vessels in
the skin constrict to diminish heat
loss.
 In cold conditions,contraction of
pilomotor muscles cause the hair
to stand on end,forming a layer of
air on the body for
insulation(gooseflesh or goose
bumps)
 External appearance is a major
contributor to self-esteem.
 Important role in identification and
communication.
 Millions of nerve endings in the
skin provide the sense of
touch,pain,pressure and
temperature.
 Sensory impulses from the skin
allow the body to adjust to the
environment,in conjunction with
the brain and spinal cord.
 A precursor for vitamin D is present
in the skin ,which in conjunction
with ultraviolet rays from the
sun,produces vitamin D
 Abreak in the surface of the skin
triggers immunological responsesin
the skin.
WOUND CARE
absorption
Elemination
 Substance.such as medication,can
be absorbed through the skin for
local and systemic effect.
 Water,electrolytes,and
nitrogenous wastes are excreted in
small amounts in sweat.
Factors placing an individual at risk for skin
alteration;
1- Occupation , or any activity that gives the person a prolonged
exposure to the sun.
2- Changes in health state , dehydration or malnutrition.
3- Illness,( diabetes mellitus).
4- Therapeutic measures, such as ,bed rest ,casts , medications
&radiation therapy.
Factors affecting skin integrity;
 Healthy skin ,& mucous membrane serve as the first lines of
defense against harmful agents.
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Resistance to injury of the skin varies among people ,include
people age &any illness.
Adequately nourished &hydrated body cells resistance to any
injury.
Adequate circulation is necessary to cell life.
WOUND CARE
Wounds; is a break or disruption in the normal integrity of the
skin &tissue ,it ranges from a small injury in the finger to a third
degree of burn .
Types of Wound; according to the cause of inJury;
1- Incision
2- Contusion
3- Abrasion
4- laceration
5- Microbial
6- Thermal
7- Pressure ulcer
 Cutting with a sharp instrument,
Has close approximation edges.
 Blunt instrument ,skin remains
intact ,causing bruising&
hematoma.
Friction ,rubbing&scrunching upper layer
of skin.
Tearing of skin &tissue with irregular
instrument.
Secretion of exotoxins released by living
organisms.
High or low temperature , causing cellular
Necrosis
Alteration in circulation secondary to
pressure & friction.
Classification of the Wounds;
1- Intentional wound , a wound result from invasive therapy or
treatment (surgery).
2- Unintentional wound ,or accidental resulting from accidents
&causing trauma.
3- Open wound , causing damage to the skin ,bleeding &entery
to infection.
4- Closed wounds ,results from a blow , force or strain after fall.
WOUND CARE
WOUND Healing;
Is a physiological process of tissue response to repairing , by
replacing the connective tissue with a scar tissue .

Types of Wound Repair;
Primary intention; wounds are well approximated (skin edges
together ) such as surgical wounds.

Secondary intention; wounds are open ,large ,not
approximated, such as from burns or trauma.

Tertiary intention; a delayed wound, open wounds left for
several days to allow edema or exudates and contaminated to
drain.
Phases of Wound Healing;
1- Hemostasis ;It occurs immediately after initial injury
,involved blood vessels constrict&blood clotting
WOUND CARE
begins.(exudates), it is a liquid formed by a plasma & blood
Scab, ifthe wound is small the clot loses fluid and a hard
scab formed to protect the injury.
2 - Inflammatory phase; it lasts about 4-6 days, WBC
(Leukocytes)arrive to ingest bacteria. acute inflammation
characterized by ( pain , heat ,redness,& swelling ).
3-Proliferation,(regenerative) or fibroblastic phase; it lasts for
several weeks a new tissue is built to fill the wound through the
fibroblast action ,which is fibroblast are a connective tissue cells
secrete collagen&producethe growth factor responsible for
inducing blood vessels formation &movement of endothelial
cells.Granulation tissue ;it is a new tissue forms the
foundation of a scar tissue, it is highly vascular, red ,& bleeds
easily.collagen, synthesis and accumulation
continue for 4-7 days.
4-Mauration phase ;is the final stage of healing about 3
weeks after the injury .new collagen continue to be deposited to
make the healed wound stronger & compresses the blood vessels
to form the Scar.
Factors affecting Wound healing ;
a- Local factors; wound healing can be prolonged by this;
1- Pressure; excessive pressure interferes with blood flow to
the tissue & delay healing.
2- Desiccation ; is the process of drying up the cells causing the
crust which delays healing.
3- Maceration (damage of the skin) ; it is a overhydration of
cells related to fecal & urinary incontinence that delays
healing .
4- Trauma ,& infection of the wound.
WOUND CARE
5- Edema.
b- Systematic factors.
1- Age , children & healthy adults , heal more rapidly than older
adults.
2- Circulation&oxygenation; adequate blood flow to deliver
nutrients& oxygen ,removing local toxins ,bacteria &debris
essential for wound healing.
3- Nutritional status; wound healing requires adequate proteins ,
carbohydrates ,fats ,vitamins(A & C)FOR COLLAGEN
SENTHESIS,& minerals (Zinc , plays important role in
epithelialization& collagen synthesis).
4- Wound condition , large ,contaminated infected wound
healsslowly.
5- Medication & health status ; such as corticosteroid drugs ,or
post-op radiation therapy are at high risk for delayed healing.
Complication of wound healing ;
*infection ,bacteria can invade a wound at the time of surgery
clot at wound site, infection , or erosion of blood vessels , such
as a drain ,(check the dressing frequently during first 24h after
injury.
*Dehiscence & Evisceration; it is very serious complication,
Dehiscence ;isthe partial or total separation of wound
layers as a result from excessive stress on wound.
Evisceration; it is most serious ,the wound completely
separates with protrusion of the viscera through the incisional
area.
*Fistula formation ; which is abnormal passage from an
internal organ to the outside of the body .
WOUND CARE
The Nursing Process for Wounds;
Assessments;
1234-
Appearance of the skin, color, warm, any changes.
Activity /mobility , any assistance during walking.
Nutrition & elimination
If there is any pain .
Nursing Diagnosis;
 Impaired skin integrity.
 Risk for infection
 Acute pain
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 Disturbed body image.
Nursing intervention;
Nursing intervention
 Bed rest
Incision site care
Outcomes
Wound healing, primary
intention.
Wound care & change dressing
Pressure ulcer prevention.
Pressure ulcer; it is a wound with a localized area
of necrosis.
Factors in pressure ulcer development;
REF.
Taylor ;'FUNDAMENTALS OF NURSING , THE Art, &Science of
Nursing Care' 7th , 2011, page 932.
WOUND CARE