Nursing Care for Clients with
Wounds
Nursing FundamentalsNURS B20
Wound Classifications
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Status of skin integrity
– Open Wound
– Closed Wound
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Cause
– Intentional
– Unintentional
Wound Classifications
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Severity of Injury
– Superficial
– Penetrating
– Perforating
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Cleanliness
– Wound Classifications 1- 4
Wound Classifications
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Descriptive Qualities
– Laceration
– Incision
– Abrasion
– Contusion
Healing by Primary and
Secondary Intention
Primary Intention
 Secondary Intention
 Delayed Closure
 Nutrition in Wound Healing
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Complications in Wound Healing
Hemorrhage
 Infections
 Dehiscence
 Evisceration
 Fistulas
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Factors Influencing Wound
Healing
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Age
Nutritional status
Obesity
Extent of wound
Tissue oxygenation
Smoking
Immune Status
Chronic conditions
Radiation
Stress on wound
Assessment
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In emergency settings
– Bleeding?
– Foreign bodies or contamination?
– Size of wound?
– Need for protection of wound?
– Need for tetanus antitoxin
Assessment
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Stable Setting
– Wound appearance
– Character of drainage
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Serous
Sanguineous
Serosanguineous
Purulent
Assessment
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Stable setting
– Drains
• Penrose
• Evacuator units
– Jackson Pratt drains
– Hemovac drains
– Wound closures
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Sutures
Steel staples
Clear strips
Wound glues
Drains and Wound Closures
Assessment
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Stable setting (continued)
– Palpation of the wound
– Pain
– Wound Cultures
Nursing Diagnosis
Impaired Skin Integrity
 Impaired Tissue Integrity
 Risk for Infection
 Pain
 Imbalanced Nutrition, Less than body
requirements
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Implementation
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Wound Management
– Dressings
• Purpose of dressings
• Three layers of surgical dressings
– Contact layer
– Absorbent layer
– Outer layer
Implementation
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Wound Management (continued)
– Dressings
• Types of dressings
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Gauze dressings
Wet to dry dressings
Nonadherent dressings
Self-adhesive transparent dressings
Hydrocolloid and hydrogel dressings
Implementation
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Wound Management (continued)
– Dressings
• Changing a dressing
• Packing a wound
• Securing a dressing
– Cleansing skin and drain sites
• Basic skin cleansing
• Irrigations
Cleaning a Wound
Securing A Dressing
Implementation
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Wound Management (continued)
– Suture Care
– Bandages and binders
• Provide extra protection and therapeutic benefits by:
– Exerting pressure
– Immobilizing a body part
– Supporting a wound
– Securing a splint
– Securing dressings
Implementation
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Wound management (continued)
– Principles of bandage and binder application:
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Position in normal anatomical alignment
Prevent friction between/ against skin surfaces
Apply bandages securely to prevent slippage
Wrap extremities from distal to proximal
Apply firmly with equal tension, avoid excess overlap
Position knots, pins, ties away from the wound for
sensitive skin areas
Implementation
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Wound management (continued)
– Types of binders
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Breast
Abdominal
T-Binder
Slings
Abdominal Binder
Implementation
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Wound management (continued)
– Elastic Bandage (Ace wrap)
• Wider bandages for larger body parts
• Variety of turns to cover various body parts
– Circular, spiral, figure of eight
• Evaluate distal circulation
– At least q 4 hours
– Note:
» Color
» Temperature
» Pulses
» Presence of Numbness
Types of Bandage Applications