Wound Care

Factors that Impair Wound Healing

Age
Malnutrition
Obesity/Emaciation
Poor circulation and oxygenation
Immunosuppression
Smoking
Incontinence
Medications ( Steroids )
Co-morbidities ( Diabetes)
Wound Stress
Radiation

Wounds - Classification
Intentional results from planned treatment
Unintentional wounds- results from unexpected
traumaaccident/ burns/ shooting
Open -skin broken, portal of entry
Closed trauma from force, skin intact, soft tissue
damage, internal injury, possible bleeding
Acute goes through normal/timely healing
process
Chronic fails to go through normal stages of
healing; no timely progress in healing

Wounds Classification
Superficial
Penetrating
Perforating

Clean
Contaminated
Infected
Colonized

Laceration
Puncture
Abrasion
Contusion

Pressure Ulcers
Stage I
Stage II
Stage III
Stage IV

Types of Wound
(Hahn,Olsen,Tomaselli, Goldberg ,2004)
Type

Cause

Description and
Characteristics

Incision

Sharp instrument eg. Knife

Open wound; painful

Contusion

Blow from a blunt instrument

Close wound, skin

appears ecchymotic
(bruised) because of
damaged blood vessels

Abrasion

Surface scrape, either unintentional

(eg, scraped knee from fall) or
intentional (eg, dermal abrasion to
remove pockmarks)

Open wound; involving

the skin ; painful

Puncture

Penetration of the skin and, often the

underlying tissues from a sharp
instrument

Open wound; can be

intentional or
unintentional

Laceration

Tissues torn apart, often from

accidents (eg, machinery)

Open wound; edges are

often jagged

Penetrating
wound

Penetration of the skin and the

underlying tissues

Open wound; usually

accidental ( bullet or
5 fragments)
metal

Classification of surgical wounds

(Altmeire 1999, Ayliffe & Lowbury 1992, NAS 1996)

Clean wounds: Operations in which a viscus is

not opened. This category includes nontraumatic, uninfected wounds where no
inflammation is encountered and no break in
technique has occurred.

Clean-contaminated: A viscus is entered but

without spillage of contents. This category
included non- traumatic wounds where a minor
break in technique has occurred.
6

Classification of surgical wounds

contd
(Altmeire 1997, Ayliffe & Lowbury 1992, NAS 1996)

Contaminated: Gross spillage has occurred or a

fresh traumatic wound from a relatively clean
source. Acute non-purulent inflammation may
also be encountered.

Dirty or infected : Old traumatic wounds from

a dirty source, with delayed treatment,
devitalised tissue, clinical infection, faecal
contamination or a foreign body.
7

Classification of wounds by
depth
I. Partial-thickness: Confined to the skin, the
dermis and epidermis.

II. Full-thickness : Involve the dermis,

epidermis, subcutaneous tissue, and possibly
muscle and bone
Partial Thickness

Full Thickness

Wound
assessment
A complex
process
Involve examination of the entire wound
Nurses visually assess wounds and
document their findings to monitor and
evaluate the progress of wound healing
9

Wound assessment contd

(Hahn,Olsen,Tomaselli, Goldberg ,2004)

What to assess?

1.Location
2.Dimensions/Size
3.Tissue viability
4.Exudate/Drainage
5.Periwound condition
6.Pain
7.Stage or extent of tissue damage , dictates how
often a wound is reassessed
8.Swelling

10

Risk Factors Which Increase

Patient Susceptibility to
infection
A- Intrinsic risk factors:
(Manley.K,
Bellman.
L,2000)
1. Extremes
age: Defined
as Children
aged 1
year and under, and people aged 65 years and
over.

2. Underling Conditions/Disorders
A. Diabetes
B. Respiratory disorders
C. Blood disorders

3. Smoking
4. Nutrition and build

11

Risk Factors Which Increase

Patient Susceptibility to infection
contd

B- Extrinsic
risk Bellman.
factors:L,2000)
(Manley.K,

1. Drug therapy as a risk factor: e.g.

Cytotoxic

2. Breach in the integrity of the skin

3. Items as foreign bodies
4. Bypass of defence mechanism
through devices e.g. Intubations
12

S&S of Presence of Infection

Wound

is swollen.
Wound is deep red in color.
Wound feels hot on palpation.
Drainage is increased and possibly
purulent.
Foul odor may be noted.
Wound edges may be separated with
dehiscence present.
13

Kinds of Wound
Drainage
1.Exudate is material, such as fluid and
cells, that has escaped from blood vessels
during the inflammatory process and
deposited in or on tissue surfaces. The
Nature and amount of exudate vary according
to:
A. Tissue involved
B. Intensity and duration of the inflammation
C. The presence of microorganisms
14

Kinds of Wound Drainage

contd
2.A purulent Exudate
Is thicker than serous exudate because of the presence of

pus.
It consists of leukocytes, liquefied dead tissue debris, dead
and living bacteria.
The Process of pus formation is referred to as suppuration,
and the bacteria that produce pus are called pyogenic
bacteria.
Purulent exudate vary in color, some acquiring tinges of blue,
green, or yellow. The color may depend on the causative
organism.
15

Kinds of Wound Drainage

contd
3. A sanguineous (hemorrhagic) Exudate
It consists of large amount or blood cells, indicating

damage to capillaries that is very severe enough to

allow the escape of RBCs from plasma
This type of exudate is frequently seen in open
wounds.
Nurses often need to distinguish whether the
exudate is dark or bright. Bright indicate fresh blood,
whereas dark exudate denotes older bleeding
16

Wound Complications
Infection
Hemorrhage
Dehiscence

and evisceration
Fistula formation

17

The RYB color code

(Stotts,1999)

This concept is based on the color

of
the open wound rather than the
depth or
size of a wound.

R=Red

Y=Yellow

B= Black

On this scheme, the goal of wound care are

to protect ( cover) red, cleanse yellow,
and debride black.
The RYB code can be applied to any wound
allowed to heal by secondary intention.
18

The RYB color code

contd

(Stotts,1999)
Red wounds
Usually

in the late regeneration phase of tissue repair (ie,

developing granulation tissue) and are clean and uniformly
pink in appearance

They

need to be protected to avoid disturbance to

regenerating tissue. Examples are superficial wounds,
skin donor sites, and partial- thickness or second degree
burns.
19

The RYB color code

contd
(Stotts,1999)

Red wounds contd

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
20

The RYB color code

contd
(Stotts,1999)

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 nonadherent,
hydrogel dressing, or other exudate absorbers; and consulting
with the physician about the need for a topical antimicrobial to
minimize bacterial growth.

21

The RYB color code

contd

B Black (Stotts,1999)
Wound
Covered with thick necrotic tissue or
Eschar.
e.g.. third degree burns and gangrenous
ulcer.
Required debridement .
When the eschar is removed, the wound
is treated as yellow, then red. 22

Purposes of wound
To protect thedressing
wound from mechanical injuries
To protect the wound from microbial
contamination

To provide or maintain high humidity of the

wound

To provide thermal insulation

To absorb drainage and /or debride a wound
23

Purposes of wound dressing

contd
To prevent hemorrhage (when applied as a
pressure dressing or with elastic
bandages).

To splint or immobilize the wound site and

thereby facilitate healing and prevent
injury.

To provide psychologic (aesthetic) comfort.

24

??Other Factors to Assess??

ODOR
LAB VALUES
WHAT CAUSED THE WOUND?
NEED FOR TETANUS?
WHEN DID WOUND OCCUR?
WHAT (IF ANY) TREATMENTS HAVE
BEEN TRIED?

Wound - Healing
Healthy body has the ability to restore
itself, it depends on the amount of
damage and state of health of the
individual.
Referred to as regeneration (renewal)
of tissue.
There are (3) phases of regeneration

Phase I

Wound Healing

Inflammatory phase- begins

immediately after injury.
Includes Hemostasis (cessation of bleeding) due
to vasoconstriction and platelet aggregation
Release of histamine, increasing capillary
permeability (plasma leaking) and vasodilation
Also phagocytosis ( process when
macrophages engulf microbes and secrete
growth factors that promote angiogenesis)
stimulates epithelial buds at the end of injured
tissue resulting in increased circulation which
sustains the healing process

Phase ICONTINUED Wound Healing

Inflammatory Response
4 Cardinal S/S
Pain
Redness
Heat
Edema

Phase I Inflammatory Response

SYSTEMIC RESPONSE

Elevated temperature
Elevated WBC ( norms 5000-10000 )
Malaise

Phase II

Wound Healing

Proliferation (Fibroplasia) Phase second phase , fibroblasts synthesize

collagens which add strength to the wound.
Begins 2-3 days after injury.
Thin layer of epithelial cells forms, blood flow
is reinstituted. Tissue forms - known as
granulation tissue. Translucent red
color/fragile/bleeds easily.

Phase III

Wound Healing

Maturation (Remodeling) Phase- final

phase begins about 3 weeks after the injury.
Collagen originally in haphazard order
remodels and reorganizes into a a more
orderly structure.
Scar (cicatrix) forms - avascular tissue ,
doesnt sweat, grow hair, or tan.
Keloid- abnormal amount of collagen laid
down, hypertrophic scar. ( common in dark
skin).

Types of Wound Healing

Primary Intention: clean, straight line, edges well
approximated with sutures, rapid healing
Secondary Intention: larger wounds with tissue
loss, edges not approximated, heals from the inside
out, granulation tissue fills in the wound, longer
healing time, larger scars
Tertiary Intention: delay 3-5 days before injury is
sutured, greater access for pathogens to invade,
greater inflammation, more granulation, larger
scars .

Wound Complications
Infection- S/S purulent drainage, pain, redness around wound,
edema, increased temp, elevated WBC
Hemorrhage S/S large amts sanquineous drainage + other
symptoms of hypovolemic shock. Check UNDER clients
Dehiscence- S/S wound edges pulling away; not wellapproximated. Early sign = increasing serosanquineous drainage
Evisceration- S/S wound opens revealing internal organs.
Emergency rx = sterile NS gauze to cover; prepare for OR
Psychosocial impact Encourage verbalization of feelings;
encourage self-care as tolerated by client

Promotion of Wound Healing

Dressings: keep wound covered & clean
Wound bed moist / Surrounding skin dry
Debridement when necessary
Remove exudate:
Drains, Wound VAC, Irrigation
Pack wounds loosely
Nutritional interventions

Debridement Methods
Surgical
Mechanical
Enzymatic ( proteolytic enzymes)
Autolytic
Maggots

Wound Dressing
Principles
If exudate is present - Select one that
absorbs exudate.
Keep wound bed moist but surrounding
skin dry
Pack wounds loosely to avoid pressure on
new granulation tissue
Fasten securely using tape, binders etc
OR self-adhesive type dressing materials.

Dressings for DRY wounds

Transparent: gas exchanged between wound &
environment but bacteria prevented from entering.
Creates moist healing environment Example:
Tegaderm
Hydrogels: High water content enhances
epithelialization and autolytic debridment.
Needs cover dressing and wound edge barrier
Example: Carrasyn
Wet to- Moist Gauze dressings: keeps wound
bed moist. Minimizes trauma to granulation tissues

Dressings for DRY wounds

Wet to Moist Gauze

Dressings for MOIST wounds

Hydrocolloid: hydrophilic particles mix with water to
from a gel... wound stays moist. DO NOT use in infected
wounds.
Example: Duoderm
Absorption Materials: beads, powders, rope or sheets
that absorb large amount of exudate
Example: Calcium Alginate
Foam: Made of hydrophilic material. Highly absorbent.
Example: Allevyn
Dry Gauze: Can absorb wound drainage. Can be
impregnated with agents to promote healing

Dressings for MOIST wounds

Irrigations
Cleanses a wound using pressure
Sterile Normal Saline = usually prescribed
Avoid caustic agents ie: peroxide, iodine
etc.
Pressure between 4-15 pounds per
square inch (psi) i.e. 60ml syringe with
catheter tip

Other Therapies
Wound V.A.C. negative pressure
vacuum assisted closure system.
Removes drainage and helps wounds
close.
Hydrotherapy Pulse lavage, Whirlpool
Aids in debridement and cleansing, warm
water vasodilation.
Hyperbaric Oxygen
Electrical Stimulation

Other Therapies

Electrical Stimulation:
- electrical signals direct
cell migration in wound
healing

Types of Topical Wound

Dressings

Hydrocolloid dressings
Hydrogel dressings
Alginate dressings
Hydrofiber dressings
Transparent film dressings
Foam dressings
Absorption dressings
Gauze dressings
Composite dressings
Biologic dressings
Other

Hydrocolloid
Dressings

Hydrocolloid Dressings

Made up of pectin based wafer

material
Absorb minimal to moderate exudate
Occlusive should not be used on
infected wounds
Come in various shapes and sizes
Should not be used if you need to
change more than q 2-3 days

Hydrogel Dressings

Hydrogel Dressings

Made up of primarily water in a polymer

to maintain moist wound base
Come in amorphous or sheet formulations
Should be used in dry wounds
Should not be used in more than
minimally exudating wounds
Should not be used with an absorbant
dressing, e.g. hydrocolloid, foam, etc.

Hydrogel Sheet Dressing

Hydrogel Amorphous
Dressing

Alginate Dressings
With or Without Silver

Alginate Dressings

Made up of seaweed from the North

Sea
Absorb moderate amounts of
drainage
Dry formulation, that becomes a gel
when it comes into contact with
wound fluid through Calcium/Sodium
ion exchange
Should not be used with hydrogels

Hydrofiber Dressings

Work the same as

alginates but
absorb ~ 30 %
more exudate.
Use with caution
in mildly draining
wounds.

Foam Dressings

Made up of polyurethane foam

Absorbs moderate to large amounts
of drainage
Available in various sizes and shapes
Some types my macerate periwound
skin if it allows drainage to wick
laterally

Foam Dressings

Silicone Backed Foams

Allevyn Gentle
Border

Mepilex Border

Absorbent Dressings

Frequently made with diaper

technology to absorb more
drainage than traditional ABD pad
Many are covered with nonadherent layer, e.g. ExuDry

Absorbent Dressings

Acrylic Absorbent Dressing

Specialty Dressings

Silver dressings e.g. Acticoat

Biologic Dressings SIS (Oasis)
Skin Substitutes Appligraf/
Dermagraft

Silver Dressings

Antimicrobial to reduce bioburden

of wound through slow release of
silver ion into the wound

Biologic Dressings

SIS (Sterile intestinal submucosa) Oasis

Skin Substitutes

Appligraf
Dermagraft

Specialty Products
KCI Wound VAC

Bandages & Binders

Secures dressings in place
Determine size needed
Outer covering must cover entire wound
Tape to secure (initial,date time)

Heat & Cold Therapy

Heat- reduces pain & promotes healing
through vasodilation
Increases oxygen and nutrients to aid in
inflammatory response
Reduces edema by promoting removal of
excessive interstitial fluid
Promotes muscle relaxation

Heat & Cold Therapy

Cold- decreases pain by vasoconstriction
Decreased blood flow to the area
decreases inflammation and edema
Raises the threshold of pain receptors
thereby decreasing pain
Decreases muscle tension

Safety Precautions
Heat & Cold Therapy
Need physicians order
Very young and very old
Peripheral vascular disease
Decreased LOC
Spinal cord injury
Presence of edema and/or scar tissue
NO LONGER than 20-30minutes at a time.
Rebound phenomena