Wound and Wound Dressing Dressing: Presentedby Mrs - Sylvia Ranjan Mathew Principal MGM College of Nursing

WOUND AND WOUND
DRESSING
DRESSING
PRESENTEDBY
MRS.SYLVIA RANJAN MATHEW
PRINCIPAL
MGM COLLEGE OF NURSING
DEFINITION OF
WOUND
A wound is a break or cut in the continuity
of any body structure, internal or external
caused by physical means.
CLASSIFICATION OF WOUND
According to status of skin integrity

 Open wound
 Closed wound
According to the cause of the wound

 Intentional or surgical wound
 Unintentional wound
CON…
According to severity of injury

 Superficial (Abraded) wound
 Penetrating wound
 Perforated wound
 Puncture or stab wound
According to cleanliness / contamination

 Clean wound
 Contaminated wound
 Infected or septic wound
 Colonized wound
WOUND HEALING PROCESS
Stage 1 Inflammatory
phase
Stage 2 Destructive
phase
Stage 3 Proliferative
phase
Stage 4 Maturation phase
Inflammatory phase
• Within few seconds after injury, inflammation begins and

lasts for about 3 days.
• Injured tissues and mast cells secrete histamine, resulting in
vasodilation of surrounding capillaries and exudation of
serum and while blood cells into damaged tissues.
• Leukocytes reach the wound within few hours. The neutrophil
begins to ingest bacteria and small debris. The neutrophil
dies in a few days.
• During this period the monocyte which transforms into
macrophages cells clean the wound bacteria, dead cells and
debris.
• This process continues for about 48 hours. Finally a thin layer
of epithelial tissue forms over the wound, which is later
absorbed.
Destructive phase
 This begins before the inflammatory phase ends and

lasts for about 2 to 5 days.
 Macrophages continue its cleaning process and
stimulate the formation of fibroblast.
Proliferative phase
 This phase begins with the appearance of the new

blood vessels and lasts from 3 to 24 days. Fibroblasts
appear alongside the capillaries. These two together
constitute the granulation tissue.
 Subsequently there is epithelization. All the cells
forming the surface epithelium undergoes rapid
division and migrates as a thin film covering the
wound.
 The wound appears pink owing to the new capillaries
in the granulation tissue and the area is soft and
tender.
Maturation phase
This final phase may take more than one year there
is scar formation by the fibroblasts. The capillaries
and lymphatic endothelial buds in the new tissues
disappear and the scar then shrinks. The collagen
scar continues to regain strength over several
months.
FACTORS AFFECTING HEALING PROCESS
 Nutrition
 Age
 Blood supply
 Hormones
 Drugs
 Extent of the injury
 Infection
 Chronic diseases
 Smoking
 Obesity
 Radiation
 Wound stress
COMPLICATIO
N
 Hemorrhage
 Infections
 Wound dehiscence
 Wound evisceration
 Fistula
 Abscess formation
 Cellulitis
 Necrosis or Gangrene
 Keloids
 Pain
 Fluid collection
 Interference with organ function
DEFINITION OF WOUND DRESSING
It is a sterile protective covering applied to a

wound/incision with aseptic technique with or
without medications.
TYPES OF DRESSINGS
Dressings are vary by type of material and mode of

application.
 Gauze dressings
 Non-antiseptic dressings
 Antiseptic dressings
 Wet dressings
 Pressure dressings
 Non-adherent gauze dressings
 Self-adhesive transparent film
PURPOSES OF WOUND DRESSINGS
 To prevent infection.
 To prevent further tissue damage.
 To promote healing.
 To absorb inflammatory exudate and to promote drainages.
 To convert the contaminated wound into a clean wound.
 To prevent hemorrhage.
 To prevent skin excoriation.
 To apply medication in place.
 To restore the function of the part.
 To provide physical and mental comfort to the patient.
 To promote thermal insulation to the wound surface area.
 To provide maintenance of high humidity between the wound and
dressing.
PRINCIPLES INVOLVED IN WOUND
DRESSINGS
 Micro-organisms are present in environment, on the

articles and on the skin. Pathogenic organisms are
transmitted from the source to the new host directly
or indirectly.
 Bacteria travel along with the dust particles.
 Cleaning the area where there is less number of
organisms, before cleaning an area where there is more
organisms. Minimize the spread of organisms to the clean
area.
 A break in the skin and mucus membrane acts as the
portal of entry for the pathogenic organisms.
CON..
 Respiratory tract harbors micro-organisms that can enter
the wound.
 Nutrients and oxygen are carried to the wound via blood
stream and are essential for collagen formation.
 Moisture facilitates growth and movement of micro-
organisms.
 Fluid moves downwards as a result of gravitational
pull.
 Fluids move through materials by capillary action.
 Unfamiliar situations produce anxiety.
 Systematic ways of working saves time, energy and
material.
GENERAL INSTRUCTIONS FOR THE WOUND
DRESSING
 Practice strict aseptic technique to prevent cross infection to the
wound and from the wound. All materials touching to the wound
should be sterile.
 All articles should be disinfected thoroughly to make sure that they
are free from pathogens. Special care must be taken when there is
any reason to suspect the presence of pathogenic spores particularly
those causing the dreaded wound infections of gas gangrene and
tetanus. These spores are destroyed only by the sterilization with
steam under pressure.
 Wash hands thoroughly before and after procedure.
 Instruments used for one dressing can not be used for another until
they have been re-sterilized.
 Use masks, sterile gloves and gowns for large dressings to minimize
the wound contamination.
 Dressings are not changed for at-least 15 minutes after the room has
been swept or cleaned. Sweeping and dusting of the room will raise
the dust and the wound will be contaminated.
 Use individually wrapped sterile dressings and equipment for the
greatest safety of the wound. The practice of storing dressings and
instruments in large trays and drums and opening them every now
and then should be condemned.
 Create a sterile field around the wound by spreading sterile towels.
 Avoid talking, coughing and sneezing when the wound is opened.
 During the procedure the nurse works carefully to avoid
contaminating the patient’s skin. Clothing and bed linen with soiled
instruments and dressings. All the soiled dressings and contaminated
instruments should be carefully collected and disposed safely.
 Cleaning of the wound should be done from the most clean area to the less
clean area. Consider the wound area cleaner than the skin area even if the
wound is infected. Therefore clean the wound from its center to the
periphery. When cleaning the circular wound, start from the center of the
wound and go to the periphery. When cleaning a linear wound, the first swab
cleanses the wound line and the subsequent swabs cleanse the skin on either
side of the wound.
 If the dressings are adherent to the wound due to the drying of the secretions
or blood, wet it with physiologic saline before it is removed from the wound.
 When dressing the wound, keep the wound edges as near as possible
to promote healing.
 When drains are in place, anticipate drainage and re-enforce the dressings
accordingly. The dressings over the drains should not combined with the
dressings on the wound line. This enables a nurse to change the dressings
over the drains without disturbing the wound dressings and thereby
minimizing the wound infections.
 The amount of discharge from the wound should be accurately
measured by recording the number and size of the dressings
changed. Note the colour, odour, amount and consistency of
the drainage.
 When the wound drainage is diminished the drains are to be
shortened. This should be done in consultation with the doctor.
Usually the doctor gives a written order.
 Before doing the dressings, inspect the wound for any
complications such as dehiscence and evisceration. If present,
report it immediately to the surgeon and immediate steps are to
be taken.
 Avoid meal timing.
 Give an analgesics prior to the painful dressings.
THANK
YOU

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WOUND AND WOUND

According to status of skin integrity

According to the cause of the wound

According to severity of injury

According to cleanliness / contamination

• Within few seconds after injury, inflammation begins and

 This begins before the inflammatory phase ends and

 This phase begins with the appearance of the new

It is a sterile protective covering applied to a

Dressings are vary by type of material and mode of

 Micro-organisms are present in environment, on the

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