2.

​ Untidy wounds
WOUND CARE -​ These are wounds resulting from crushing,
tearing avulsion, vascular injury or burns,
Wound - is a type of physical trauma whereby the and contain devitalized tissue
integrity of the skin or any tissue is compromised -​ They are usually multiple and irregular
-​ Commonly associated with fractures
1. Acute wound - result of tissue damage by -​ Such wounds can not be closed primarily
trauma. Usually heals in the anticipated time and therefore should be allowed to heal by
frame second intention
​ Ex: surgical wound, heat, electricity,
chemicals, friction ACCORDING TO: INTEGRITY OF THE SKIN:

2. Chronic wound - fails to heal/progress or 1.​ Open wounds

respond to treatment over the normal expected -​ Type of wounds in which the skin
healing time. has been compromised and
​ Ex: pressure ulcers, venous leg ulcers, underlying tissues are exposed
diabetic foot ulcers -​ Open wounds can be classified into
a number of different types
Layers of the skin according to the object that caused
the wound:
●​ Epidermis: outer layer -​ Examples include incised wounds,
-​ Vascular layer laceration, punctured wounds etc
-​ Regenerated every 2-4 weeks
2.​ Closed wounds
●​ Dermis - middle layer -​ Wounds in which the skin has not
-​ Receptors for heat, cold, pain and been compromised, but trauma to
pressure underlying structures has occurred
-​ Closed wounds have fewer
●​ Hypodermis - inner most categories, but are just as
layer/subcutaneous dangerous as open wounds
-​ Adipose tissue, connective tissue, -​ Examples of closed wounds are:
and blood vessels ●​ Contusions - (more
-​ Stores lipids, protect underlying commonly known as a
organs, provide insulation and bruise) - caused by blunt
regulate temperature force trauma that damages
tissue under the skin
ACCORDING TO
Rank-Wakefield classification system ●​ Hematoma - (also called a
blood tumor) - caused by
1.​ Tidy wounds damage to a blood vessel
-​ These are wounds inflicted by sharp that in turn causes blood to
instruments and contain no collect under the skin
devitalized tissue
-​ Such wounds can be closed According to: WOUND DEPTH
primarily with the expectation of 1.​ Superficial wounds
quite primary healing -​ Only the epidermis is affected and
-​ They are usually single with clean has to be replaced
cut. Associated fractures are -​ A truly superficial wound does not
uncommon in tidy wounds bleed and heals within a few days
Examples: surgical incisions, cuts from -​ Examples include most abrasions
glass and knife wound and blisters
 3.​ Crush wounds
2.​ Partial thickness wounds -​ Crush wounds are caused by a great or
-​ The epidermis and part of the dermis is extreme amount of force applied over a
affected long period of time. These occur when a
-​ A partial-thickness wound does bleed heavy object falls onto a person, splitting
-​ If left uncovered, a blood clot will cover the the skin and shattering or tearing
wound and a scar will form underlying structures.
-​ The missing tissue will then be replaced, -​ They are often accompanied by degloving
followed by regeneration of the epidermis injuries and compartment syndrome
A partial-thickness wound can take from
several days to several weeks to heal, 4.​ Abrasions
depending on the patient and the wound -​ An abrasion is a shearing injury of
treatments chosen the skin which the surface is rubbed
off. Most are superficial and will heal
3.​ Full-thickness wounds by epithelialization.
-​ Involves the epidermis and dermis
-​ If full-thickness wounds cannot be 5.​ Laceration
sutured, the healing process will -​ Caused by tearing of tissues
create new tissue to fill the wound, -​ Wounds have irregular borders
followed by regeneration of the -​ Loss of tissue is limited to skin and
epidermis. subcutaneous tissue
-​ The full-thickness wound takes
longer time to heal than does a 6.​ Penetrated wound
partial-thickness wound, sometimes -​ Cause by sharp pointed objects like
as long as several months nails. Have relatively small opening
-​ May be very deep Infection/ foreign
According to MORPHOLOGICAL particles might have been carried
CHARACTERISTICS: deep in to wound opening is
1.​ Bruises/contusion - closed wounds inadequate for drainage
-​ Caused by blunt trauma -​ eg: punctured wound on foot due to
-​ characterized by skin discoloration gathered nail
due to bleeding into the tissues.
Blows to the chest, abdomen, or 7.​ Perforating wound
head with a blunt instrument can -​ Have two openings one of entrance
cause contusions and other of exit
-​ Ex: gunshot wound
2.​ Hematoma
-​ These are also closed wounds
caused by damage to a blood According to: DEGREE OF CONTAMINATION
vessel that in turn causes blood to 1.​ Clean wounds
collect under the skin -​ No break in aseptic technique
-​ Initially this is fluid, but it will clot -​ Incision is made under sterile
within minutes or hours ⇒later after conditions
few days the hematoma will again -​ No inflammation is encountered
liquefy → increased risk of -​ The respiratory tract, alimentary,
secondary infection → pus genital or uninfected urinary tracts
formation are not entered
-​ Primary closure
-​ No drain
-​ Eg Herniorrhaphy
 ●​ Increased Macrophages
2.​ Clean contaminated wound
-​ Operative wounds in which the PROLIFERATIVE PHASE
respiratory, alimentary, genital or -​ After the inflammatory stage, the
urinary tract is entered under proliferative stage lasts about 3 weeks (or
controlled conditions and without longer, depending on the severity of the
unusual contamination wound)
-​ Aim: repair of wounded tissue
3.​ Contaminated wound -​ Characterized by:
-​ Open, fresh or accidental wounds; ●​ Angiogenesis - is the process of new
operations with major breaks in blood vessel formation and is necessary to
sterile technique or gross spillage support a healing wound environment
from the gastrointestinal tract; and ●​ Fibroplasia and granulation tissue
incisions in which acute, formation
non-purulent inflammation is ●​ Epithelialization
encountered ●​ Wound contraction

4.​ Dirty or infected wounds MATURATION AND REMODELING PHASE:

-​ Old traumatic wounds with retained The maturation phase of tissue repair begin when
devitalized tissue and those that the levels of collagen production and degradation
involve existing clinical infection equalize. The maturation phase can last for a
year or longer, depending on the size of the
wound and whether it was initially closed or left
According to: SEVERITY open. Scar tissues is formed.

1.​ Simple wound - The integrity of the skin is Types of wound healing:
traumatized without loss or destruction of 1.​ Primary intention
tissue and without the presence of a 2.​ Secondary intention
foreign body in the wound 3.​ Tertiary intention
2.​ Complex wound - Tissue is lost or
destructed by means of a crush, burn, or PRIMARY INTENTION (Primary Closure)
foreign body in the wound occurs when a wound is created aseptically with
minimal tissue damage. Healing takes place by
the approximation of tissue edges with suture,
WOUND HEALING staples, wound sealant etc

Phases: SECONDARY INTENTION

1.​ Inflammatory Occurs in wounds that are already infected and
2.​ Proliferative are usually left open and allowed to heal by
3.​ Maturation and remodeling phase epithelialization and wound contraction/ May be
caused by infection, excessive trauma, tissue
INFLAMMATORY PHASE loss, or inability to reapproximate the tissue. It is a
-​ Immediate to 2-5 days slow process
-​ Aim: to stop bleeding and to prevent
further injury. Ooze may be present TERTIARY INTENTION
-​ Characterized by :- Wounds that are heavily contaminated and are
●​ Clotting cascade-haemostasis likely to develop an infection if closed primarily
●​ Platelets aggregation may be left open for 3-5 days. This allows the
●​ Vasoconstriction and vasodilatation wound to be cleaned and allows the body’s
●​ Increased polymorphonuclea natural defenses to decrease bacterial count The
neutrophils wound can then be closed and allowed to heal,
producing a wound with characteristics similar to 2. Wound Cleansing
primary closure
●​ Purpose: Remove debris, bacteria, and
exudates without damaging healthy tissue.
METHODS OF WOUND CARE: ●​ Steps:
1.​ Wash hands and wear gloves.
1.​ Open method - keep open to environment 2.​ Use sterile normal saline or a
Ex; burns patients wound-cleansing solution (avoid
2.​ Closed method - after cleaning and antiseptics like iodine unless
application of medication on the wound is prescribed for infection).
covered with dressings 3.​ Clean from least contaminated
(center) to most contaminated
(edges).
DRESSINGS: 4.​ Avoid aggressive scrubbing to
Dry to dry - for wounds closing prevent tissue trauma.
Wet to dry - infected wounds
Rationale: Proper cleansing minimizes infection
Wet to wet - clean open wound
risk while preserving viable tissue.

III. Nursing Management in

Wound Care 3. Dressing Changes
1. Wound Assessment ●​ Dressing promotes moist wound healing,
protects from infection, and absorbs
Regular assessment is critical to track progress
exudate. Follow physician’s order for type
and identify complications.
of dressing.
●​ Key Parameters: Steps:
○​ Location and Size: Measure
length, width, and depth. 1.​ Prepare Equipment:
○​ Appearance: Note tissue type ○​ Sterile gloves, dressing materials,
(granulation, slough, necrosis). saline, trash bag, adhesive tape.
○​ Drainage/Exudate: Assess type, 2.​ Remove Old Dressing:
amount, and odor: ○​ Gently peel back, noting exudate
■​ Serous: Clear, watery. type/amount. Dispose of it properly.
■​ Sanguineous: Blood-tinged. 3.​ Clean the Wound:
■​ Purulent: Yellow, green, or ○​ Use aseptic technique with
foul-smelling (indicates prescribed solution.
infection). 4.​ Apply New Dressing:
○​ Surrounding Skin: Check for ○​ Types of dressings:
redness, swelling, or maceration. ■​ Hydrocolloids: Maintain
○​ Pain: Evaluate and document. moist environment for
○​ Signs of Infection: Erythema, granulation.
warmth, increased drainage, ■​ Foams: Absorb exudate for
systemic fever. moderate to heavy drainage.
■​ Transparent Films: Ideal for
Rationale: Accurate wound assessment guides superficial wounds.
appropriate interventions and ensures timely ■​ Alginates: Absorb large
adjustments to care. amounts of exudate.
○​ Secure dressing with tape or
bandage.
Rationale: Dressing selection should match 1.​ Chronic Wounds (e.g., Diabetic Foot
wound type to facilitate optimal healing and Ulcers, Pressure Ulcers):
minimize complications. ○​ Implement multidisciplinary care
(nutritionist, physical therapist).
○​ Encourage high-protein diet and
hydration to promote healing.
4. Infection Prevention 2.​ Age-Related Factors:
○​ Older adults may have delayed
●​ Hand Hygiene: Always perform before
healing due to reduced collagen
and after wound care.
production and circulation.
●​ Aseptic Technique: Use sterile gloves
○​ Maintain gentle handling to avoid
and materials for dressing changes.
skin tears.
●​ Patient Education: Teach the patient
3.​ Nutrition:
about signs of infection and proper
○​ Ensure adequate intake of Vitamin
hygiene.
C, Zinc, and protein for wound
Rationale: Infection prevention is vital to avoid repair.
delayed healing, sepsis, or further complications.
Rationale: Comprehensive care tailored to
individual needs enhances outcomes.

5. Pain Management

●​ Administer prescribed analgesics 30 V. Documentation in Wound

minutes prior to dressing changes.
●​ Use atraumatic techniques during care. Care
Rationale: Reducing pain improves patient 1.​ Key Points to Include:
compliance and comfort. ○​ Date and time of dressing change.
○​ Wound location, size, and
appearance.
○​ Type of dressing applied.
6. Monitoring and Managing ○​ Patient’s response to care (pain
Complications level, tolerance).
○​ Any complications or observations.
●​ Infection:
○​ Observe for redness, warmth, Rationale: Clear and accurate documentation
swelling, or purulent drainage. facilitates continuity of care and legal compliance.
○​ Administer antibiotics if prescribed.
●​ Dehiscence/Evisceration:
○​ Protect wound with sterile
saline-soaked gauze and notify the VI. Patient and Family Education
physician immediately.
●​ Pressure Injury: 1.​ Teach about proper wound care
○​ Reposition patient every 2 hours. techniques if home care is required.
○​ Use pressure-relieving devices. 2.​ Discuss the importance of nutrition,
hydration, and smoking cessation.
Rationale: Early detection and intervention 3.​ Educate on recognizing signs of infection
prevent worsening of wound conditions. and when to seek medical help.

Rationale: Empowering patients and caregivers

ensures proper wound management and reduces
readmissions.