NURSING CARE FOR PATIENT

WITH WOUND

By
Purwaningsih
 Break in skin
or
mucous membranes

What are wounds ?

 Injury to any of
the tissues of the body,
especially that caused by
physical means and with
interruption of continuity
is defined as a wound.

n d
ou
e W
Th
 Wound healing is a natural
and spontaneous
as
e h d phenomenon.
su te t
ti rup tha l
s
en is l y a
h n d re he
W ee ve ot y :
b se nn all
so t ca tur
i na

* dead tissue and foreign bodies

must be removed,
* infection treated,
* and the tissue must be held in
apposition
 Until the healing
process provides
the wound with
sufficient strength
to with stand stress
A wound may
without
be approximated
mechanical
with sutures,
support.
staples, clips,
skin closure
strips, or topical
adhesives.
 1. Intentional Vs. Unintentional.
2. Open Vs. Closed.
3. Degree of contamination.
4 . Depth of the

Classification of wounds
 Intentional Vs. Unintentional wounds

Intentional wound: occur during therapy. For

example: operation or venipuncture.
Unintentional wound: occur accidentally.
Example: fracture in arm in road traffic accident.
 Open Vs. Closed wounds
Open wound: the mucous membrane or skin
surface is broken.

Closed wound: the tissue are traumatized

without a break in the skin.
 Degree of contamination
Clean wounds: are uninfected wounds in which
minimal inflammation exist, are primarily closed
wounds.
Clean –contaminated wound: are surgical wounds in
which the respiratory, alimentary, genital, or urinary
tract has been entered. There is no evidence of
infection.
 Degree of contamination
Contaminated wounds: include open, fresh,
accidental wounds. There is evidence of
inflammation.
Dirty or infected wounds: includes old,
accidental wounds containing dead tissue and
evidence of infection such as pus drainage.
 Depth of the wound
Partial thickness: the wound involves dermis and
epidermis.

Full thickness: involving the dermis, epidermis,

subcutaneous tissue, and possibly muscle and
bone.
 Types of wounds
1. Incision: open wound, painful, deep or
shallow, due to sharp instrument.
2. Contusion: closed wound, skin appears
ecchymotic because of damaged blood
vessels, due to blow from blunt instrument.
 Types of wounds
3. Abrasion: open wound involving skin only,
painful, due to surface scrape.

4. Puncture: open wound, penetrating of the

skin and often the underlying tissues by a
sharp instrument.
 Types of wounds
5. Laceration: open wound edges are often
jagged, tissues torn apart. Often from
accidents.
6. Stab wound: open wound, penetration of the
skin and the underlying tissues, usually
unintentional.
 Wound Healing
• Primary Intention
– skin edges are approximated (closed) as in a surgical
wound
– Inflammation subsides within 24 hours (redness, warmth,
edema)
– Resurfaces within 4 to 7 days
• Secondary Intention: tissue loss
– Burn, pressure ulcer, severe lasceration
– Wound left open
– Scar tissue forms
 Wound Healing
• Inflammatory Response
– Serum and RBC’s form fibrin network
– Increases blood flow with scab forming in 3 to 5 days
• Proliferative Phase: 3-24 days
– Granulation tissue fills wound
– Resurfacing by epithelialization

• Remodeling: more than 1 year

– collagen scar reorganizes and increases in strength
– Fewer melanocytes (pigment), lighter color
 Some Factors Influencing Wound Healing
• Age
• Nutrition: protein and Vitamin C intake
• Obesity decreased blood flow and increased risk for infection
• Tissue contamination: pathogens compete with cells for
oxygen and nutrition
• Hemorrhage
• Infection: purulent discharge
• Dehiscence: skin and tissue separate
• Evisceration: protrusion of visceral organs
• Fistula: abnormal passage through two organs or to outside
of body
 Complications of wound healing
1. Hemorrhage: some escape of blood from a
wound is normal, but persistent bleeding is
abnormal.
2. Hematoma: localized collection of blood
underneath the skin, and may appear as a
reddish blue swelling.
3. Infection
 Risk Assessment

• Alterations in mobility
• Level of incontinence
• Nutritional status
• Alteration in sensation or response to discomfort
• Co-morbid conditions
• Medications that delay healing
• Decreased blood flow to lower extremities when
ulceration is present
Assessment and Documentation
• Location
• Stage and Size
• Periwound
• Undermining
• Tunneling
• Exudate
• Color of wound bed
• Necrotic Tissue
• Granulation Tissue
• Effectiveness of Treatment
 Pressure Ulcer Assessment
• Tissue Type
– Granulation Tissue: red and moist
– Slough: yellow stringy tissue attached to wound
bed; removal essential for healing
– Eschar: necrotic tissue which is brown or black
appearance must be debrided
 Pressure Ulcer Assessment

• Wound Deterioration
– Skin surrounding ulcer
• Redness, warmth, edema
• Exudate
– Amount, color, consistency, odor
 Assessment
• In emergency settings
– Bleeding?
– Foreign bodies or contamination?
– Size of wound?
– Need for protection of wound?
– Need for tetanus antitoxin
 Assessment
• Stable Setting
– Wound appearance
– Character of drainage
• Serous
• Sanguineous
• Serosanguineous
• Purulent
 Assessment
• Stable setting
– Drains
• Penrose
• Evacuator units
– Jackson Pratt drains
– Hemovac drains
– Wound closures
• Sutures
• Steel staples
• Clear strips
• Wound glues
Drains and Wound Closures
 Pressure Ulcer Staging 2

Stage I Stage II Stage III Stage IV

 Pressure Ulcer Stages
• Stage I: No Skin Break
– Skin temperature, consistency (firm), sensation
(pain or itching)
– Persistent redness in light skin tones
– Persistent red, blue or purple hue in darker skin
tones
 Pressure Ulcer Stages
• Stage II: Superficial
– Partial-thickness skin loss (epidermis and/or dermis
– Abrasion, blister or shallow crater

• Stage III
– Full-thickness skin loss (subcutaneous damage or necrosis
and may extend down to but not through fascia
– Deep crater
 Pressure Ulcer Stages
• Stage IV: full thickness skin loss and destruction, necrosis of
the tissue, damage to muscle, bone, tendons and joint
capsules and sinus tract

• Types of Dressings
• Transparent film (Tegraderm, Bioclusive)
• Hydrocolloid (Duoderm, Comfeel)
• Hydrogel
• Gauze Roll (Kerlix)
– Provide moist environment
– Loosen slough and necrotic tissue
– Wick drainage from wound
 Nursing Diagnosis
• Impaired Skin Integrity
• Impaired Tissue Integrity
• Risk for Infection
• Pain
• Imbalanced Nutrition, Less than body
requirements
 Care Planning .

Overall strategy and scope of the

treatment plan depends on patient’s
condition, prognosis, and reversibility of
the wound.
 Appropriate Goals
• Prevent complications or the deterioration of an
existing wound
• Prevent additional skin breakdown
• Minimize harmful effects of the wound on the
patient’s overall condition
• Promote wound healing
 Interventions
Dressing considerations should include:

• Patient’s condition and prognosis

• Caregiver ability
• Ease and continuity of use
• Ability to maintain moisture balance
• Frequency of change
 Specific Points Affecting
Wound Healing
• Keep wound clean and scab free
• Keep wound moist
• Avoid steroid creams
• Suturing wound splints skin
• Wounds actually shrinks
 Pain Management
1) Medicate the resident prior to dressing
changes
2) Some treatment regimes may be
uncomfortable for the resident
3) Provide maintenance doses of medication
for those patients who have pain.
4) Adjuvant therapy may be appropriate
5) Consider non-medicinal approaches
Wound Preparation

• Removal of hair
– Not eyebrow
• Scrubbing the wound
• Irrigation with saline
– Avoid peroxide, betadine,
tissue toxic detergents
 Basic Elements of Wound Care

• Cleanse Debris from the

Wound
• Possible Debridement
• Absorb Excess Exudate
• Promote Granulation and
Epithelialization When
Appropriate
• Possibly Treat Infections
• Minimize Discomfort
 Interventions
Stage I
GOALS:
TREATMENTS:
• Maintain skin integrity
•Preferred
Skin toagents
remain(dry
clean and odor free
skin)
•• Protect and moisturize
Aloe Vesta skin creamskin
Preferred agents (at risk for breakdown due to incontinence/pressure)
• Aloe Vesta protective ointment
• Dermarite Perigaurd barrier ointment
 Interventions
Stage II, III, IV
Dry to Minimal Exudate

GOALS:
TREATMENTS:
• Minimize dressing changes
• Maintain moist environment
Preferred agents:
• Prevent infection
• Hydrofiber (Aquacel)
• Prevent additional skin
breakdown • Viscopaste
• Hydrocolloid (DuoDERM
Extra Thin)

Follow product guidelines for

frequency of dressing change
 Interventions
Stage II, III, IV

Moderate Exudate

GOALS:
• Minimize dressing changes
• Maintain moist environment
• Prevent infection
• Prevent additional skin
breakdown
TREATMENTS:
Preferred Agents:
• Hydrofiber (Aquacel)
• Hydrocolloid (DuoDERM
Signal)

Follow product guidelines for

frequency of dressing change
 Interventions
Stage II, III, IV
Copious Exudate

GOALS:
• Minimize dressing changes
• Manage Exudate
• Prevent infection
• Prevent additional skin
breakdown
TREATMENTS:
Preferred Agents:
• Hydrofiber (Aquacel)
• Hydrocolloid (DuoDERM
Signal)

Follow product guidelines for

frequency of dressing change
 Interventions
Infected Wounds …

Diagnosis of wound infection: Treatments:

• Swab Cultures not recommended
• Based on clinical signs (fever,
increased pain, friable granulation
tissue, foul odor)
Preferred agents:
• Hydrofiber (Aquacel Ag)
• Silvadene ointment and non-
sterile gauze

Tissue culture or biopsy is not DO NOT USE:

optimal for the hospice patient.
• Providine Iodine
• Iodophor
• Dakin’s solution
• Hydrogen peroxide
• Acetic Acid
Cleaning a Wound
Securing A Dressing
 REFERENCES

1. Bucky Boaz, Principles of Wound Closure

2. Magdy Amin RIAD, Wound care, University of Dundee
3. Teresa V. Hurley, Skin Integrity and Wound Care
4. UNC Emergency Medicine, Wound Management
5. VITAS Healthcare Corporation, Wound CareBest Practice Guidelines
Thank you