Wound Care &

Dressing
THE SKIN

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 Skin
• Skin is the largest organ of the body
• Skin is not just one static layer; it varies in thickness
depending on the location of the body. The thickest skin is
found on the bottoms of the feet, while the thinnest is found
around the eyes
• There are 3 layers of the Skin:
Epidermis, Dermis & Subcutaneous

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 FUNCTIONS OF THE SKIN
Defense against
Synthesis of microorganisms
Maintenance of hydration Vitamin D

Waste removal
Immune function Healthy Skin

Protection against injury Sensation

Thermoregulation

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Wound-Definitions
(Manley, Bellman, 2000)

A loss of continuity of the skin or mucous

membrane which may involve soft
tissues, muscles, bone and other
anatomical structure.

• Any disruption to layers of the skin

and underlying tissues

• Due to multiple causes including

trauma, surgery, or a specific
disease state
 Wound Assessment
• Appearance: granulation tissue, eschar, slough, edema, tunneling,
undermining, sinus tracts, color
• Drainage: serous--- Clear Fluid,
• Serosanguineous---- Fluid with blood,
• Sanguineous----- Blood,
• Purulent---- Fluid with pus and amount
• Pain
• Size & location on body
• Presence of sutures/staples
• Presence of drains/tubes
• Wound edges
 ??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?
 PHASES OF WOUND HEALING

Healing is a quality of living tissue; it is also referred to as

regeneration (renewal) of tissue.

A. The Inflammatory phase

B. The Regenerative (Proliferative) phase

C. The Maturative (Remodeling) phase

(Manley, Bellman, 2000)
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 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 I 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
more orderly structure.
• Scar forms - avascular tissue , doesn’t sweat, grow hair, or tan.
• Keloid- abnormal amount of collagen laid down, hypertrophic scar. (
common in dark skin).
 Factors Affecting Wound Healing
(Manley.K, Bellman. L,2000)

Developmental Age
Nutrition
Lifestyle
Medication
Infection
Wound perfusion Contamination
Bacteria present on surface
PH of the wound interface Colonization
Foreign bodies Bacteria attach to tissue and multiply

Infection
Bacteria invade healthy tissue and overwhelm immune defences
 Wound Complications
• Infection- S/S purulent drainage, pain, redness around wound, edema, increased
temp, elevated WBC

• Hemorrhage – S/S large amounts sanguineous drainage + other symptoms of

hypovolemic shock. Check UNDER clients

• Dehiscence- S/S wound edges pulling away; not well-approximated. Early sign =
increasing serosanguineous 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
 Types of Wound
(Hahn,Olsen,Tomaselli, Goldberg ,2004)

Type Cause Description and

Incision Sharp instrument eg. Knife
Contusion Blow from a blunt instrument
Abrasion Surface scrape, either unintentional (eg,
scraped knee from fall) or intentional (eg,
dermal abrasion to remove pockmarks)
Characteristics
Open wound; painful
Close wound, skin appears
ecchymotic (bruised) because
of damaged blood vessels
Open wound; involving the skin
; painful

Puncture Penetration of the skin and, often the Open wound; can be intentional
underlying tissues from a sharp instrument or unintentional

Laceration Tissues torn apart, often from accidents Open wound; edges are often
(eg, machinery) jagged
Penetrating Penetration of the skin and the underlying Open wound; usually accidental
wound tissues ( bullet or metal fragments)
 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
 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.
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The RYB color code cont’d
(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.

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The RYB color code cont’d
(Stotts,1999)

Red wounds cont’d

• 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
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The RYB color code cont’d
(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.

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The RYB color code cont’d
(Stotts,1999)

B – Black 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. 23
Purposes of wound dressing
To protect the 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
 Purposes of Wound Dressing

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.

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