Prepared by: Donnel Rolle RN
April 16, 2013
Objectives
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Review of anatomy and physiology of the skin
Define the term wound
State classification of wounds
Identify the types of wounds
Describe phases of wound healing
Discuss factors that affect wound healing
Discuss wound complications
State the steps of wound assessment and wound care
List some nursing diagnosis for patient with a wound
The skin: anatomy and physiology
http://www.compareskincare.co.uk/blog/wp-content/uploads/2011/04/skin_structure.gif
The skin
 The skin is the largest organ of the body as it is the natural
layer covering the body.
 The structure of the skin is made up of three layers known as
the epidermis, dermis and subcutaneous layers.
 The skin has four primary functions that include: protection,
maintenance of body temperature, excretion and
perception/sensation.
Intact skin: refers to the presence of normal skin without any
wounds.
Definition of a wound
A break or disruption in the normal integrity of the skin and
tissues.
http://www.orthopaedics.com.sg/wp/wp-content/uploads/2011/07/LacerationWound.jpg
Classification of wounds
1. Intentional versus unintentional
2. Open versus closed
3. Acute versus chronic
4 . Depth of the wound
Intentional versus unintentional wounds
Intentional wound
* Occurs as a result of planned
invasive therapy. For example:
surgery or venipuncture.
* Risk of infection is decreased
because wound was made under
sterile conditions.
Unintentional wound
* Occurs accidentally from
unexpected trauma such as
motor vehicle accident, stabbing
or gun shot wound.
* High risk of infection because
wounds occur in an unstable
environment and there is longer
healing time.
Open versus closed wounds
Open wound
 The mucous membrane or skin
surface is broken.
 Can be caused from intentional
or unintentional trauma.
 Portal of entry for organisms
Closed wound
 The tissues are traumatized
without a break in the skin.
 Results from a blow, force or
strain.
 Internal injury and hemorrhage
may occur.
Acute versus chronic wounds
Acute wounds
 Wound edges are well
approximated.
Chronic wounds
 Chronic wound edges are not
approximated.
 Usually heal within days to weeks.
 Increased risk of infection.
 Less risk of infection.
 Normal healing time delayed.
 Includes wounds such as surgical
 Examples include: deep
incisions.
pressure ulcers, venous ulcers
Depth of 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
Source:
http://www.bing.com/images/search?q=classification+of+wounds&FORM=HDRSC2#view=detail
&id=87F15B02DBF94A6943C0098D3CEBDB324F53BE7B&selectedIndex=4
Types of wounds - Abrasion
 Skin scraped against rough
surface
 Top layer of skin wears away
exposing numerous capillaries
 Often involves exposure to dirt
and foreign materials
 Increased risk for infection
http://www.organicfacts.net/health-benefits/home-remedies/home-remedies-for-abrasions.html
Types of wounds - Laceration
 A jagged wound or cut.
 Sharp or pointed object
tears tissues – results in
wound with jagged edges.
 May also result in tissue
avulsion.
http://www.utahmountainbiking.com/firstaid/cuts.htm
Types of wounds - Penetrating wound
 Open wound, penetration of
the skin and often the
underlying tissues by a
sharp instrument usually
unintentional.
 Foreign object entering skin
at high velocity.
http://onsurg.com/wordpress/wp-content/uploads/2013/07/tumblr_inline_mqccn9SkQ61qz4rgp.jpg
Types of wounds - Puncture
 A small hole or wound
made by a sharp object.
 A wound that is deeper
than it is wide, produced
by a narrow pointed
object.
https://edc2.healthtap.com/ht-staging/user_answer/reference_image/9449/large/foot_puncture_wound.jpeg?1349479793
Types of wounds - Burn
 A burn is a type of injury
to the skin caused by
heat, electricity,
chemicals, light, radiation
or friction.
http://www.elginburninjurylawyer.co/library/images/stock-images/fire-burn/burn-injury-hand-1.jpg
Types of wounds - Incision
 A cut or a wound made by
cutting with a sharp
instrument.
 Wounds with smooth
edges.
http://www.thefootandankleclinic.com/surgery/1256-460.jpg
Types of wounds - Avulsion
 Skin is torn from body
 Major bleeding
 Place avulsed tissue in moist
gauze (saline), plastic bag,
and immerse in cold water
 Take to hospital for
reattachment
http://www.utahmountainbiking.com/firstaid/images/pics-firstaid/flap1a.jpg
Types of wounds - Pressure Ulcer
A lesion caused by unrelieved pressure that
results in damage to underlying tissue.
https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcSj-Oau3ifZGrONDCbxrRz1yUvToXHAs94f4zgref8goTVpxvIRsg
A wound with a localized area of tissue necrosis.
Also called decubitus ulcer or bedsore
https://encrypted-tbn2.gstatic.com/images?q=tbn:ANd9GcTgVmpH29ZaGUGLvLjhkHM3SFsEqsyR0CopWHi6z45zeAlr8pHw
Pressure Ulcer Risk Factors
1. Immobility and inactivity.
2. Inadequate nutrition
3. Fecal and urinary incontinence.
4. Decreased mental status: because there is decreased in the
respond to the pain associated with prolonged pressure.
5. Diminished sensation: paralysis or other neurologic disease
may cause loss of sensation in a body area.
NPUAP Pressure Ulcer Stages
SUSPECTED DEEP TISSUE
INJURY
A localized area of discolored (purple or maroon)
intact skin or blood-filled blister. The area may be
painful, firm, mushy, boggy, warmer or cooler
compared to adjacent tissue.
STAGE I
A reddened area on the skin that when pressed is
‘nonblanchable’ (does not turn white). This
indicates that a pressure ulcer is starting to
develop.
STAGE II
The skin blisters or forms an open sore. The area
around the sore may be red and irritated.
STAGE III
The skin breakdown now looks like a crater where
there is damage to the tissue below the skin.
STAGE IV
The pressure ulcer has become so deep that there
is damage to the muscle and bone and sometimes
tendons and joints.
Source: National Pressure Ulcer Advisory Panel. Pressure ulcer stages revised by NPUAP (online) 2007.
Available from: http://www.npuap.org/pr2.htm
Stages of Pressure Ulcer
http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-categorystaging-illustrations/
Braden Scale
for predicting pressure sore risk
The Braden Scale is used to assess the patient’s level of risk for development
of pressure ulcers.
The evaluation is based on six indicators: sensory perception, moisture,
activity, mobility, nutrition, and friction or shear.
The Braden Scale is a summated rating scale made up of six subscales
scored from 1-4, for total scores that range from 6-23. A lower Braden Scale
score indicates a lower level of functioning and, therefore, a higher level of
risk for pressure ulcer development. A score of 19 or higher, for instance,
would indicate that the patient is at low risk, with no need for treatment at
this time (15-16 = low risk, 13-14 = moderate risk, 12 or less = high risk).
The assessment can also be used to evaluate the course of a particular
treatment.
http://www.bradenscale.com/images/bradenscale.pdf
Phases of Wound Healing
http://www.worldwidewounds.com/2002/april/Vowden/images/WBP-Figure-8.jpg
1 - Inflammatory Phase
 Begins at time of injury and prepares wound for
healing. Consists of two phases; vascular phase and
cellular phase
Vascular phase
Hemostasis
Vasoconstriction
Formation of exudate – causing
swelling, pain heat and redness. Scar
formation if small wound.
Cellular phase
Movement of WBC (leukocytes) to wound
Release of growth factors needed for
growth of epithelial cells and new blood
vessels.
Patient may have increased temperature,
and general malaise during this phase
2 - Proliferative Phase
 Begins within 2 - 3 days up to 2 - 3 weeks
 a) Granulation - new tissue built to fill wound space and forms
the foundation for scar tissue development.
- Fibroblasts lay bed of collagen
- Fills defect and produces new capillaries
 b) Contraction - Wound edges pull together to reduce defect
 c) Epithelialization
3 - Remodeling Phase
 Final stage that begins about 3 weeks after injury
 Collagen that was haphazardly deposited in the
wound is remodeled, making the healed wound
stronger and more like adjacent tissue.
 Scar now becomes a flat, thin line.
Factors Affecting wound healing
Age
Children and healthy adults heal more quickly than older adults.
Skin loses turgor and is more fragile.
Circulation and
oxygenation
Adequate blood flow is needed to deliver nutrients and oxygen
and to remove toxins, bacteria and other debris.
Nutritional status
Good nutrition is vital to wound healing. (specifically adequate
intakes of protein, carbohydrates, fluids, and vitamin C).
Wound condition
Size, presence or absence of infection etc.
Health status
Presence of chronic illnesses like diabetes mellitus, hypertension
etc. or impaired immune function can impair wound healing.
Surgical Wound Closures
http://umm.edu/health/medical/ency/carepoints/incision-closures
Wound Complications
 Wound complications include:
 Infection
 Hemorrhage
 Dehiscence
 Evisceration
Wound Infection
 Caused by invasion of bacteria usually at the time of
trauma or during surgery causing contamination
leading to infection.
 Symptoms include: purulent drainage, drainage,
redness, pain, and swelling around the wound,
body temperature and WBC’s.
 Symptoms usually apparent within 2 – 7 days post
surgery or injury.
Hemorrhage
 May occur due to a dislodged clot, infection, or the
erosion of blood vessels.
 Nursing action – check dressing frequently during
first 48 hours post-surgery and the q8 hours.
 If excessive bleeding, apply additional sterile pressure
dressing and call physician.
Dehiscence and Evisceration
 Dehiscence – partial or total
disruption of wound layers.
Patient may say, “something
has suddenly given way”.
 Evisceration – the
protrusion of viscera
through the incisional area.
http://img2.tfd.com/mk/D/X2604-D-12.png
Wound Assessment
Patient assessment – wound healing is determined by overall health of
the patient
Wound assessment – assessment should include
 Wound location, size and type
 Characteristics of the wound bed, such as necrotic tissue, granulation tissue and
infection
 Odor and exudate (none, low, moderate, high)
 The condition of the surrounding skin (normal, oedematous, white, shiny, warm,
red, dry, scaling, thin)
 Signs of infection: delayed healing, odor, abnormal granulation tissue, increased
wound pain and excessive exudate
 Pain: location, type, duration, intensity
Also included in the assessment are sutures, drains, tubes and
manifestations of complications
http://www.coloplast.com.au/woundandskincare/topics/woundmanagement/woundassessment/
Wound Care and Dressings
 A dressing is used as a protective covering placed over the
wound as it heals.
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Prepare patient and provide privacy
Hand-washing before and after procedure
Assessment of wound
Clean wound using aseptic technique
Clean from most contaminated to least contaminated - from
inside out
 Apply recommended sterile dressing
NANDA Nursing Diagnosis
NANDA International Inc has a list of nursing diagnosis.
These are the ones that are relevant to this topic
 Impaired skin integrity
 Risk for infection
 Acute pain
 Disturbed body image
http://www.nanda.org/nursing-diagnosis-list.html
Conclusion
 The skin is a barrier to the outside world protecting the body
from injury and invasion by organisms.
 Wounds occur when the skin is broken or damaged because
of injury.
 There are many types of wounds that can damage the skin
including abrasions, lacerations, punctures, and penetrating
wounds etc.
 The body responds systematically to trauma.
 An adequate blood supply and good nutrition are essential for
wound healing.
References
Definition of wound. Retrieved from: http://www.surgeryencyclopedia.com/StWr/Wound-Care.html#b#ixzz2P3vqABkw
Wound definition retrieved from: http://www.thefreedictionary.com/wound
Doherty , J. L. Wound Care (ppt) Florida International University - Department of Health,
Physical Education, and Recreation.
Four functions of skin. Retrieved from: http://www.ehow.com/facts_4830670_fourfunctions-skin.html#ixzz2QZe15fkL
Phases of wound healing retrieved from: http://www.medicaledu.com/phases.htm
Taylor, C., Lillis, C. and LeMonde, P. 2005. Fundamentals of Nursing, 5th ed. Chapter 38.
Skin integrity and wound care. Lippincott Williams and Wilkins
Wounds and wound care. Retrieved from:
http://www.emedicinehealth.com/wound_care/article_em.htm#wound_care_facts