WOUND CARE

TYPES OF WOUNDS
Incision
= sharp instrument (knife)
Contusion
= blow from blunt instrument
Abrasion
= surface scrape
Laceration
= tissues torn apart
Penetrating
= deeper penetration: from bullet
Puncture
= shallow penetration
 
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DEGREE OF WOUND CONTAMINATION
a. Clean wounds
 Uninfected, no inflammation; respiratory,
genital and urinary tracts are not entered
b. Clean contaminated wounds
 Surgical wounds and respiratory, genital
and urinary tracts has been entered
c. Contaminated wounds
 Open, fresh, major break in sterile
technique, signs of inflammation
d. Dirty or infected
 old, accidental wounds with dead tissue,
with infection, purulent drainage
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CLASSIFICATION OF WOUND BY DEPTH:
a. Partial thickness
 Confined to skin
 Epidermis and dermis

b. Full thickness
 Dermis, epidermis, subcutaneous, muscle
and bone
WOUND CARE
WOUND HEALING
 quality of living tissue; regeneration
THREE PHASES: (IPM)
1. Inflammatory phase
- initiated immediately and lasts 3-4 days
- marked with HEMOSTASIS and PHAGOCYTOSIS
2. Proliferative phase
- until day 21 post injury
- Collagen formation – whitish protein substance that
adds to tensile strength of wound; eschar formation
3. Maturation phase
- begins at day 21 until 1 - 2 years; scar formation
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TYPES OF HEALING
1. Primary Intention; FIRST INTENTION
- tissue surfaces have been closed and
minimal tissue loss;
- SURGICAL INCISION

2. Secondary Intention
- extensive and with tissue loss, edges
cannot be
approximated;
- PRESSURE ULCER
Note: repair time is longer
scarring is greater
susceptibility to infection is greater
WOUND CARE
TYPES OF HEALING:

3. Tertiary intention healing;

- DELAYED or secondary closure
- indicated when there is reason to
delay a
suturing wound
- ABDOMINAL WOUND THAT IS LEFT
OPEN FOR DRAINAGE AND IS LATER
CLOSED
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KINDS OF WOUND DRAINAGE
1. Serous:
= serum; from clear portion of the blood,
clear to brownish
2. Sanguineous:
= bloody, BRIGHT red
3. Serosanguineous
= combination of blood and serum, pinkish
4. Purulent:
= pus, YELLOW OR yellow-green
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COMPLICATIONS OF WOUND HEALING
H = HEMORRHAGE
I = INFECTION
D = DEHISCENCE = opening
E = EVISCERATION = coming out
C = CALL for help and assistance
C = COVER wound with saline soaked
sterile OS
K = KEEP MOIST
D = DON’T REINSERT protruding organs
D = DORSAL RECUMBENT position
D = DO VSQ5M and prepare for surgery
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RYB COLOR CODE OF WOUNDS
- Based on the color of an open wound rather
than depth and size of wound
- Can be applied to wound allowed to heal by
SECONDARY INTENTION

Goals of wound care:

a. RED : Protect (cover)
b. YELLOW : Cleanse
c. BLACK : Debride
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RYB COLOR CODE OF WOUNDS

a. RED : PROTECT
- Gentle cleansing
- Avoiding use of dry-gauze or wet to dry saline
dressings
- Application of topical antimicrobial agent
- Transparent film or hydrocolloid dressing
- Change dressing infrequently
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RYB COLOR CODE OF WOUNDS

b. YELLOW : CLEANSE
 To absorb drainage and remove nonviable
tissue
 Apply wet-wet dressing
 Irrigating the wound
 Use of absorbent dressing material
 Consult MD as to use of antimicrobial agent
WOUND CARE
RYB COLOR CODE OF WOUNDS

c. BLACK : DEBRIDEMENT
 full thickness or third degree burns, gangrene
 Covered with occlusive dressing to provide
moist environment
 Eschar removal
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NURSING INTERVENTIONS
a. Wound dressing
b. RYB color code
c. Surgical dressing
d. Wound drains
e. Wound irrigation
f. Sutures
g. Heat and cold application
h. Supporting and immobilizing wounds
a. bandages and binders