A) Wound Care

Wound – a disruption in the continuity and regulatory processes of the tissue cells
Wound healing – the restoration of the disruption in the continuity of the skin

Phases of Wound healing

a. Inflammatory phase
 Vascular and cellular responses are immediately initiated when the tissue is cut or injured
 Vasoconstriction temporarily occurs until platelets clot to control bleeding and close the
wound
 Edema, redness, warmth and pain happens as the blood vessels dilate pouring the
antibodies, leukocytes and RBC’s at the site of injury
 Vasodilatation is caused by serotonin, histamine and prostaglandin

b. Proliferative phase
 Fibroblasts multiply and new budding capillaries combine forming a granulation tissue
 The new capillaries will nourish the multiplying fibroblasts/connective tissues

c. Maturation Phase
 From the start of collagen synthesis, collagen fibers undergo a process of lysis and
regeneration. The collagen fibers become more organized, aligning more closely to each
other and increasing tensile strength
 Scar tissue is formed from the collagen growth. If the collagen growth exceeds the lysis,
a keloid forms

Types of Wound Healing

a. Primary Intention Healing
 Wounds have minimum tissue loss, and wound edges are properly approximated
 Scar tissue is also minimal

b. Secondary Intention Healing

 Wounds are left to heal spontaneously. The wound fills with granulation tissue, and when
it heals it produces a deeper and wider scar because of greater tissue loss

c. Tertiary intention healing

 Occurs when there is a delayed surgical closure of an infected wound

Wound Management:
1. Assess wound integrity
2. Ensure asepsis during dressing changes
3. Reinforce initial dressing when bleeding is noted and change dressings promptly when saturated with
drainage
4. Minimize strain on the incision change
a) use appropriate tape, bandages or binders
b) splint chest and abdominal incisions when coughing, changing positions and movement
c) instruct patient to avoid touching the incision or dressing to avoid and minimize wound injury
and contamination
5. Assess patient’s nutritional intake and degree of hygiene or assistance needed to support wound
healing
6. Instruct the patient and significant other to report immediately following signs of infection like redness,
marked swelling, tenderness, increased warmth around the site and presence of discharges
7. Reinforce the value of taking prescribed prophylactic medications such an antibiotics and analgesics

Dressings
1. Purposes
a. to protect the wound from mechanical injury
b. to splint or immobilize the wound
c. to absorb drainage
d. to prevent contamination from bodily discharges
e. to debride the wound
f. to inhibit the growth and kill microorganisms using dressings with antimicrobial properties
g. to provide moisture and a physiologic environment conducive for healing
i. to provide mental and physical comfort to the patient

Types of Dressings:
1. Sterile dressing – also known as “ambulance dressings” which consist of a dressing pad with a
bandage attached; the dressing pad is made up of a piece of gauze or lint packed by a layer of
cotton wool padding; are considered sterile because they are sold in single units in a variety of
size, are sealed with protective wrappings, if the seal is broken on the protective covering the
dressing is no longer sterile

2. Gauze dressing – made from layers of gauze that form a soft, pliable covering for wounds;
adhesive strapping is used to secure the dressing or a roller bandage if pressure is required
STEPS in application:
1. Hold the gauze pads by the edges and place it directly on the wound
2. Add a layer of cotton wool padding on top of the gauze
3. Secure with adhesive strapping or a roller bandage

3. Adhesive dressings – commonly known as plasters that are useful for small wounds; these consists
of a gauze or cellulose pad attached to an adhesive backing; some especially shaped plasters are
available for fingertips, heels and elbows

STEPS in applying adhesive dressings:

a. Remove the wrapping and hold the dressing, pad side down, by the protective strips
b. Peel back, but do not remove the protective strips without touching the dressing pad,
place it directly on to the wound
c. Carefully pull away the protective strips. Press the ends and edges down.

General rules in applying dressings:

1. The dressing pad should always extend well beyond a wound’s edges
2. Place dressing directly on a wound. Do not slide them on from the side, and replace any that slip
from place.
3. If bleeding strikes through a dressing, do not remove it. Instead, apply another dressing over the
top.
 4. If there is only one sterile dressing, use this to cover the wound and use other clean materials as
top dressings.
5. Wear disposable gloves, if available.
6. Wherever possible, wash your hands thoroughly before dressing a wound.
7. Avoid touching the wound or any part of the dressing that will come into contact with the wound.
8. Try not to talk, sneeze or cough over the wound.

Types of dressing application

1. Dry-to-dry dressings
- offers good protection, absorption of drainage and pressure but may adhere to the wound
surface when it dries causing pain and disruption of the granulation tissue during removal

2. Wet-to-dry dressing
- Gauze is saturated with normal saline and is packed into the wound and covered by a dry
dressing. As drying occurs, debris and necrotic tissue are absorbed into the dressing allowing
wound debridement

 wet-to-wet dressing
- Sterile saline or antimicrobial agent are used to saturate the dressings which are packed on the
wound. It provides an optimum environment for wound healing, better removal of exudates and
patient comfort but increased infection can occur when the wound becomes macerated and the
linens may become damp