Wound Care

Wound care is a crucial aspect of nursing that involves preventing

infection, promoting healing, and maintaining patient comfort. Proper
wound care requires an understanding of wound types, stages of healing,
and various management techniques to ensure optimal recovery.
Understanding Wounds

A wound is any disruption in the skin’s integrity, which can be caused by trauma,
surgery, or underlying medical conditions. Wounds can vary in depth, severity,
and type, which influences the approach to treatment and healing.
Types of wounds
1. Acute Wounds:
• Caused by trauma or surgical interventions.
• Heal within an expected timeframe (typically within 4–6 weeks) when treated properly.
• Examples: surgical incisions, cuts, abrasions, burns.

2. Chronic Wounds:
• Wounds that fail to heal properly, usually within 6 weeks.
• Often caused by underlying conditions such as diabetes, poor circulation, or immobility.
• Examples: pressure ulcers, diabetic foot ulcers, venous stasis ulcers.
3. Open Wounds:
• The skin is broken, exposing the tissue underneath.
• Examples: lacerations, puncture wounds, abrasions.

4. Closed Wounds:
• The skin remains intact, but damage occurs beneath the surface.
• Examples: contusions (bruises), hematomas.

5. Burns:
• Tissue damage caused by heat, chemicals, electricity, or radiation.
• Classified by depth: superficial (first-degree), partial-thickness (second-
degree), or full-thickness (third-degree).
Stages of Wound Healing

Wound healing is a complex process that occurs in four overlapping stages:

1.Haemostasis (Minutes to Hours):

• The immediate response to tissue injury, where blood vessels constrict to reduce blood flow, followed
by clot formation to stop bleeding.
• Platelets release growth factors that initiate the healing process.
2.Inflammation (Days 1–4):
• White blood cells, especially neutrophils and macrophages, migrate to the wound site to clear debris,
bacteria, and dead cells.
• The area may appear red, swollen, and warm due to increased blood flow.
3.Proliferation (Days 4–21):
• New tissue (granulation tissue) forms, consisting of collagen and extracellular matrix to rebuild the
wound bed.
• Blood vessels regenerate (angiogenesis), and epithelial cells migrate across the wound to close the skin
surface (epithelialization).
4.Maturation (Weeks to Months):
• The wound contracts as collagen is remodelled and strengthened.
• Scar tissue forms, which may be less elastic and weaker than normal skin
Factors Affecting Wound Healing:

• Age: Elderly patients may experience slower healing due to reduced

skin elasticity and circulation.
• Nutrition: Adequate protein, vitamins (especially A and C), and zinc
are essential for wound healing.
• Chronic Conditions: Conditions like diabetes and vascular diseases
can impede healing due to poor circulation and immunity.
• Medications: Corticosteroids and chemotherapy can delay healing by
suppressing the immune system.
• Smoking: Reduces oxygen supply to the wound, slowing healing.
• Infection: Delays healing and can cause complications such as sepsis.
 Wound Assessment

Regular wound assessments are necessary to monitor healing progress and detect complications
early.
Components of Wound Assessment:
1. Location: Where is the wound on the body?
2. Size: Measure the length, width, and depth of the wound using a sterile ruler.
3. Wound Bed:
• Granulation Tissue: Healthy, red, and moist tissue that indicates healing.
• Necrotic Tissue: Black or brown dead tissue that must be removed.
• Slough: Yellow, stringy tissue that may indicate infection or delayed healing.
4. Exudate (Wound Drainage):
• Serous: Clear, watery drainage (normal in small amounts).
• Sanguineous: Blood-tinged drainage (normal in early stages of healing).
• Purulent: Thick, yellow/green, or foul-smelling drainage (sign of infection).
5. Wound Edges: Are the edges of the wound contracting (healing) or are they undermined
(worsening)?
6. Surrounding Skin: Redness, warmth, or swelling in the skin around the wound can indicate
Using the TIME Framework for Wound
Assessment:

• T (Tissue): Evaluate the wound bed for necrosis or granulation.

• I (Infection/Inflammation): Monitor for signs of infection (redness,
warmth, purulent discharge).
• M (Moisture Imbalance): Ensure appropriate moisture balance to
support healing (not too wet or dry).
• E (Edge): Check the wound edges for signs of healthy tissue or delays
in healing.
Principles of Wound Management

Wound care involves cleaning, dressing, and monitoring the wound while addressing underlying conditions that
may affect healing.

1. Wound Cleaning:
Basic Principles:
• Aseptic Technique: Maintain cleanliness to prevent introducing pathogens to the wound.
• Sterile Materials: Use sterile gloves, dressings, and cleaning solutions when cleaning an open wound.
• Irrigation: Gently irrigate the wound with a sterile solution (e.g., normal saline) to remove debris
without damaging healthy tissue.
Cleansing Solutions:
• Normal Saline (0.9% Sodium Chloride): Preferred for wound irrigation due to its isotonic nature, which
doesn’t damage tissues.
• Antiseptics: (e.g., iodine, chlorhexidine) are used sparingly, as they can delay healing by damaging new
tissue.
• Sterile Water: Can also be used to clean superficial wounds.
Wound Irrigation:
• Use a syringe with a catheter or irrigation tip to flush out debris from the wound bed with saline.
• Irrigation pressure should be gentle enough to avoid damaging tissue but strong enough to clean the
wound effectively.
Wound Cleaning Steps/
Procedure:
1.Gather all necessary supplies (e.g., gloves, gauze, saline, sterile
swabs).
2.Perform hand hygiene and don clean gloves.
3.Irrigate the wound using a syringe filled with saline, starting at the
cleanest part of the wound and moving to the dirtiest.
4.Pat the wound dry with sterile gauze before applying any dressings.
5.Dispose of materials properly and perform hand hygiene again.
2. Wound Debridement:
Debridement is the removal of necrotic tissue to promote healing. It
can be performed in several ways:
1.Autolytic Debridement: Using moisture-retentive dressings (e.g.,
hydrogels) to soften and remove dead tissue naturally.
2.Mechanical Debridement: Involves physically removing dead tissue
(e.g., wet-to-dry dressings, wound irrigation).
3.Surgical Debridement: Performed by a surgeon to remove large areas
of necrotic tissue.
4.Enzymatic Debridement: Uses topical enzymes to break down dead
tissue.
3. Wound Dressing
Dressing wounds protects them from contamination, maintains a moist
environment, and supports healing.
Types of Dressings:
1. Gauze Dressings: Used for basic wound protection, they absorb exudate but
may adhere to the wound.
2. Hydrocolloid Dressings: Gel-forming dressings that maintain moisture, ideal
for partial- to full-thickness wounds.
3. Foam Dressings: Absorbent dressings that provide cushioning and moisture
retention, suitable for wounds with moderate exudate.
4. Transparent Films: Thin, adhesive films used for superficial wounds; allow
visualization of the wound without removing the dressing.
5. Hydrogels: Gel-based dressings that provide moisture to dry or necrotic
wounds, aiding in autolytic debridement.
6. Alginate Dressings: Made from seaweed, these highly absorbent dressings are
ideal for wounds with heavy exudate.
Dressing Change Procedure:
1. Prepare all necessary materials (sterile gloves, wound cleanser,
dressings).
2. Wash hands thoroughly and put on clean or sterile gloves.
3. Carefully remove the old dressing, observing any drainage or odor.
4. Clean the wound as needed, using appropriate wound irrigation
techniques.
5. Apply the new dressing, ensuring it covers the wound adequately.
6. Secure the dressing with tape or a bandage, ensuring it stays in
place but does not constrict circulation.
Infection Control in Wound Care

Preventing infection is paramount in wound care, as infections can severely

delay healing and lead to complications like sepsis.
Signs of Wound Infection:
• Increased redness, swelling, or warmth around the wound.
• Pus or foul-smelling drainage.
• Pain that is worsening instead of improving.
• Fever, chills, or general malaise.
Infection Prevention Strategies:
• Hand Hygiene: Always perform proper hand washing before and after wound care.
• Aseptic Technique: Use sterile gloves, dressings, and instruments when managing the
wound.
• Clean Environment: Ensure the wound dressing area is clean and free from
contamination.
• Antibiotics: Administer topical or systemic antibiotics as prescribed for infected
wounds.
Summary
• Effective wound care requires a thorough understanding of wound
types, healing processes, and the appropriate cleaning, dressing, and
management techniques. Regular assessment, proper hygiene, and
the use of appropriate dressings are essential for promoting healing
and preventing complications such as infection. Nurses must also
tailor wound care to individual patient needs, considering factors like
the type of wound, underlying conditions, and overall health status.