WOUND

CARE
JPP

SKIN INTEGRITY

Intact skin refers to the presence of

normal skin and skin layers
uninterrupted by wounds.
The appearance of the skin and the
skin integrity are influenced by internal
factors such as genetics, age, and the
underlying health of the individual as
well as external factors such as activity.

PHYSIOLOGY OF THE SKIN

Hypodermis
Temperature regulation via vasodilation,

vasoconstriction, sweating and shivering.

Absorption of some oxygen, carbon
dioxide, fat soluble vitamins( A, D, E and
K); certain steroid hormones and some
toxic substance
Sensory reception for touch, temperature,
pain, pressure, and stretch.

PHYSIOLOGY OF THE SKIN

Dermis
Protects against blood loss.
Synthesis of pigments and vitamin D
Temperature regulation via vasodilation,

vasoconstriction, sweating and shivering.

Absorption of some oxygen, carbon dioxide, fat
soluble vitamins( A, D, E and K); certain steroid
hormones and some toxic substance
Elimination of wastes: salts, water, and urea
Sensory reception for touch, temperature,
pain, pressure, and stretch.

PHYSIOLOGY OF THE SKIN

Epidermis
Protects against: dehydration, mechanical

injury, pathogens, UV light, blood loss.

Synthesis of pigments and vitamin D
Absorption of some oxygen, carbon dioxide,
fat soluble vitamins( A, D, E and K); certain
steroid hormones and some toxic substance
Elimination of wastes: salts, water, and urea
Sensory reception for touch, temperature,
pain, pressure, and stretch.

TYPES OF WOUNDS

INTENTIONAL
Occur during therapy
Ex. Operations or venipuncture.
UNINTENTIONAL
Accidental trauma
Ex. Fractured arm in an
automobile collision.

TYPES OF WOUNDS

CLOSED
If the tissues are traumatized without a

break in the skin.

OPEN
When the skin or mucous membrane

surface is broken.

TYPE

CAUSE

DESCRIPTION&CHARACTERISTICS

INCISION

Sharp instrument

Open wound; deep or shallow

CONTUSION

Blow from a blunt

instrument

Closed wound; skin appears

ecchymotic (bruised) because of
damaged blood vessels.

ABRASION

Surface scrape, either

unintentional or
intentional

Open wound involving the skin

PUNCTURE

Penetration of the skin

and often the
underlying tissues by a
sharp instrument ,
either intentional or
unintentional

Open wound

LACERATION

Tissues torn apart, often Open wound; edges are often jagged
from accidents (e.g.,
with machinery)

PENETRATIN
G WOUND

Penetration of the skin

and the underlying
tissues, usually
unintentional (e.g., from
a bullet or metal
fragments)

Open wound

TYPES OF WOUNDS

Incision

TYPES OF WOUNDS

TYPES OF WOUNDS

TYPES OF WOUNDS
-wounds

can also be described according to

the likelihood and degree of wound
contamination.

CLEAN WOUNDS
CLEAN-CONTAMINATED WOUNDS
CONTAMINATED WOUNDS
DIRTY OR INFECTED WOUNDS

TYPES OF WOUNDS

CLEAN WOUNDS
Uninfected wounds in which minimal

inflammation is encountered
The respiratory, alimentary, genital, and
urinary tracts are not entered.
Primarily closed wounds.

TYPES OF WOUNDS

CLEAN-CONTAMINATED WOUNDS
Surgical wounds in which the
respiratory, alimentary, genital or
urinary tract has been entered.
Such wounds show no evidence of
infection.

TYPES OF WOUNDS

CONTAMINATED WOUNDS
Include open, fresh, accidental
wounds and surgical wounds
involving a major break in sterile
technique or a large amount of
spillage from the GI tract .
Show evidence of inflammation.

TYPES OF WOUNDS

DIRTY OR INFECTED WOUNDS

Include wounds containing dead
tissue and wounds with evidence
of a clinical infection, such as a
purulent drainage.

Degree of wound
contamination

Degree of wound
contamination

TYPES OF WOUNDS
Wounds are also classified by depth (tissue
layers involved)
PARTIAL THICKNESS
Confined to the skin, that is, the dermis

and epidermis.
Heal by regeneration.

FULL THICKNESS
Involving the dermis, epidermis,

subcutaneous, and possibly muscle and

bone.
Require connective tissue repair.

WOUND HEALING
REGENERATION
(RENEWAL OF TISSUES)

TYPES OF WOUND
HEALING*

PRIMARY INTENTION HEALING

Primary union or first intention healing.
Occurs where the tissue surfaces have

been approximated (closed) and there is

minimal or no tissue loss.
Characterized by the formation of minimal
granulation tissue and scarring.
E.g., closed surgical incision, the use of
tissue adhesive, a liquid glue that can be
used to seal clean lacerations.

PRIMARY INTENTION HEALING

TYPES OF WOUND HEALING

SECONDARY INTENTION HEALING

A wound that is extensive and involves

considerable tissue loss, and in which the

edges cannot or should not be
approximated
E.g., pressure ulcer
Differs from primary intention healing in
three ways:

The repair is longer

The scaring is greater
The susceptibility to infection is

PHASES OF WOUND
HEALING

INFLAMMATORY PHASE
PROLIFERATIVE PHASE
MATURATION OR REMODELING PHASE

INFLAMMATORY PHASE
Initiated immediately after injury and lasts 3 to 6 days.
2 major processes occur during this phase: hemostasis and
phagocytosis.
Hemostasis
The cessation of bleeding
Results from vasoconstriction of the larger blood vessels in
the affected area, retraction (drawing back) of injured
blood vessels, the deposition of fibrin (connective tissue)
and the formation of blood clots in the area. *
A scab also forms on the surface of the wound.*
Below the scabs, epithelial cells migrate into the
wound from the edges.
The epithelial cells serve as a barrier between the
body and the environment, preventing the entry of
microorganisms.

INFLAMMATORY PHASE

Also involves vascular and cellular

responses intended to remove any foreign
substances and dead and dying tissues.
Vascular response

The blood supply to the wound

increases, bringing with it oxygen and
nutrients needed in the healing
process. The area appears reddened
and edematous as a result.

Cellular response
During cell migration, leukocytes (specifically
,neutrophils) move into the interstitial space.
These are replaced about 24hours after injury by
macrophages, which arise from the blood monocytes.
The macrophages engulf microorganisms and cellular
debris by a process known as PHAGOCYTOSIS.
The macrophages also secrete an angiogenesis factor
(AGF), which stimulates the formation of epithelial
buds at the end of injured blood vessels.
The microcirculatory network that results sustains the
healing process and the wound during its life.
This inflammatory response is essential to healing,
and measures that impair inflammation, such as
steroid medications, can place the healing process at
risk.

PROLIFERATIVE PHASE

Second phase in healing, extends from day 3 or 4 to about day 21

post injury.
Fibroblasts (connective tissue cells), which migrate into the wound
starting about 24hours after injury, begin to synthesize collagen.*
Capillaries grow across the wound, increasing the blood supply.
Fibroblasts move from the bloodstream into the wound, depositing
fibrin.
As the capillary network develops, the tissue becomes translucent
red color (GRANULATION TISSUE).*
When the granulation tissue matures, marginal epithelial cells
migrate to it, proliferating over this connective tissue base to fill
the wound. (EPITHELIALIZATION)
If the wound does not close by epithelialization, the area
becomes covered with dried plasma proteins and dead cells.
(ESCHAR).*

MATURATION PHASE

Begins about day 21 and can extend 1 or

2 years after the injury.
Fibroblast continue to synthesize collagen.
The collagen fibers reorganize into a more
orderly structure.*
The wound is remodeled and contracted.*
In some individuals, particularly dark-

skinned persons, an abnormal amount of

collagen is laid down. This can result in a
hypertrophic scar (KELOID)

KINDS OF WOUND DRAINAGE

3 MAJOR TYPES OF EXUDATE
SEROUS
PURULENT
SANGUINEOUS
(HEMORRHAGIC)

KINDS OF WOUND
DRAINAGE

Serous exudate
Consists chiefly of serum
derived from blood and the
serous membranes of the body,
such as the peritoneum.
Looks watery and has few cells.
E.g., the fluid in a blister from a
burn

KINDS OF WOUND
DRAINAGE

Purulent exudate
Thicker than serous exudate because of the
presence of pus.
Pus - consist of leukocytes, liquefied dead
tissue debris, and dead and living bacteria.
SUPPURATION- the process of pus
formation
PYOGENIC BACTERIA- bacteria that
produce pus. *
Vary in color, some acquiring tinges of blue,
green, or yellow.*

KINDS OF WOUND
DRAINAGE

Sanguineous (hemorrhagic) exudate

Consists of large amounts of RBC.*
E.g., open wounds

MIXED TYPES OF EXUDATES ARE

OFTEN OBSERVED:
Serosanguineous- consisting of clear and

blood-tinged drainage. e.g., surgical incisions.*

Purosanguineous- consisting of pus and

blood.
E.g., new wound that is infected.

COMPLICATIONS OF
WOUND HEALING
BLEEDING

(HEMORRHAGE)
INFECTION
DEHISCENCE (WITH
POSSIBLE EVISCERATION)

COMPLICATIONS OF
WOUND HEALING

Hemorrhage
Massive bleeding
May be caused by a dislodged clot, a

slipped stitch, or erosion of a blood vessel.

Internal hemorrhage
May be detected by swelling or distention in
the area of the wound and, possibly, by
sanguineous drainage from a surgical drain.
Hematoma- a localized collection of blood
underneath the skin that may appear as a
reddish blue swelling (BRUISE)

COMPLICATIONS OF
WOUND HEALING

Hemorrhage
The risk is greatest during the
first 48hours after surgery.*
Is an emergency case.
Nursing responsibility: the
nurse should apply pressure
dressings to the area and
monitor the clients vital

COMPLICATIONS OF
WOUND HEALING

INFECTION*
Occurs when the microorganisms colonizing the wound

multiply excessively or invade tissues.*

Infection suggested by the presence of a change in wound
color, pain, or drainage is confirmed by performing a
culture of the wound.
Severe infection

Causes fever and elevated WBC count.

Clients who are immunosuppressed are susceptible.*
A wound can be infected with microorganisms at the time

of injury, during surgery, or postoperatively.

Surgical infection is most likely to become apparent

2 to 11 days postoperatively.

COMPLICATIONS OF
WOUND HEALING

DEHISCENCE WITH POSSIBLE EVISCERATION

Dehiscence

is the partial or total rupturing of a

sutured wound.
usually involves an abdominal wound in
which the layers below the skin also
separate.
Evisceration

- Is the protrusion of the internal viscera

through an incision.

COMPLICATIONS OF
WOUND HEALING

DEHISCENCE

More likely to occur 4 to 5 days post operatively before

extensive collagen is deposited in the wound.

Factors that heightens clients risk of wound dehiscence:
Obesity
Poor nutrition
Multiple trauma
Failure of suturing
Excessive coughing
Vomiting
Dehydration
May be preceded by sudden straining, such as coughing or
sneezing.

COMPLICATIONS OF
WOUND HEALING

DEHISCENCE
Nursing responsibility

The wound should be quickly

supported by large sterile dressings
soaked in sterile normal saline.
Place the client in bed with knees bent
to decrease pull on the incision.
The surgeon must be notified because
immediate surgical repair of the area
may be necessary.

FACTORS AFFECTING WOUND

HEALING

AGE
NUTRITIONAL STATUS
LIFESTYLE
MEDICATIONS

NURSING MANAGEMENT

Assessment
Skin integrity
Wounds

Untreated and Treated wounds.

UNTREATED WOUNDS
-seen shortly after an injury. e.g., at the
scene of an accident or in an
emergency center.

Assessment: Untreated Wounds

-assess the size and severity of the

wound
-inspect the wound for bleeding.*
-inspect the wound for foreign bodies
-assess associated injuries such as
fractures, internal bleeding, spinal cord
injuries, or head trauma.
-If the wound is contaminated with
foreign material, determine when the
client last had a tetanus toxoid injection.*

Nursing Interventions

Control severe bleeding by

a. Applying direct pressure over the wound
b. Elevating the involved extremity.
Prevent infection by
a. Cleaning/flushing abrasions/lacerations with water
b. Covering the wound with a clean dressing, if possible
( a sterile dressing is preferred).*
Control swelling and pain by applying ice over the wound
and surrounding tissues.
If bleeding is severe or if internal bleeding is suspected,
and if emergency equipment is available, assess the client
for signs of shock.

NURSING MANAGEMENT
TREATED WOUNDS

Sutured wounds
Usually assessed to determine the progress of
healing.
These wounds may be inspected during changing
of a dressing.
If the wound itself cannot be directly inspected,
the dressing is inspected and other data regarding
the wound (e.g., the presence of pain)*
Nursing Responsibility-Observe its appearance, size,
drainage, and the appearance of swelling, pain, and
status of drains or tubes.

NURSING MANAGEMENT

Undermining
-occurs when the wound reaches under the skin surface.
-The edges of the wound around an open center may be raw or
appear healed but the undermining can result in a sinus tract or
tunnel that extends the wound many centimeters beyond the
main wound surface.
-to fully assess the size of the wound explore the undermined
area with a thin, flexible probe. Once the end of the tract is
reached, gently raise the probe so that the bulge created by the
end can be seen and its length measured on the skin surface.*
-sinus tracts are often caused by infection and have significant
drainage.
-treatment: antibiotics, irrigation, surgical incision to open and
drain the tract, or vacuum therapy for large tracts.

NURSING MANAGEMENT

DIAGNOSING
Risk for Impaired Skin
Integrity
Impaired Skin Integrity
Impaired Tissue Integrity
Risk for Infection
Pain

NURSING MANAGEMENT

PLANNING
The major goals for clients at risk for
impaired skin integrity are to maintain
skin integrity and to avoid potential
associated risks.
Clients with impaired skin integrity need
to demonstrate progressive wound
healing and regain intact skin.
Include planning for home care.

NURSING MANAGEMENT

IMPLEMENTING
Nursing interventions for maintaining

skin integrity and wound care involve

supporting wound healing
preventing pressure ulcer
treating pressure ulcers
dressing and cleaning wounds
applying heat and cold
supporting and immobilizing wounds

Supporting
Wound
Healing

Supporting wound healing*

Obtaining sufficient nutrition
and fluids.
Preventing wound infections
Proper positioning *

Supporting wound healing*

Preventing wound infections

2 main aspects:

Preventing microorganisms
from entering the wound
Preventing the transmission of
blood borne pathogens to or
from the client to others.

Preventing wound infections

GUIDELINES:
-Standard Precautions
-Proper wound care

Standard Precautions
Wear gloves when touching blood
and body fluids, mucous membranes,
or non intact skin of all clients, and
when handling items or surfaces
soiled with blood or body fluids.
Wash hands thoroughly after
removing gloves, and if contaminated
with blood or body fluids.

Wound care
Wash hands before and after caring for

wounds
Wear gloves, surgical masks, and protective
eyewear as appropriate if procedures
commonly cause droplets or splashing of blood
or body fluids (e.g., wound irrigation)
Touch an open or fresh surgical wound only
when wearing sterile gloves or using a sterile
instrument.
Remove or change dressings over closed
wounds when they become wet.

>Preventing
pressure ulcer
>Treating
pressure ulcers

Treating Pressure Ulcers

-Follow agency protocols and the
physicians orders.
-The RYB color code
Wound care guide
This concept is based on the color of an
open wound- red, yellow, or black
(RYB).
On this scheme, the goals of wound
care are to protect (cover) red, cleanse
yellow, and debride black.

Treating Pressure Ulcers: Red wound

-wounds in the late regeneration phase of tissue
repair.
-they need to be protected to avoid disturbance to
regenerating tissue.
-Nursing responsibility
a. gentle cleansing
b. avoid the use of dry gauze or wet to dry
dressings
c. apply topical antimicrobial agent
d. apply appropriate dressing
e. change the dressing as infrequently as
possible.

Treating Pressure Ulcers :Yellow wounds

-characterized primarily by liquid to semi-liquid
slough that is often accompanied by purulent
drainage.
-wounds are cleanse to remove nonviable tissue.
-methods used:
Applying wet-to-damp dressings
Irrigating the wound
Using absorbent dressing materials
Topical antimicrobial

Treating Pressure Ulcers: Black wounds

-wounds that are covered with thick necrotic tissue, or
eschar.
-require debridement( removal of necrotic material) this
must occur before the wound can heal.
4 different ways:
sharp, mechanical, chemical and autolytic.
-When the eschar is removed, the wound is treated as
yellow, then red.
-When more than one color is present, treat the most
serious color first, that is, Black, yellow then red.

dressing and cleaning wounds

DRESSING WOUNDS

Dressings are applied for the following

purposes:
To protect the wound from mechanical injury
Microbial contamination
To provide or maintain high humidity of the

wound
To provide thermal insulation
To absorb drainage or debride a wound or both
To prevent hemorrhage
To splint or immobilize the wound site and
thereby facilitate healing and prevent injury.

TYPES OF DRESSING

The type of dressing used depends on

The location, size and type of the wound
The amount of exudate
Whether the wound requires debridement

or is infected
Frequency of dressing change, ease or
difficulty of dressing application and cost.

TYPES OF WOUND
DRESSINGS

DRESSING

DESCRIPTION

PURPOSE

EXAMPLES

Transparent
adhesive tapes/
wound barriers

Adhesive plastic,
semipermeable,
nonabsorbent
dressings allow
exchange of
oxygen between
the atmosphere
and wound bed.
They are
impermeable to
bacteria and water.

To provide
protection
against
contamination
and friction; to
maintain a clean
moist surface
that facilitates
cellular
migration; to
provide
insulation by
preventing fluid
evaporation;
and to facilitate
wound
assessment.

Op-Site,
Tegaderm,
Bioclusive

TYPES OF WOUND DRESSINGS

DRESSING

DESCRIPTION

PURPOSE

EXAMPLES

Impregnated non
adherent dressing

Woven or
nonwoven cotton
or synthetic
materials are
impregnated with
petrolatum,
saline, zinc-saline,
antimicrobials, or
other agents.
Require
secondary
dressings to
secure them in
place, retain
moisture, and
provide wound
protection.

To cover, soothe,
and protect
partial-and fullthickness wounds
without exudate

Adaptic, Carrasyn,
Xeroform

TYPES OF WOUND DRESSINGS

DRESSING

DESCRIPTION

PURPOSE

EXAMPLES

Hydrocolloids

Waterproof
adhesive wafers,
pastes, or
powders.
Wafers,designed
to be worn for up
to 7 days, consist
of two layers. The
inner adhesive
layer has particles
that absorb
exudate and form
a hydrated gel
over the wound;
the outer film
provides a seal.

To absorb
exudate; to
produce a moist
environment that
facilitates healing
but does not
cause maceration
of surrounding
skin; to protect
the wound from
bacterial
contamination,
foreign debris,
and urine or
feces; and to
prevent shearing.

DuoDerm,
Comfeel,
Tegasorb, restore,
Replicare

TYPES OF WOUND DRESSINGS

DRESSING

DESCRIPTIO
N

PURPOSE

EXAMPLES

Hydrogels

Glycerin or
water-based
non-adhesive
jellylike
sheets,
granules, or
gels are
oxygen
permeable,
unless
covered by a
plastic film.
May require
secondary

To liquefy
Aquasorb,
necrotic tissue elasto-gel,
or slough,
vigilon
rehydrate the
wound bed,
and fill in
dead space.

TYPES OF WOUND DRESSINGS

DRESSING

DESCRIPTION

PURPOSE

EXAMPLES

Polyurethane
foams

Nonadherent
hydrocolloid
dressings; these
need to have
their edges
taped down or
sealed. Require
secondary
dressings to
obtain an
occlusive
environment.
Surrounding
skin must be
protected to
prevent
maceration

To absorb light
to moderate
amounts of
exudate; to
debride wounds

Lyofoam,
allevyn,
vigifoam,
flexzan

TYPES OF WOUND DRESSINGS

DRESSING

DESCRIPTION

PURPOSE

EXAMPLES

Exudate
absorbers
(alginates)

Nonadherent
dressings of
powder, beads
or granules,
ropes, sheets,
or paste
conform to the
wound surface
and absorb up
to 20 times
their weight in
exudate;
require a
secondary
dressing

To provide a
moist wound
surface by
interacting with
exudate to form
a gelatinous
mass; to absorb
exudate; to
eliminate dead
space or pack
wounds; and to
support
debridement.

Debrisan,
Sorbsan,
Kaltostat,
Algiderm

APPLYING WOUND
DRESSINGS

APPLYING WOUND
DRESSINGS

Prepare materials to be needed

Explain to the client what you are going to do, why is it
necessary, and how he/she can cooperate.
Wash hands and observe appropriate infection control
procedures.
Provide for client privacy. Assist client to a comfortable
position in which the wound can be readily exposed.
Apply clean gloves and remove the existing dressing,
discarding it accordingly.
Thoroughly clean the skin area around the wound.
Put on gloves .
Clean the skin well but gently with normal saline or a mild
cleansing agent. Always rinse the adjacent skin well
before applying a dressing

APPLYING WOUND
DRESSINGS
-clean the wound if indicated.
Put on clean/ sterile gloves in accordance with
agency practice.
Clean the wound with the prescribed solution.
Dry the surrounding skin with dry gauze.
-assess the wound
-apply the wound barrier.
Follow the manufacturers instruction.*
Remove and dispose of gloves.
-assess and change the dressing as indicated
-document the dressing change and the clients
response.

SECURING
DRESSINGS

SECURING DRESSINGS

The correct type of tape must be selected

for the purpose.
Elastic tape can provide pressure
Nonallergenic tape is used when a client
is allergic to other tape.

SECURING DRESSINGS

STEPS TO FOLLOW:
Place the tape so that the dressing cannot be

folded back to expose the wound. Place strips at

the ends of the dressing, and space tapes evenly
in the middle.
Ensure that the tape is long and wide enough to
adhere to several inches of skin on each side of
the dressing, but not so long or wide that the
tape loosens with activity.
Place the tape in the opposite direction from the
body action, for example, across a body joint or
crease, not lengthwise.

CLEANING WOUNDS

CLEANING WOUNDS

Involves the removal of debris (i.e.,

foreign materials, excess slough,
necrotic tissue, bacteria, and other
microorganisms.
The choices of cleaning method
depend largely on agency protocol and
the physicians preference

CLEANING WOUNDS

Use solutions such as isotonic saline or

tap water to clean or irrigate wounds. If
antimicrobial solutions are used, make
sure they are well diluted.
When possible, warm the solution to body
temperature before use.*
If the wound is grossly contaminated by
foreign material, bacteria, slough, or
necrotic tissue, clean the wound at every
dressing change.*

CLEANING WOUNDS

If the wound is clean, has little exudate,

and reveals healthy granulation tissue,
avoid repeated cleaning.*
Use gauze squares. Avoid using cotton
balls and other products that shed fibers
onto the wound surface.*
Clean superficial noninfected wounds by
irrigating them with normal saline.
To retain wound moisture, avoid drying a
wound after cleaning it.

CLEANING WOUNDS

Hold cleaning sponges with forceps or

with a sterile gloved hand.
Clean from the wound in an outward
direction to avoid transferring
organisms from the surrounding skin
into the wound.
Consider not cleaning the wound at all
if it appears to be clean.

WOUND IRRIGATION AND

PACKING

WOUND IRRIGATION AND PACKING

IRRIGATION(LAVAGE)
Is the washing or flushing out of an area.
Sterile technique is required for a wound
irrigation because there is a break in the skin
integrity.
Irrigation pressures should range from 4 to 15
pound per square inch (psi).
Below 4 psi, the irrigation may not be
effective, and above 15 psi, it may damage
tissues.
A 35ml syringe with a 19 gauge needle or
catheter provides approx. 8psi.

WOUND IRRIGATION AND PACKING

Gauze Packing
Using the wet to damp technique
has been used to pack wounds for
debridement.

IRRIGATING A WOUND

Prepare materials to be needed

Explain to the client what you are going to
do, why is it necessary, and how he/she
can cooperate.
Wash hands and observe appropriate
infection control procedures.
Provide for client privacy.

IRRIGATING A WOUND

Prepare the client

Assist the client to a position in which the
irrigating solution will flow by gravity from the
upper end of the wound to the lower end and into
the basin.
Place the waterproof drape over the client and
the bed.
Put on gloves and remove and discard old
dressing
If indicated, clean the wound.
Assess the wound and drainage
Remove and discard clean gloves

IRRIGATING A WOUND

Prepare the equipment

Irrigate the wound.
Instill a steady stream of irrigating solution

into the wound. Make sure all areas of the

wound is irrigated.
If using a catheter, insert the catheter into
the wound until resistance is met.
Continue irrigating until the solution
becomes clear.
Dry the area around the wound

IRRIGATING A WOUND

Assess and dress the wound.

Document the irrigation and the
clients response.

Applying Heat and Cold

HEAT AND COLD APPLICATIONS

Local effects of heat

Heat causes vasodilation and increases
blood flow to the affected area, bringing
oxygen, nutrients, antibodies and
leukocytes.
Softens exudates.
Application of heat promotes soft tissue
injury and increases suppuration.

HEAT AND COLD APPLICATIONS

Cold can decrease blood flow to the

wound, thereby inhibiting healing.
In traumatic injury cold compress
decreases bleeding by constricting
blood vessels, decreases edema by
reducing capillary permeability.

Contraindications to the use

of heat and cold

Use of heat
The first 24h after traumatic injury.

(increases bleeding and swelling)

Active hemorrhage
Noninflammatory edema ( increases
capillary permeability)
Localized malignant tumor(metastases)
Skin disorder that causes redness or
blisters

Contraindications to the use

of heat and cold

Use of cold
Open wounds- increase tissue damage
by decreasing blood flow to an open
wound
Impaired circulation- further impair
nourishment of the tissues and cause
tissue damage.

supporting and
immobilizing
wounds

SUPPORTING AND IMMOBILIZING

WOUNDS

Bandages and binders serve various

purposes:
Supporting a wound
Immobilizing a wound
Applying pressure
Securing a dressing
Retaining warmth

SUPPORTING AND IMMOBILIZING

WOUNDS

Inspect and palpate the area for swelling

Inspect for the presence of and status of wounds
Note the presence of drainage
Inspect and palpate for adequacy of circulation
Ask the client about any pain experienced.
Assess the ability of the client to reapply the
bandage or binder when needed.
Assess the capabilities of the client regarding
activities of daily living and assess the assistance
required during the convalescent period.

HOME CARE PLANNING

Teaching: Home Care

Maintaining intact skin

Discuss relationship between adequate

nutrition and healthy skin.

Demonstrate appropriate positions for pressure
relief
Establish a turning or repositioning schedule.
Demonstrate application of appropriate skin
protection agents and devices
Instruct to report persistent reddened areas.
Identify potential sources of skin trauma and
means of avoidance.

Teaching: Home Care

Promoting wound healing

Discuss relationship between adequate

nutrition and healthy skin.

Instruct in wound assessment and
provide mechanism for documenting.
Emphasize principles of asepsis, esp.
hand washing and proper methods of
handling used dressings.

Teaching: Home Care

Provide information about signs of

wound infection and other

complications to report.
Reinforce appropriate aspects of
pressure ulcer prevention.
Demonstrate wound care techniques
such as wound cleansing and dressing
changing.
Discuss pain control measures, if
needed.

Home care considerations

Wound care
Perform appropriate client teaching for

promoting wound healing and maintenance

of healthy skin.
Instruct the client and family on where to
obtain needed supplies. Be sensitive to the
cost of dressings.
Instruct in proper disposal of contaminated
dressings.
Verify how the client may bathe with the
wound.

Thank you!