Introduction:

Wound is any break in the continuity of body tissue. Examples: grazes, burns, surgical incisions,
stabs, leg ulcers, decubitus ulcers (pressure sores). The purpose or goal of doing wound care is to
facilitate hemostasis, decrease tissue loss, promote wound healing, minimize scar formation, keep the
wound moist and therefore enhance epithelialization, clean the wound or keep it clean and protect the
wound from physical trauma or bacterial invasion.

Mechanism of Injury
Wounds are caused by three different types of forces; Shear Compressive and Tensile. Shear
Forces result from sharp objects has Low energy, minimal cell damage, result in straight edges, little
contamination and heals with a good result. Compressive forces result from blunt objects impacting the
skin at a right angle. Results in stellate or complex laceration, ragged or shredded edges and more prone
to infection. Tensile force result from blunt objects impacting the skin at an oblique angle that results in
triangular wound, sometimes produces a flap and more prone to infection.
Cleansing the wound
Reasons for cleansing the wound to remove excess exudate and signs of infection, remove
foreign body contamination ( eg. grit in a graze) remove presence of devitalised tissue ( slough or
necrotic tissue) and to assess the wound.
Types of Cleansing Fluids
Antiseptics: generally discouraged now- can be toxic to tissue healing
Saline solutions: normal saline sachets commonly used
Tap water: Why not!! tip: cleansing fluids should be at body temperature

Methods of Cleansing
Swabbing: not particularly effective, mainly redistributes organisms
Bathing: useful for chronic wounds such as leg ulcers. Take care with equipment to avoid cross
contamination
Irrigation: shower head, waterjug, syringes - dont be overzealous

Suturing
The process of joining two surfaces or edges together along a line by or as if by sewing. (will be
discussed more in the next page)
Wound Dressing Principles
If exudates is present - Select one that absorbs exudates. Keep wound bed moist but
surrounding skin dry. Pack wounds loosely to avoid pressure on new granulation tissue. Fasten securely
using tape, binder or self-adhesive type dressing materials.
Dressings for dry wounds
Transparent: gas exchanged between wound & environment but bacteria prevented from
entering. Creates moist healing environment and r educe surface friction. Indicated for; Minor
burns, lacerations, Skin donor sites, Pressure ulcers: stage I and some stage II (partial thickness,
lightly exuding), Dry necrotic wounds that need autolytic debridement.
Example: Tegaderm
Hydrogels: High water content enhances epithelialization and autolytic debridment. Needs
cover dressing and wound edge barrier. Indicated with Partial- and full-thickness wounds,
Wounds with necrosis or slough, Burns and tissue damaged by radiation, Dermal ulcers, Painful
wounds.
Example: Carrasyn
Wet to- Moist Gauze dressings: keeps wound bed moist. Minimizes trauma to granulation
tissues.
Dressings for MOIST wounds
Hydrocolloid: hydrophilic particles mix with water to from a gel... wound stays moist. DO NOT
use in infected wounds. Impermeable to external bacteria and contaminants, Support autolytic
debridement, Minimally to moderately absorptive, Can be used with compression (treatment of
venous stasis ulcers) and Thin forms diminish friction Reduces pain. Indicated with Partial-
thickness wounds, Pressure ulcers: superficial stage III and some approved clean stage IV,
Wounds with necrosis or slough, Wounds with mild to moderate exudates.
Example: Duoderm
Absorption Materials: beads, powders, rope or sheets that absorb large amount of exudate
Example: Calcium Alginate
Foam: Made of hydrophilic material. Highly absorbent.
Example: Allevyn
Dry Gauze: Can absorb wound drainage. Can be impregnated with agents to promote healing.
Indicated with; Exudative wounds, Wounds with dead space, tunneling, or sinus tracts, Wounds
with combination exudate or necrotic debris.

Heat & Cold Therapy
Heat reduces pain & promotes healing through vasodilation. It increases oxygen and nutrients to
aid in inflammatory response, reduces edema by promoting removal of excessive interstitial fluid and
promotes muscle relaxation. Cold decreases pain by vasoconstriction , decreased blood flow to the area
decreases inflammation and edema, raises the threshold of pain receptors thereby decreasing pain and
decreases muscle tension.


Bibliography
Sue C. DeLaune, P. K. (2002). FUNDAMENTALS OF NURSING Standard & Practice Second Edition. United
States of America: Delmar, a division of Thomson Learning, Inc.