TABLE OF CONTENT

 INTRODUCTION.
 ANATOMY OF THE SKIN.
 DEFINITION OF WOUND.
 CLASSIFICATION AND TYPES OF WOUND.
 SIGNS AND SYMPTOMS OF WOUND INFECTION.
 FACTOR AFFECTING WOUND HEALING.
 WOUND HYGIENE.
 BASIC WOUND CARE.
 7 STEPS FOR WOUND CARE.
 PRINCIPLE OF WOUND MANAGEMENT.
 NURSING MANAGEMENT OF PATIENT WITH WOUND.
 MAXIMIZING HEALTH CARE OUTCOME IN LOW RESOURCES
SETTING AND BEST PRACTISE INNOVATIVE SOLUTION.
 STRATEGIES FOR IMPLEMENTATION TO IMPLEMENT BEST
PRACTICES IN WOUND CARE REGIMEN.
 COMPRESSION THERAPY.
 DO’S AND DON’T OF WOUND DRESSING.
 CHALLENGES OF WOUND DRESSING.
 COMPLICATIONS OF WOUND DRESSING.
 CONCLUSION.
 REFERENCES.
 INTRODUCTION
A wound is a disruption of anatomical and cellular continuity of
tissue.

According to wound healing society, wounds are physical injuries

that result in an opening or break of the skin that causes disturbance in
the normal skin anatomy and function, they result in the loss of
continuity of epithelium with or without the loss of underling
connective tissue.

Wound healing is a complex physiological process that involve the

coordination of cellular molecular and biochemical mechanism to
restore tissue integrity and function. The process can be divided into 4
phases : Hemostasis inflammatory, proliferative and remodelling.
Factors that affect wound healing include local factors such as
oxygenation and infection, as well as systemic factors like age, gender,
sex hormone, stress, diabetes mellitus, obesity, drugs, alcohol, smoking
and nutrition
Wound dressing plays an important role for all wound to heal,
care giver and health personnel should have it in mind that aseptic
procedure and assessment of wound is highly expected use of antibiotics
is very vital in wound care.
 ANATOMY OF THE SKIN
The skin is made up of several layers, including the epidermis,
dermis and hypodermis.

 Epidermis : This is the most superficial layer of skin which protects

the body from substances entering the body. Epidermis is made up
of stratum basale, stratum spinosum and stratum lucidum and
stratum corneum.

 Dermis : This is a tough and flexible layer below the epidermis which
is made up of collagen and elastin responsible for the skin’s firmness,
elasticity and texture. This layer also contains blood and lymphatic
vessels, sweat and sebaceous glands, sensory nerve endings and hair
follicles.

 Hypodermis : This is the bottom layer of the skin which is also known
as subcutaneous tissue. It insulates and protects the body, also
stores energy.
The skin is the largest organ of he human body. It protects the
body, regulates body temperature and allows sensations such as
touch, heat and cold.
 DEFINITION OF WOUND

1. A wound is a disruption of the anatomical and cellular

continuity of tissue.
2. Wound is also defined as any injury to the body and typically
damage to the epidermis of skin (e.g cut, blow, or other impact)
that disturb its normal anatomy and function.
3. A wound is a flaw or a breech in the skin that occurs as a
consequence of physical or thermal damage or as a result of a
underlying medical or physiological condition.
4. It is a circumscribed injury which is caused by external force
and it can involve any tissue or organs.

CLASSIFICATION OF WOUND
 Classification of wounds:

 Acute wound : It is a sudden injury that breaks the skin or

tissue, they range from minor cut to more serious lacerate
and punctures e.g cut, laceration, abrasion, burns and surgical
wound.
They heal by first intention. It heals in a timely manner
as expected example a closed surgical wound. Healing is with
4-6 weeks.

 Chronic wound: It is a wound that does not heal within 6

weeks and extends to three months or more.
Chronic wound arise when there is poor blood
circulation, infection or a weak immune system.
 Types of wounds:

 Laceration wound  Pressure ulcer.

.  Arterial
 Puncture wound. insufficiency ulcer.
 Avulsion wound.  Bruise.
 Burns wound.  Infected wound.
 Traumatic wound.  Amputation.
 Diabetic foot  Animal bite.
ulcer.  Electric injuries.
 Venous stasis.  Incision.
 Abrasion.  Malignant wound.
  Skin tearing.
SIGNS AND SYMPTOMS OF WOUND INFECTION
1. Redness - discoloration of the skin.
2. Swelling.
3. Pain.
4. Fever temperature spike (380c - 390c).
5. Exudate - drainage of pus, cloudy fluid or a bad smell.
6. Swollen lymph node.
7. Wound size - wound has increased in size and dept.
8. Chills or rigor.

FACTORS AFFECTING WOUND HEALING.

 Local factors:
1) Infections.
2) Necrotic tissue and foreign body.
3) Poor blood supply.
4) Venous or lymph stasis.
5) Tissue tension
6) Hematome.
7) Large defect or poor apposition.
8) Reccurent trauma.
9) X-ray irradiated area.
 Systemic factors:
1) Age and gender.
2) Stress.
3) Ischaemia.
4) Disease e.g diabetes, keloid, fibrosis.
5) Hereditary healing disorder.
6) Alcoholism and smoking.
7) Immune compromised condition e.g cancer radiation therapy,
Aids.
8) Nutrition.
 WOUND ASSESSMENT
It is an important part of wound management, it is a process of
gathering information about wound and the patient, to help plan
treatment.
a. Assessment of (patient):
i. Full medical history.
ii. Medication.
iii. Nutrition status.
iv. Life style.
v. Quality of life.
vi. Treat the while person not the hole in the person.
b. Assessment of (wound):
i. Who does wound assessment:
 Tissues nurse, home care nurse, physician, any
health care giver who manage wound.
ii. Objectives of wound assessment:

 To determine heal - ability of a wound.

 To determine right choice of treatment modality.
 To evaluate the efficacy of treatment.
 To monitor progress of wound healing .
 for early decision on actual and proper line of
management e.g surgical intervention.
 For early detection of complication therefore all
wound must be assessed.
iii. Wounds are to be assessed for:
 Location and size:
 Wound bed.
 Odour : signs of infection, such as
slimming odour, color.
 Exudate : Volume of purulent
discharge.
 Surrounding skin : Hairless, thick,
thin oedematous tumor, swelling.
 Pain : gait will denote pains.
 Color: Yellow, red or black.
  Granulation tissue, e.g, hyper granulation,
healthy granulation, unhealthy granulation, scanty or
no granulation tissue.

iv. Superficial wound wound infection (NERDS):

 N : none healing wound.

 E : exudate wound.
 R : red viable tissue, bleeding wound surface
granulation tissue.
 D : debris - yellow or black nectrotic tissue.
 S : smell - umpleasant odour.

v. Deep wound infection (STONEES):

 S : size is bigger.
 T : temperature increased.
 O : OS ( probe to or exposed bone ).
 N : new satellite areas of breakdown.
 E : exudates, erythema, oedema.
 E : erythema.
 S : smell.

All wound assessment must be done, document and report all

finding for evaluation and line of treatment.
 WOUND HYGIENE
Wound hygiene is a four step regime designed to clean and
decontaminate a wound, and over come the barriers to healing often
caused by the presence of biofilm.
Just as we follow basic hygiene everyday by washing our hands,
brushing our teeth and showering, we should apply regular basic
hygiene to wounds to keep them clean and remove biofilm.
By implementing wound hygiene, you can ensure every wound
is properly for healing every time.
4 STEPS REGIMEN
1. STEP ONE :
Skin and wound cleansing. Clean the wound bed to remove
devitalized tissue, debris and biofilm, clean the periwound skin to
remove dead skin scales and callus and to decontaminate it.
2. STEP TWO:
 Wound debridement: Removal of necrotic tissue, slough,
debris and biofilm at every dressing change.
TYPES OF DEBRIDEMENT
 Autolutic debridement.
 Mechanical debriment.
 Enzymatic debridement.
 Sharp debridement.
3. STEP THREE:
 Refashioning of wound edges: Remove nectrotic, crusty and
or over - hanging wound edges that may be harbouring
biofilm. Ensure the skin edges align with the wound bed to
facilitate epithelial advancement and contraction.
4. STEP FOUR:
 Dress the wound: Address residual biofilm which preventing/
delaying regrowth of biofilm by using dressing containing anti-
biofilm and or antimicrobial agents.

BASIC WOUND CARE

 Proper care of wounds can prevent infection and speed the body’s
healing process.
 Treatment immediately after the injury, wash thoroughly with clean
water and mild soap or savlon.
 Remove any visible dirt or debris from the wound and apply a cold,
wet cloth.
 If blisters nform, do not pop or drain.
 Apply a thin layer of bacitracin antibiotic ointment or white
petroleum to the wound.
 Cover with a bandage.
 Clean area twice daily with soap and water and apply new bandage
and ointment after cleaning.
 There is no need to use hydrogen peroxide or alcohol for cleaning.
 Continue this care until wound is fully healed.
 Deep or gaping wounds may need stitches or other wound care from
a medical professional.
 Some bite injuries may also require special attention.

7 STEPS FOR CARING FOR WOUND.

 Step 1. Wash your hand:
Preventing infection is critical in wound care, therefore ensure
all wound are dressed under aseptic condition, use sterile instrument,
gauze, surgical glove, tray and others.

 Step 2. Stop the bleeding:

To stop bleeding, apply pressure to the wound, do this by using a
clean cloth or bandage. You should, also raise the wound area above the
heart level if possible. This can help to use gravity to slow blood flow to
the wound.

 Step 3. Clean the wound:

Use running water to clean the wound . do thus for at least five
minutes. Do not use soap directly on the wound. If the wound is from a
fall outside, there could be debris that can cause infection, if the debris
embedded in the wound, seek a medical professional for wound care.
Do not irritate the wound. Do a gentle cleaning. The purpose of this step
is to create an ideal environment for healing.
You may use normal saline as alternative to water and soap. It
will not further damage the tissues. As a final step, of cleaning pat the
area dry with a clean towel or wad of tissues.

 Step 4 :
Apply anti bacteria ointment if the wound is minor, e.g
Neosporin to prevent infection.
 Step 5. Protect the wound:
Cover the wound with a sterile dressing and secure it in place
with bandage, preferably with a non adhensive pad. This protects the
skin surrounding the wound and also prevent the wound from increasing
in size.

 Step 6. Change the Dressing:

The dressing should changed at least once daily. While
changing the dressing evaluate the healing process and see a doctor if
the wound bleeds on contact a has a yellowish discharge or dark red
color. These are signs of abnormal wound healing.

 Step 7. Observe symptoms:

Be on the lookout for signs of infection, severe pain, bad odor, thick and
yellowish discharge. And a darkening of the skin around the wound are
all signs of abnormal wound healing and should be evaluated by a doctor
right away.

PRINCIPLE OF WOUND MANAGEMENT

 Assessment and exclusion of disease process.
 Wound cleaning.
 Timeling dressing change.
 Appropriate dressing choice.
 Consider antibiotic prescription.
 Curriculum wound dressing has to change.
 Not all wound will heal.
 Determine your goal while doing dressing.
 Foundation for modern wound care is wound assessment,if you
understand the language of wound, then you will know what to
give .
 Don’t just do dressing, dressing , dressing, dressing dress and
dressing.

NURSING MANAGEMENT OF PATIENT WITH WOUND

 Observation.  Diet.
 Assessment of wound.  Environmental and personal
 Cleaning and dressing of hygiene.
wound.  Pain management.
 Debridement of wound.  Reassurance.
 Infection control.  Health education.
 Medication.
WOUND CARE PRODUCT
 Autolitic : Honey, hydrogel, hydrocoloid, calcium alginate.
 Biological : Sterile maggot to eat dead.
 Chemical : Hydrogen peroxide sodium hypochloride, hyrogen
peroxide deterred healing.
 Surgical : Debridement, surgical, sharp debridement.
 Enxymatic : Debrigate.
 Mechanical : Wound irrigation, e.g normal saline.
 Infective agent : Honey, povidone iodine, Cadexomer iodine.
 Silver dressing : Ionic form, silver nitrate (curium) accucell silver
copper agent.
 Tropical antibiotics : Mupiroxin, paconic powder
 Activated charcoal.
 Skin donation : Relation of a patient can donate his/her skin for
grafting to their patient.
 Corban.
 Primarose.
 Transpore tape.
 Micro pore tape : Use for general dressing application.
 Drez powder.
 Drez ointment.
 Theruptor novo.
 Medcu-copper wound dressing.
 Sutra tule.
 Batigras.
 Cutimed.

MAXIMIZING HEALTH CARE OUTCOME IN LOW RESCOURSES

SETTING : BEST PRACTICES INNOVATIVE SOLUTION.
 In low resources setting, effective wound care is hindered.
 In adequate training.
 Poor accessment to resources.
 Improvises lack standardization.
 Financial limitation.
 Poor infrastructure can delay timely intervention.
 Work force shortage.
 Social and cultural factor such as misconception, stigma around
chronic wound.
 IDENTIFYING BEST PRACTICES
 Focus on evidence base.
 Cost effectiveness.
 Availability and sustainability.
 Tailored interventions that will address specific cultural, logistical
challenges of each setting are essential for success

STRATEGIES FOR IMPLEMENTATION TO IMPLEMENT BEST

PRACTICES IN WOUND CARE REGIMEN
 Collaboration and strategic action is needed.
 Education and training program can empower health workers to
deliver effective care.
 Standardization of care and practise.
 Community engagement.
 Partnership with local organization and global stake holder.
 Use of low cost, effective intervention.
 Regular monitoring.
 Innovative solution.
 Mobile health technology enable patient’s monitoring.
 Telemedicine connects to patients.
 Low cost medication technology point of care testing.
 Community base initiative foster prevention and timely intervention.
 Electronic health record (EHR).
 Improve patient’s outcome by reducing the burden of chronic
wound.
COMPRESSION THERAPY
 Ted stockings : prevents deep vein thrombosis (DVT).
 For patient on bed rest.
Pressure at the calf.
Lower pressure.
For chronic oedema.

 Compression bandage.
 Compression stocking.
 Coban.
 Ankle brachial index.
USE OF ALL THE ABOVE 4
 For chronic oedema.
 For ambulatory patients.
 Graduated pressures from the ankle.
TYPE OF DEBRIDMENT
 Autolytic debridment : honey, hydrogel.
 Biological : sterile maggot.
 Chemical : sodium hypochloride, hydrogem peroxide, Eudol not in
use again.
 Surgical debridement : bedside, radical, hydro surgical.
 Enzymatic debridement : collagenase papurea.
 Mechanical debridement : jet lavage, wound irrigation, wet to dry
dressing.
 Sharp debridement : forceps removal of nectrotic tissue, scrapping.

DO’S OF WOUND DRESSING

 Wash your hand before wound dressing.
 All wound should be dressed under aseptic technique.
 Use of sterile glove or clean disposable glove and methylated spirit
before wound dressing.
 Minimise movement during wound dressing.
 Empathise with patient but be firm in doing dressing.
 Document your finding doing assessment and report to the senior
nurse / doctor.
 Snap wound before and after for healing progress.
 Set all your dressing trolley, or tray before commencing wound
dressing.
 Cleaning and tidy your trolley and your environment before starting
another dressing.
 Use appropriate dressing product don’t improvise . reaction may
occur.
 All wound should be moisturized.
 Use disposable glove to remove old dressing and use sterile glove to
dress wound.
 All fan should be put off doing dressing.
 always use your face mask.

DON’TS OF WOUND DRESSING

 Don’t expose your patients nakedness during, respect their privacy
from other patients.
 Do not use unsterile material for dressing.
 Don’t waste patient’s dressing material.
 Do not allow wound to be dehydrated except cannula dressing and
surgical dressing and catheter dressing.
 Do not do surgical debridment, do only sharp debridment.
 Do not apply coban dressing of there is no pulsation at the dorsalis
pedis artery of the ankle.

CHALLENGES OF WOUND CARE

 Limited knowledge of infection prevention control.
 Lack of standardize wound assessment protocol.
 High reliance on traditional healers particularly in rural community.
 Lack of commitment by health workers.
 Survilliance system.
 Role of primary health care.
 Delay in obtaining medical treatment.
 Underlying medical conditions like diabetes, vascular disease or
malnutrition.
 Poor compliance with treatment base on wound type and severity.
 Inapproprriate debridment technique.
 Limited access to specialized wound care professional.
 Financial constraint.


COMPLICATIONS OF WOUND CARE
 Infection.
 Wound dehiscence.
 Scarring / keloid formation.
 Delayed healing.
 Gangrenous.
 Deformity.
 Amputation.
 Social relegation.
 Depression.
 Loss of job.
 Incapacitation.
 Death.
 CONCLUSION
A more scientific approach based on current research and
understanding needs to be undertaken by nurses for correct and
effective clinical management of wound (Butcher 2013).
If a treatment regimen will be effective, its vital that wound
care product are selected correctly. This implies that the nurse must be
aware of the practical use and benefit of wound care products. As
wound healing progress, the dressing requirement or management
region will change.
Therefore, it is important that healthcare providers in Nigeria
particularly nurses are fully abreast with current trends in wound care.
There should be integration of advanced wound care into current
practice. “ If there is a will, there is a way”. To fully understand the
language wound speaking terms of best approach to wound
management, modern wound dressing technique which is the current
trend and best practise in wound care must be adopted and integrated
into practice in Nigeria. This will breach the wide gap between
knowledge and practice.

REFERENCES
 Oluwatosin A.M. care of wound bed assessment.
 Professor Iyun A.O UCH ibadan.
 Nurse babalola E.O O.A.U TH ife, osun state.
 Dr Achibong FMC ebute metta.
 Dr mrs kemi ogunwusi.
 Dr Oyinloye.
 Maxson .S. Lopez E.A. Yoo D
 Song H. Tikom Dj. Hager S, Hauser J, Skin Wound healing and update
on the current knowledge and concepts 2017