COLLEGE OF MEDICINE AND HEALTH

SCIENCES, SCHOOL OF NURSING AND

MIDWIFERY
DEPARTMENT OF ADULT HEALTH
NURSING

Presentation On Diabetes Mellitus

By Honelet Debebe
DESSIE ETHIOPIA
APRIL 2023

11/27/2023 Honelet.D 1
 COLLEGE OF MEDICINE AND HEALTH SCIENCES,
SCHOOL OF NURSING AND MIDWIFERY
DEPARTMENT OF ADULT HEALTH NURSING

Presentation On Chronic wound

By Honelet Debebe
DESSIE ETHIOPIA
APRIL 2023
11/27/2023 Honelet.D 2
 Presentation outlines
 Definition
 Types of wound
 Phases of wound healing
 Factors affecting wound healing
 complications of wound healing
 principles of wound care
 Wound cleansing solutions and wound dressing
 Nursing management
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 Objectives
 At the end of this class learner will be able to:

Define Wound and wound care

List type & Classification of wound

Describe Phases of wound healing

Identify complications of wound

Describe principles of wound care

 Demonstrate dressing of wound with commonly available
wound dressing products

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 Wound
 A loss of continuity of the skin or mucous
membrane which may involve soft tissues,
muscles, bone and other anatomical structure.
 Possible causes are trauma, surgery, or a
specific disease state.

(Benbow M, 2016)

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 Chronic wound
• When wounds or ulcers fail to progress in an
orderly and timely manner (approximately 4
weeks) they are diagnosed as chronic wound
• Clinical signs of chronicity include:
 lack of healthy granulation tissue
 non-viable tissue (slough and/or necrosis)
 no reduction in overall size over 2-4 weeks
 recurrent tissue breakdown and
 presence of wound infection
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 Causes
•Wound chronicity is often secondary to the presence
of intrinsic and extrinsic factors including
• Age
• Immobility
• Comorbidities
• compromised nutrition
• medications
• inappropriate dressing selection
• patient non-compliance.
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 Classifications of chronic wound
Type based on aetiologies
• pressure injuries
• venous ulcers
• arterial/mixed ulcers
• diabetic foot ulcers (DFU)
• non-healing surgical wounds

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 Treatment
Based on wound type (etiology) Management
considerations include:
• Offloading
• Compression
• Assessment of surrounding tissue
• Cleansing of wound base
• Exudate control
• Antibiotics
• Debridement
• High-priority surgical referral
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 Wound healing
 Wound healing is a complex cellular and
biochemical cascade that leads to restitution of
integrity and function.
 No matter how trivial or extensive the wound,
healing always includes three overlapping phases:
inflammation, proliferation, and maturation.

(Schiwartiz,s principles of surgery, 11th edition)

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Stages of wound healing
1. Inflammatory Stage
• Lasts for three to five days.
• Within minutes of the initial injury, neutrophils,
monocytes and macrophages are on the scene to
control bacterial growth and remove dead tissue.
•Neutrophils often kill healthy host cells.
• Characteristic red color and warmth is caused by
the capillary blood system increasing circulation &
laying foundation for epithelial growth.

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• Vascular and cellular responses are
immediately initiated when tissue is cut or
injured
• Transient vasoconstriction occurs immediately
at the site of injury
• Subsequent dilation of small venules occurs
• Localized vasodilation is the result of direct
action by histamine and other chemicals
• WBC enter the wound to engage in
destruction and ingestion of wound debris.

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2. Proliferation Stage
• Begins within 2-4 days of the initial injury and
may continue for up to 21 days
• Is complete when the wound is completely
resurfaced with epithelial tissue & the functional
barrier of the skin has been restored
•It is characterized by 4 crucial events:
• Angiogenesis :-formation new blood vesseles
• Granulation:-new connective tissue
• Wound contraction
• Epithelialisation
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3. Maturation (Remodeling) Phase
• The wound matures and the collagen in the scar
undergoes repeated degradation and re-synthesis
• This is the longest phase of wound healing
• The tensile strength of the scar increases
• Between the 1st and the 14th day, tissues regain
approximately 30% to 50% of their original strength
• Tensile strength continues to increase to
approximately 80% of normal tissue strength
• Wounds never completely regain the tensile
strength of unwounded tissue.

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 WOUND HEALING MECHANISMS
First-intention Healing (Primary Union)
 The usual method of choice for most clean
surgical wounds and recent traumatic injuries.
 The edges of the wound are individually
sutured with the individual layers being brought
together.
 Granulation tissue is not visible and scar
formation is typically minimal.

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Secondary Intention
 In wounds that have sustained a large amount of
tissue loss as a result of surgery, trauma or chronic
ulceration, it may be impossible to bring the edges of
the wound together.
 This is when the wound is left to heal by secondary
intention.
Tertiary-intention Healing (delayed primary inte)
 Is a combination of primary and secondary intention.
 Is preferred when a wound is heavily contaminated
to reduce the risk of the wound becoming infected.
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 Factors Influencing Wound
Healing
 Intrinsic (Systemic) factors
 Hydration
 Nutrition
 Concurrent disease
 Vascular insufficiencies
 Age
 Immuno suppression, drugs and radiation therapy
 Systemic infection
 Lack of sleep / rest
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 Extrinsic (local) Factors
 Pressure
 Temperature
 Duration of wound
 Bacterial burden
 Size of wound
 Necrotic tissue / slough
 Skin maceration
 Foreign Bodies

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 Complications of wound healing
Hemorrhage
Infection
Shock
Dehiscence
Evisceration
Fistula
Hypertrophic scar
Keloid
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 Wound care
 Wound care is a nursing duty that requires
excellent skills and knowledge to prevent
massive complications, such as infection,
gangrene and amputation or, in severe cases,
even death.

(BaMohammed.A et al, 2018)

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 Goals of wound care
• Facilitate hemostasis
• Decrease tissue loss
• Promote wound healing
• Minimize scar formation

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 Principles of Wound Care
 Do warm solutions used to irrigate before use
to maintain optimum wound healing
 Longer showering or bathing (>10min)
unnecessarily increases the risk of skin
maceration.
 Do not clean the wound with cotton wool or
swabs as this will disturb healing tissue and
leave fibres in the wound.

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 Apply silicone or paraffin gauze dressing to
secondarily healing wounds.
 wound irrigation pressures range from 4 to 15
pounds per square inch (psi). Pressures lower than 4
psi will not cleanse the wound adequately, while
pressures greater than 15 psi may damage tissue
and force bacteria deeper into the tissue.
 The way of cleansing should enable to remove
superficial slough, excess exudate, visible debris or
foreign bodies and any material from previous
dressings.
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• Wound cleansing helps optimize the healing
environment and decreases the potential for
infection.
• It loosens and washes away cellular debris
such as bacteria, exudate, purulent material
and residual topical agents from previous
dressings. Most wounds should be cleansed
initially and at each dressing change.

(British nursing Skin & Wound Committee,2018)

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Normal Saline
• The most commonly used irrigating solution.
• Due to its physiologic nature, it is always safe to
use in wounds.
• However, it does not contain any
surfactants ,which are more effective at lifting
bacteria and debris from the wound or
periwound area.
• Also it does not contain any preservatives to
prevent microbial growth. It should be discarded
after as little as 24 hours after opening.
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• National Athletic Trainers’ Association stated
that no differences were noted in the rates of
infection and healing between the use of tap
water and normal saline in the cleansing of
acute and chronic wounds.

(Joel W. Beam, et al 2016)

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Hydrogen per oxide
• Cytotoxic to healthy cells and granulating tissues.
• Foam as gas cleansing action helps to lift debris
from the wound surface when used at full
strength. If used full strength, irrigation with
normal saline after use is recommended.
• Ineffective at killing bacteria below 3%.
• Do not use on wounds with sinus tracts.

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Sodium Hypochlorite (Dakin Solution):
• Cytotoxic to healthy cells and granulating tissues
• An oil-based ointment such as petroleum jelly
can be applied to surrounding healthy tissue to
reduce skin irritation and prevent debridement
of viable tissue.
• Bactericidal effect against most organisms
commonly found in open wounds.
• Frequently used in pressure ulcers with necrotic
tissue to help control infection.

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• Occasionally used over cancerous growths to
control bacteria and minimize odor.
• Should not be used for periods longer than 7-
10 days.
• It is usually applied once a day on lightly to
moderately exudative wounds and twice a day
for highly exudative or contaminated wounds.

( Michael K, et al , 2019)

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 Chronic wound dressing

 Are used to manage drainage while maintaining a moist

environment
• Maceration
• Excoriation
 Basically 5 categories:
 Films
 Hydrogel
 Hydrocolloids
 Alginates
 Foam
(Edwards .H, et al,2013)
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 Dressing tips
 DO:
 Relieve pain, especially prior to dressing change
 Relieve pressure! turn at least every 1-2 hours!
 Consider specialty support surfaces for bed/chair
 Fill in dead space if wound is deep
 Protect skin from incontinence by using barrier cream
 Protect periwound tissue by using Skin Prep
 DO NOT:
 Use wet-to-dry dressings!
 Wrap tape completely around an extremity! Tourniquet effect
 Pull dressing off a wound : Can cause further tissue damage

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 Dressing selection
Determined by :
• condition of the wound bed.
• amount of exudate (drainage)
• cost and availability of dressings at your
institution.
• Healing progression.

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Dressings that add moisture
• Films-retain moisture, protect from infection
• Hydrogel- creates moist environment, not for
excessive drainage
• Hydrocolloid- moist environnent, promotes
autolytic debridement
 Dressings that absorb moisture
• Foams for moderate drainage
• Calcium alginate for moderate to heavy
drainage, homeostasis
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Antibiotics
Control of wound bioburden: Antimicrobial
dressings for wound contamination
 Antibiotics only for infected wounds
Specialty Dressings
 Antimicrobial dressings
 Silver
 Cadexomer iodine

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Debridement
• Is the act of removing necrotic material,
eschar, infected tissue, slough, pus,
hematomas, foreign bodies, debris,
bone fragments, or any
other type of bioburden from
a wound with the objective to
promote wound healing.

(Daniel.S, et al 2017)
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• Debridement is NOT advised for pressure
ulcers to heels in the absence of good arterial
circulation as the risk of infection in these
cases outweighs the delayed healing .This
principle also applies to DFU .

(Canadian Association of Wound Care, 2018)

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 Nursing management
wound assessment
• Accurate and considered wound assessment is
essential to fulfill professional nursing requirements

and ensure appropriate wound management.

( Benbow .M ,2016)
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 T= Tissue both in and around the wound—granulation,
slough, necrotic black, pink.
 I= Infection. Any open area always has the potential for
infection.
 M= Moisture (exudate). This determines type of dressing
needed to maintain balance.
 E= Edges. Are they contracted, rolling, undermining?

(Kate Brawn, et al , 2018)

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NANDA Nursing Diagnoses
 Pain
 Impaired skin integrity
 Impaired tissue integrity
 Risk for impaired skin integrity
 Risk for infection

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Goals in Planning Client Care
 Pain
o Assess pain by using pain assessment tool
o Give non pharmacologic or Pharmacologic management
 Risk for impaired skin integrity
o Maintain skin integrity
o Avoid or reduce risks factors
 Impaired skin integrity
o Progressive wound healing
o Regain intact skin
 Client and Family Education
o Assess and treat existing wound
o Prevention of pressure ulcers

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 References
1. Current concepts in the physiology of adult wound healing, 2015.
2. 3. Fernandez R. Wound cleansing : which solution , what technique ? 2015
4. Best practice in wound assessment. Nursing Standard(2016)
5. Principles of Wound Management and Wound Healing (2017)
6. HSE wound management guidelines, 2018
7. Schiwartiz,s principles of surgery, 11th edition.
8. Ubbink DT, Bro FE, Go PMNYH, Vermeulen H. Evidence-Based Care of Acute
Wounds : A Perspective. 2015;4(5):286–94.
9.Brawn K, Viability T, Policy M, Settings C. GUIDELINES FOR THE ASSESSMENT
& MANAGEMENT OF WOUNDS,2018:1–37.
10.Marion Richardson B, CertEd R. The management of animal and human
bite wounds. Medicine.22(1):10-3.

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 THANK
YOU!!
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