Wound Care

A wound is a defect or break in the skin that resulting from physical, mechanical or thermal damage or as a result of the presence of an underlying medical or physiological condition.

Wound that heals in a timely manner going through all the stages of a wound healing process. Generally minimal skin loss and healed by primary intention. Often wound edges joined with sutures/staples.

Mechanical- abrasion, contusions, lacerations, trauma, grafting, bites, surgical wound

Burns-  thermal, cold condition, chemical woulds, electrical wound, radiation

A wound that gets stuck in a stage and remained unhealed for more than 6 weeks

Eg: pressure ulcers, leg ulcers, diabetic foot ulcers, post op open wounds

• Nutrition
• depressed immune system
• age
• Illnesses
• autoimmune diseases
• medication
• decreased oxygen supply
• Vascular circulation
• lifestyle factors - smoking, alcohol, drugs, deficiency.

*slows down bleeding due to vaso-constricting of blood vessels

*platelets is released and a clot is formed

This is your body’snormal response to injury. This phase activates protective measures through chemical activity causing HEAT, REDNESS, PAIN, SWELLING,LOSS OF FUNCTION. Wound ooze may be present and this is also a normal body response.

This is the time when your wound is healing. Your body makes new blood vessels,which cover the surface of the wound. The result is that your wound will become smaller as it heals.

• *Fibroblasts continue to make collagen
• *Capillaries continue to regenerate
• *granulation continues
• *wound edges begin to join together
• *scar is forming

This is the final phase of healing, when scar tissue is formed.

The TIME framework is a useful practical tool based on identifying the barriers to healing and implementing a plan of care to remove these barriers and promote wound healing.

Used to assess a wound bed.

Tissue - viable or non-viable

Infection - infection or inflammation

Moisture - imbalance

Edge - epithelium advancing our undermining

A framework for wound assessment, it encapsulates key wound parameters that should be addressed in the wound assessment and management of chronic wounds.

As the wound heals growth of granulation tissues decreases the wound depth and volume. Measures of wound size are important indicators of healing. 


may use a ruler to measure length, width, depth (use of sterile swabs), area

Acute wound: fluid contributes to would healing process as it contains growth factors which help with tissue regeneration. Also inhibit bacteria growth and help degrade necrotic tissue

Chronic wound: may contain high levels of inflammatory cytokine levels and decreases glucose which are associated with non- healing wound.

Appearance of the wound bed, tissue type and amount. 

• Wound bed colour:
• *Black- dehydrated
• *Yellow- fibrous tissue or slough
• *Red- presence of granulation, bright red and moist indicates healthy granulating
• *Paler appearance may indicate infection or anaemia
• *pink - final stages of wound healing, the wound is epithelising

Assessment of pain is important, patient comfort or indicator of wound infection. 

Management can be challenging

Consider underlying conditions and pain associated with these conditions.

Need to look, measure the internal wound area.

The wound will not heal unless the edges are firmly attached to the wound bed

Time varies with different wound. Need to loo at both short and long term goals. 

Assess for signs of infection and deterioration, must be done at every dressing change.

The wound edge and surrounding skin provide important information that can assist in the wound treatment

• Remove excess exudate
• Maintains a moist enviroment
• Impermeable to micro-organisms and free from irritants
• Does not shed particles into the wound
• Does not adhere to skin tissue
• Performs as a semi permeable membrane
• Provides thermal insulation
• Easy to apply and cost effective

• Form a gel like covering when come in contact with exudate
• Helps maintain optimum moisture and temperature
• Made of soft non-woven fibres derived from seaweed
• Form of pads, ropes or ribbons
• Best used with moderate to heavily exudating wounds

• Work by absorbing exudate and maintain a moist environment
• Provide thermal insulation
• Suitable for minimal to heavily exudating wounds
• Not suitable for dry epithelializing wounds or dry scars
• Have added advantage of providing cushioning and comfort

• Work by donating and absorbing liquid within wound bed
• Promote autolysis of dead tissue
• Promote a moist environment
• Requires secondary dressing when applied as gel
• Suitable for light to moderately exudating wounds
• Re-hydrates dry and necrotic wounds
• Cleanse sloughy wounds by enhancing autolytic debridemet

• Waterproof but allow passage of oxygen and water vapour to and from the wound site
• Prevent wound contamination by bacteria
• Help maintain a moist environment and retain growth factors from exudate close to the wound bed

• Absorb liquid and form a gel
• Used for light to moderately exudating wounds
• Do not adhere to wound beds

• Absorb exudate 
• Form a soft gel on contact with exudate
• Gel aids the removal of non-viable tissue from wound

Act as a shock absorber and insulator where it stores fats for energy reserves.

A moist wound environment encourages healing by promoting granulation an the body's own ability to debride a wound. Must be maintained to keep wound form becoming dry or too moist, both of which can contribute to wound healing

This helps to determine whether the epithelium tissue is advancing or whether the wound is undermining

Diffusion through skin

• Sometimes called tertiary closure 
• Wounds such as bite wounds or dehisced surgical wounds
• Wounds that are infected and need infection clearer prior to primary closure

This describes a surgically closed wound that has partially or completely separated resulting in a cavity wound. This occurs when the wound has failed to develop sufficient strength to  withstand the forces placed upon it. Although it is generally seen 5-10 days postop, it can occur up to one month after surgery. The primary causes of dehiscence are:

• *Poor suturing/stapling technique
• *Haematoma formation between the opposed tissues, which can prevent normal healing
• *Wound infection

• warm
• pain
• swelling/edema
• erythema
• inflammation
• high temperature
• decreased appetite
• wound not healing
• fatigue
• cellulitus