CLINICAL APPLIED ANATOMY IN

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WOUND CARE
What is skin?
- Skin is the outer covering of the body and thus provides protection.
- Skin consists of 3 principal layers.
a) Epidermis
b) Dermis
c) Subcutaneous
FUNCTION OF THE SKIN

 Body temperature regulation

 Protection
 Sensation
 Excretion
 Immune function
 Blood reservoir
 Synthesis of vitamin D
 2
DEFINATION, CLASSIFICATION &
STAGES OF WOUND HEALING
 Defination
 Wound
Injury to the integument / to the underlying structure
(visible result of individual cell death or damage)

 Ulcer
An interruption of continuity of an epithelial surface with
an inflamed base

 Classification

(a) Timing

Sudden
• • Wound that failed • Wound that has
disruption of to proceed through no signs of healing
skin integrity an orderly and process within 2
timely process to to 4 weeks after
trauma / surgery appropriate
produce anatomic
function properly intervention

NON HEALING
ACUTE CHRONIC
WOUND
(b) Etiology Of Wound
(C) WOUND HEALING

 Phases of wound healing

1. Haemostasis
2. Inflammation (0 - 3 days)
3. Profilation (3 - 24 days)
4. Maturation (24 – 365 days)

 Factors Affecting Wound Healing

1. Local Factors
 Tissue oxygenation
 Infection
 Foreign body
 Venous insufficiency

2. Systemic Factors
 Advancing age
 Obesity
 Ischaemia
 Malnutrition
 Disease: Diabetes, Anaemia,
 Medications: Glucocorticoid steroids, NSAIDs, Chemotherapy
 Alcohol and smoking
 Immuno‐deficiency: Cancer, radiation therapy, AIDS
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WOUND ASSESMENT AND
DOCUMENTATION
General assessment:
Include:
 Age (extremes of age )
 Diseases or co morbidities (e.g. diabetes mellitus , renal
impairment )
 Medication (steroids , chemotherapy )
 Obesity
 Nutrition (refer to chapter on nutrition)
 Impaired blood supply (refer to chapter on arterial and
venous ulcers )
 Lifestyle (smoking , alcohol)

Local wound assessment

Include:
 A review of the wound history (How, What, When, Where,
Who)
 Assessment of the physical wound characteristics
 location, size, base/depth
 presence of pain
 condition of the wound bed
T.I.M.E

SIZE
Pink – Epithelial tissue

Size 12 x 8 x 1 cm Red – granulation tissue

Black – necrotic tissue

Exudate – moderate

(purulent) with dour

Yellow ‐ slough
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STANDARD OPERATING PROCEDURE
ON WOUND DRESSING
No ProC ess
1.  Greet / acknowledge patient.
 Provide privacy
 Explain the procedure.
 Identify type of wound dressing required. Infected
or dirty wound dressing should be done last
 Perform pain assessment
 Administer analgesic if indicated.

2.  Perform hand hygiene (observe 5 moments for hand

hygiene) using soap and water OR alcohol based hand
rub
 Wear mask
 Prepare trolley for dressing
 Provide privacy
 Place patient in a confortable position

3. Loosen dressing:
 Perform hand hygiene. Wear gloves (unsterile).
 Loosen the existing dressing but do not remove it
 Use saline or water for irrigation to furthe loosen the
dressing if necessary
 Remove gloves
4. Perform Hand Hygiene. Prepare dressing
requirements :
 clean dressing trolley
 sterile dressing set – top trolley
 dressing materials‐ bottom trolley
 cleansing solution– bottom trolley
 Plaster/bandage, Scissor
 clinical waste bin
 General waste bin.
 Check expiry date

No Pro ess
5. A complete dressing set should consists of:
 kidney dish (1)
 galipots (2)
 Non‐tooth dissecting forceps (2)
 Bryant’s dressing forceps (2)

6. Perform hand hygiene.

 Open dressing set.
 Add the right quantity of sterile dressing
materials.
 Pour cleansing agent.
 Maintain sterile field:‐
 Non sterile person should not reach across sterile
areas or touch sterile item
 Non sterile person should not contaminate sterile
items when opening, disposing or transferring
them to the sterile area
 Place only sterile items within the sterile a ea
 The sterile person should not reach across
unsterile areas or touch unsterile items
7. Perform hand hygiene.
 Wear sterile gloves.
 Remove loosen soiled dressing with a pair of
forceps.
 Discard used forceps into receiver (bottom
trolley)
 Perform wound assessment. Inform attending
doctor if there is any concern.
8. Prepare swabs for dressing
 Dip swabs into cleansing solution and squeeze
excessive cleansing solution.

No Pro ess
9.  Keep forceps facing downward and above waist line
when performing dressing.
 Avoid the soiled forceps (forceps in contact with the
wound) from touching the sterile field.

10. Perform dressing as according to the sequence

below:
 Swab from clean area to dirty area. Use one swab
for each stroke.
 Remove debris, scabs, slough, biofilm when
necessary.
 Irrigate with non antiseptic solution if required
 Clean the peri‐wound area thoroughly.
11. Choice of Dressings:
 Apply non‐allergenic dressing. To promote healing
 Use of appropriate off‐loading device if required.
 Ensure the wound is completely covered with
appropriate dressing.
 Secure dressing appropriately so as not to impair
blood circulation.

12. Label dressing done:

 Date dressing done.
 Date due for next dressing.

13.

 Clear trolley. Used dressing set to be sent to

Central Sterile Supply Unit (CSSU) for re‐
sterilization
 Perform hand hygiene.

No Process
14. Health Education
 Inform patient wound progress.
 Maintain a well‐balanced diet.
 Compliance to medication and follow up
treatment.
 Personal hygiene.

Document wound findings and care rendered in wound

15.
care chart.
 5
WOUND CLEANSING

Wound cleansing is a
process of removing
inflammatory
contaminants from the
wound surface. These
contaminants can impede
healing and increase risk
of infection.

The contaminants are:

1. Necrotic tissues
2. Excess exudates
3. Foreign objects
4. Infected tissues

Solutions used in wound

cleansing can be either
non‐antiseptic or antiseptic

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 Non-antiseptic

1. Normal saline
 Preferred cleanser for most types of wounds (physiologic and safe)
 Less effective in dirty and necrotic wounds
 Not advisable in MRSA and Pseudomonas infected wound
 Once the container is opened, it should be used within 24 hours

2. Water for irrigation

 Less physiologic compared to normal saline but still safe to be
used
 Can be used in MRSA and Pseudomonas infected wound

Antiseptic

1. Chlorhexidine gluconate 1:200 in aqueous solution

 Effective against Gram positive bacteria, fungi and also enveloped
viruses.
 Less effective against Gram negative bacteria.
 Has both bactericidal and bacterostatic action.
 Readily available in healthcare setting.

2. Super‐oxidized solution
 Good bactericidal, virucidal, fungicidal and spongicidal.
 Also blocks the inflammatory process.
 May help in biofilm removal.
 Two components in this solution are oxidized water and chlorine.
 The oxidized water is broken down into oxygen, ozone and other
oxidized species.
 Costly.

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3. Polyhexamethylene biguanide (PHMB) solution
 Helps to soften and remove the slough.
 It can remove and reduce the biofilm formation
 Less painful.
 Costly.

These solutions besides painful on application also cause harm to the normal
tissues if used as dressing solutions (cytotoxic), however a short term use may be
permissible

 Povidone iodine
 Hydrogen peroxide
 Sodium hypochlorite
 Acetic acid
 Eusol

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 6
TYPES OF DRESSING
Dressing Categories

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 DRESSINGS PURPOSE DISADVANTAGES PRACTICAL
USAGE

1. Film Protect Adherent Fluid collection Apply the film

against over the site
contamination Transparent Possibility of stripping making sure
and friction with away newly formed there is no air
measureme epithelium on removal under it
Maintain nt grid
moist surface Bacterial To remove the
barrier film, stretch the
Prevent film and pull
evaporation Waterproof slowly from the
edges
Breathable
Facilitate
assessment Frequency of
dressing change:
2‐5 days
depending on
the wound

2. Hydrogel Rehydrate , Comfortable Need secondary Apply the

debride and dressing hydrogel on the
deslough the Provide wound bed as a
wound moist Maceration of the primary dressing
environment skin around the
Promote and reduce wound Frequency of
moist healing pain dressing change:
2‐3 days
Rehydrat
e eschar
Cavity filling
Desloughing
agent
Promotes
granulati
on

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 PRACTICAL
DRESSINGS PURPOSE ADVANTAGES DISADVANTAGES
USAGE

3. Hydro‐ Provide moist Cleans and Unpleasant Apply the

colloid environment debrides by odour adhesive side
autolysis onto the wound
Absorb Forms a yellow without
exudates Easy to use liquid gel touching the
wound bed
Bacterial Cost effective Difficult to use
barrier in cavities A yellow liquid is
Promotes seen after the
granulation Maceration of dressing is left in
tissue skin around situ which needs
wound to be cleansed
Effective for low
to moderate Frequency of
exuding wounds dressing change:
2 to 5 days
Waterproof

4. Calcium Absorb wound Economical and Not helpful for Available in

Alginate exudates and easy to apply dry wounds sheet or rope
maintain form
moisture Biodegradable Need secondary
dressing Effective to stop
Haemostatic bleeding
properties
The residue of
the
biodegradable
product has to
be washed off
during the
cleansing
process

Frequency of
dressing change:
2 to 5 days

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 PRACTICAL
DRESSINGS PURPOSE ADVANTAGES DISADVANTAGES
USAGE

5. Foams Absorbent Conforms to Can adhere to Foam dressing is

body contours wounds if used as a
Cushioning exudates dries secondary
Designed for out dressing or as
cavity wounds cavity fillers.
Highly absorbent
Frequency of
Provides dressing change:
protection 2 to 3 days or
longer if for
Bacterial and
offloading
waterproof

6. Hydrofibre Manage heavy Longer wear Not helpful for The hydrofibre
exuding time dry wounds will become gel‐
wounds like layer which
Comfortable and Needs can be easily
Maintains non traumatic secondary removed
moist healing upon removal dressings
environment Frequency of
Reduce risk of dressing change:
maceration 2 to 5 days
Can be use on
infected wounds

7. Charcoal Odour Reduces odour Needs Frequency of

absorbent secondary dressing change:
dressing 2 days

8. Silver To reduce Locally acting Some silver Place the

bacterial No known dressings do dressing with
bioburden in resistance discolour the the side with
infected bacterial wound silver facing the
wounds wound bed

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