BACHELOR OF SCIENCE IN NURSING

CARE OF MOTHER & CHILD AT RISK OR PROBLEMS

(ACUTE & CHRONIC)
LABORATORY MODULE LABORATORY UNIT WEEK
3 11b 13
Wound Care

✓ Read course and laboratory unit objectives

✓ Read and understand study guide prior to synchronous
classes
✓ Read required learning resources;
refer to course unit terminologies for jargons
✓ Participate in weekly discussion board (Canvas)
✓ Answer and submit course unit tasks

At the end of this unit, the students are expected to:

1. Acquire knowledge in preventing wound complications by means of providing patient

education, observing principles of proper handwashing, and infection control
2. Assess the characteristics of wound including color, size, drainage and odor.
3. Demonstrate wound cleansing and bandaging.
4. Describe appropriate action if questions or complications arise.
Wounds
Break or disruption in the normal integrity of the skin and tissues. It may range from a small cut on
the finger to a third-degree burn covering almost all of the body. Wounds may be a result from
mechanical forces (ex. surgical incisions) or physical injury.
Types of Wounds:
1. Intentional wounds - trauma occurs during therapy. A result of planned invasive therapy or
treatment. The wound edges are clean and bleeding is usually controlled, and risk for
infection is decreased.
2. Unintentional wounds - are accidental. It occurs from unexpected trauma, such as accidents,
forcible injury, and burns. The wound usually occurs in an unsterile environment where
contamination is likely. This type of wound is at high risk for infection and has a longer healing
time.
3. Open wound – when the skin or mucous membrane surface is broken.
4. Closed wound - If the tissues are traumatized without a break in the skin.

Type Cause Description and Characteristics

Incision Sharp instrument (knife or Open wound; deep or shallow;
scalpel) once the edges have been sealed
together as a part of treatment or
healing, the incision becomes a
closed wound.
Contusion Blow from a blunt Closed wound, skin appears
instrument ecchymotic (bruised) because of
damaged blood vessels.
Abrasion Surface scrape, either Open wound involving the skin
unintentional (scraped knee
from a fall) or intentional
(dermal abrasion to remove
pockmarks)
Puncture Penetration of the skin and Open wound
often the underlying tissues
by a sharp instrument,
either intentional or
unintentional
Laceration Tissues torn apart, often Open wound; edges are often
from accidents (with jagged
machinery)
Penetrating Penetration of the skin and Open wound
wound the underlying tissues,
usually unintentional (from
a bullet or metal fragments)
Wounds may be described according to how they are acquired:
1. Partial thickness - confined to the skin, that is, the dermis and epidermis; heal by
regeneration
2. Full thickness - involving the dermis, epidermis, subcutaneous tissue, and possibly muscle
and bone; require connective tissue repair

Wounds can also be described according to the likelihood and degree of wound contamination:
1. Clean wounds are uninfected wounds in which there is minimal inflammation, and the
respiratory, gastrointestinal, genital, and urinary tracts are not entered. Clean wounds are
primarily closed wounds
2. Clean-contaminated wounds are surgical wounds in which the respiratory, gastrointestinal,
genital, or urinary tract has been entered. Such wounds show no evidence of infection.
3. Contaminated wounds include open, fresh, accidental wounds and surgical wounds
involving a major break in sterile technique or a large amount of spillage from the
gastrointestinal tract. Contaminated wounds show evidence of inflammation.
4. Dirty or infected wounds include wounds containing dead tissue and wounds with evidence
of a clinical infection, such as purulent drainage.

Types of Wound healing

1. Primary Intention healing
• Tissue surface have been closed
• Minimal or no tissue loss
• Characterized by the formation of minimal granulation tissue and scarring
2. Secondary Intention healing
• Extensive and involves considerable tissue loss
• Edges cannot or should not be closed

Phases of wound healing

1. Inflammatory Phase
• Begins at the time of injury and prepare the wound for healing
• Activities include hemostasis (blood clotting) and vascular and cellular phase of
inflammation,
• Blood vessels dilate and capillary permeability increases to allow plasma and blood
components to leak out into the area that is injured, forming a liquid called exudate.
• Lasts 3 to 6 days.
2. Proliferative Phase
• Extends from day 3 or 4 to 21 days post injury
• Fibroblasts (connective tissue cells), which migrate into the wound starting about 24
hours after injury, begin to synthesize collagen. Collagen is a whitish protein
substance that adds tensile strength to the wound.
• As the amount of collagen increases, so does the strength of the wound; thus, the
chance that the wound will remain closed progressively increases
• Capillaries grow across the wound, increasing the blood supply. Fibroblasts move
from the bloodstream into the wound, depositing fibrin. As the capillary network
develops, the tissue becomes a translucent red color. This tissue, called granulation
tissue, is fragile and bleeds easily.
• Adequate nutrition and oxygenation, as well as prevention of strain on the suture
line, are important patient care considerations.
 3. Maturation Phase or Remodeling Phase
• This begins on about day 21and can extend 1 or 2 years after the injury
• Fibroblasts continue to synthesize collagen.
• The framework (collagen) becomes more organized making the tissue stronger.
• The blood vessel density becomes less, and the wound begins to lose its pinkish
color. Over the course of 6 months, the area increases in strength, eventually
reaching 70% of the strength of uninjured skin.

EPITHELIALIZATION
o This is the process of laying down new skin, or epithelial, cells.
o Its primary purpose is to protect against excessive water loss and bacteria.
o Reconstruction of this layer begins within a few hours of the injury and is complete
within 24-48 hours in a clean, sutured (stitched) wound. Open wounds may take 7-
10 days because the inflammatory process is prolonged, which contributes to
scarring. Scarring occurs when the injury extends beyond the deep layer of the skin
(into the dermis).

Factors affecting wound healing:

1. Age - Healthy children and adults often heal more quickly than older adults, who are more
likely to have chronic diseases that hinder healing.
2. Nutrition - require a diet rich in protein, carbohydrates, lipids, vitamins A and C, and
minerals, such as iron, zinc, and copper. Malnourished clients may require time to improve
their nutritional status before surgery if this is possible. Obese clients are at increased risk
of wound infection and slower healing because adipose tissue usually has a minimal blood
supply.
3. Lifestyle - People who exercise regularly tend to have good circulation and because blood
brings oxygen and nourishment to the wound, they are more likely to heal quickly. Smoking
reduces the amount of functional hemoglobin in the blood, thus limiting the oxygen-carrying
capacity of the blood and constricts arterioles.
4. Medications - Anti-inflammatory drugs (e.g., steroids and aspirin) and antineoplastic agents
interfere with healing. Prolonged use of antibiotics may make a person susceptible to
wound infection by resistant organisms.

Wound Care
Children frequently have a dressing or bandage in place to cover a surgical incision or sutured
laceration. Such dressings differ from adult dressings in terms of material, size, and methods used
to secure them. Keeping a dressing dry to avoid introducing infection to the wound in infants and
toddlers who are not toilet-trained can be a major problem. In many instances after surgery, collodion
(a clear substance like nail polish) or other commercially available “wound glues” are used to cover
the incision. Wound glue not only takes the place of stitches but also serves as a dressing to keep
the incision line from encountering urine or feces. Since these materials are clear, they allow good
visualization of the healing surface as well. Assure parents that such a covering is adequate and
preferable if the incision is in the groin, such as a hernia repair. They are also preferable if an incision
or laceration is on the face as they heal with less scarring than if sutures were used.

If a gauze dressing is used, it can be covered with plastic and securely held in place with non-
adhesive, waterproof tape to protect it from becoming wet. Be certain when cutting plastic to cover
a dressing not to leave an extra piece behind in the crib; children could pull this over their head and
suffocate.

Occlusive dressings (hydrogel sheets, hydrocolloids, or polyurethane films) are dressings especially
designed to provide a healing surface over a wound. These need to be applied and removed
according to each product’s directions.

The skin of infants and young children is usually too sensitive for adhesive tape to be used to secure
dressings. Use non-adhesive tape (silk or paper) instead or secure a dressing with a non-adhering
bandage (Kling) or roller gauze. Young children, as a rule, find bandages comforting and accept
them as a “badge of courage,” displaying them proudly. Apply adhesive bandages (Band-Aids)
generously after venipuncture or finger punctures for this reason. Preschool children have little
concept of how long healing takes; they are often surprised that their incision or wound has not yet
healed the day after surgery. Preschoolers are often worried that a part of their body under a dressing
is missing and find it reassuring to see that the body part is still there (so they may pull a dressing
away to do this). It is better to know what something is like than to worry about the unknown.
Therefore, do not discourage children from looking at their incision during dressing changes. Even if
the area looks raw and unhealed, it may look better than what the child has envisioned was under
the dressing. Teach parents and children how to continue wound dressings when they return home.

Open wounds are covered with a dressing, such as a commercial adhesive bandage, although larger
wounds may benefit from the use of occlusive dressings. If occlusive dressings are applied, parents
should learn how to apply and remove the dressings correctly. For example, hydrocolloid dressings
adhere best if a wide margin is left around the wound and the dressing is pressed against intact skin
until it adheres. If a dressing needs to be secured, a nonalcohol skin barrier can be applied to protect
the skin, or the wound can be “picture framed” with hydrocolloid dressing and dressing tape can be
secured to the hydrocolloid. This method of securing the dressing protects the skin when the tape is
removed. Montgomery straps or stretch netting can also be used to secure dressings and to avoid
the use of tape.

Dressings are removed carefully to protect intact skin and the epithelial surface of the wound. When
removing transparent or hydrocolloid dressings, the nurse or parent should raise one edge of the
dressing and pull parallel to the skin to loosen the adhesive. The longer the dressings are left on,
the easier they are to remove. Less frequent dressing changes decrease wound contaminant.

Lacerations present a special challenge. The injured child and family are usually distressed by the
bleeding. Scalp lacerations tend to bleed profusely. Parental guilt and shock usually accompany the
injury. The initial nursing intervention is to apply pressure to the area and to attempt to calm the child
before further examination. Unless there is bleeding from a severed artery, the wound is cleansed
with a forced jet of sterile tepid water or saline (via syringe) and examined for extent; depth; and
presence of foreign material such as dirt, glass, or fabric fragments.

Purposes of Wound care:

1. To prevent complications and preserve functions.
2. To help the wound heal faster.
3. To remove loosely attached cellular debris and bacteria from the wound bed in order both
prepare the wound bed for healing and help prevent infection

Wound care procedure:

1. Verify order for wound care.
2. Prepare the equipment needed.
3. Provide privacy
4. Greet and identify patient.
5. Explain the procedure
6. Assess the client’s pain level and medicate if needed.
7. Assist patient to a comfortable position. Waterproof pad in a position that will allow the irrigate
to flow.
8. Wash hands and apply gloves. Remove soiled dressings carefully and discard.
9. Assess the wound’s appearance color, odor. Remove gloves
10. Open sterile dressings and supplies on work area. Wear sterile gloves.
11. Used the sterile forceps if desired. Clean from top to button, used one gauze for each wipe.
Clean around drain, if present in a circular motion. Apply antiseptic solution if needed
12. Apply a layer of dry sterile dressings over wound, surgi-pad or ABD at outermost area.
13. Remove gloves. Apply tape.
14. Perform hand hygiene. Remove all equipment. Make patient comfortable.
15. Document all assessment findings and actions taken.
ACTIVITY: CRITICAL THINGKING EXERCISES Nursing management of the client with a
wound infection

SITUATION: A 39-year-old female underwent a partial bowel resection (removal of the bowel)
as treatment for a malignant tumor. Prior to her surgery, she received radiation and
chemotherapy to reduce the size of the tumor. She has lost a significant amount of weight over
the past six months and is about twenty pounds under weight under her ideal weight.
Currently, her incision is well approximated, free of redness, tenderness or swelling.
1. The nurse adds the diagnosis of “risk for wound infection” to the client’s plan of care. Is
the nurse justified in adding this diagnosis since there are no indications of infection?
Why or why not?
2. How will the nurse know if the client is developing a wound infection?
3. What is the single most important nursing intervention to protect the woman from
developing a postoperative wound infection? 4. Cite several other nursing interventions
that are appropriate for this client.

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Concepts, practice, and Process, 10th edition. Pearson Education, Inc.

Hockenberry, M.J., and David, W., (2019). Wong’s Nursing Care of Infants and Children, 11th
edition. Elsevier.

Potter, P., Perry, A., Stockert, P., and Hall, A. (2018) Fundamentals of Nursing 9th Edition.
Elsevier Inc

Weber, J. R. and Kelley, J. H. (2014). Health Assessment in Nursing, 5 th Edition. Wolters

Kluwer.