4 Functions of the skin Covering and protection of the body Temperature regulationExcretionFunctions as a vessel for many organsForming of Vitamine D
5 Classification of wounds Open and closed woundsCauses of woundsColour of the wound
6 Open woundsThe cohesion of all layers of the skin or the mucous membrane is severed.Examples: cuts, stab wounds or surgical wounds
7 Closed woundsNot all layers of the skin or mucous membrane have been severed. The outer layer is intact, the inner tissue is damaged.Examples: Haematoma orbruise
8 Causes wounds Mechanical wounds Chemical wound Burns Abrasion, cut, stab wound, insect bite or shot woundChemical woundskin or mucous membrane has necrotizedBurnsburning or frostbiteElectricity wounds
9 Causes wounds Oncological wounds Radiation wounds Infection wounds metastases of the skin and skin cancerRadiation woundssun, radiationInfection woundsBlood circulation insufficiencyinsufficient blood and oxygen supply of the tissue (gangrene)ulcus cruris and bed sores/pressure sores
10 Wound healing Primary wound healing Wounds will heal by themselves. The blood removes bacteria and dirt from the wound. As soon as blood comes into contact with air a blood clotting mechanism starts, a scab. When the healing process has been completed, the scab falls off.
11 Wound healing Secundairy wound healing When there is severance of the tissues, the body will first have to clean the wound. The wounded area will first get inflamed. If the wound area has insufficient blood circulation, then necroses will take place. If there is a lot of dead tissue and dead bacteria, one speaks of pus. If the wound is clean, the primary healing process can take place.
16 Factors that influence wound healing Features of the woundColour, extent of contamination and exudates, size, state of surrounding tissue, blood circulationAge of the care seekerState of nutritionMedicationSmoking, drugs, lifestyleRelated illnessesPsychosocial situation
17 WCS classificationMethod used to determine the best course of action for local wound care: examine the wound and its colour to determine the phase of wound healingOn finding mixed colours: choose course of action to treat the most urgent problem
23 How to examine a wound? wound type site of wound colour/odour exudates/colour of exudatesnecroses (wet/dry)hydration of the skinmeasurement wound /depth of woundHow to examine a wound?
24 How to examine a wound? pain ulcer edge inflammation signs Apart from that it is important to observe the patient from a holistic point of view, and his/her underlying suffering and his/her the physical and mental wellbeing.