Woundcare

Definition wound A wound is a severance of the natural cohesion of living tissue.

Skin The skin is the largest organ of our body.

Functions of the skin Covering and protection of the body Temperature regulation Excretion Functions as a vessel for many organs Forming of Vitamine D

Classification of wounds Open and closed wounds Causes of wounds Colour of the wound

Open wounds The cohesion of all layers of the skin or the mucous membrane is severed. Examples: cuts, stab wounds or surgical wounds

Closed wounds Not all layers of the skin or mucous membrane have been severed. The outer layer is intact, the inner tissue is damaged. Examples: Haematoma or bruise

Causes wounds Mechanical wounds Chemical wound Burns Abrasion, cut, stab wound, insect bite or shot wound Chemical wound skin or mucous membrane has necrotized Burns burning or frostbite Electricity wounds

Causes wounds Oncological wounds Radiation wounds Infection wounds metastases of the skin and skin cancer Radiation wounds sun, radiation Infection wounds Blood circulation insufficiency insufficient blood and oxygen supply of the tissue (gangrene) ulcus cruris and bed sores/pressure sores

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.

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.

Woundhealing

Sutures

Staples

Glue

Factors that influence wound healing Features of the wound Colour, extent of contamination and exudates, size, state of surrounding tissue, blood circulation Age of the care seeker State of nutrition Medication Smoking, drugs, lifestyle Related illnesses Psychosocial situation

WCS classification Method used to determine the best course of action for local wound care:  examine the wound and its colour to determine the phase of wound healing On finding mixed colours: choose course of action to treat the most urgent problem

Red wound

Yellow wound

How to examine a wound? wound type site of wound colour/odour exudates/colour of exudates necroses (wet/dry) hydration of the skin measurement wound /depth of wound How to examine a wound?

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.

Questions?