1. Wounds

2. Break in the integrity of skin and tissueOr
An injury to living tissue caused by a cut, blow, or other impact, in which the skin is broken.
It may or may not associated with destruction of structure or function

3. Classification of wounds
Simple wounds
Only skin layer is affected / break
Complete wounds
Skin and tissue got broken including Vessels, muscles, tendons, ligaments, bones

4. Open wounds Closed wounds
Underlying tissue or muscles or bones are exposed
Closed wounds
No problems externally, but internal portions are affected

5. Open wounds Avulsion – complete or partial tearing of skin
Laceration –a deep cut or tear of skin or flesh
Puncture – a small hole type of injury by long sharp objects, pointing needles or objects
Incision – injury caused by sharp objects like blade, knife. Bleeding will be profuse
Abrasion – injury caused by rub or scratch with a rough area

10. Closed wounds
Hematoma – any injury to the vessels cause clotting of blood and accumulation in that area. Thus leads to hematoma
Crush injury – by accidental pressures, internal tissues/ vessels get damaged. Eg- accidents
Contusion or Bruise – superficial injury due to accumulation of blood under tissue. (a type of hematoma)

12. Clean wound
There will not be formation of debris and any signs of inflammation. All clean wounds will heal fast
Contaminated wounds
Completely with debris and infection. The healing only takes place with proper wound management

13. Period of healing Acute – heals very fast. Predictable healing period
Chronic – long term healing eg- diabetic ulcer

14. Involvement of part
Superficial thickness – only epidermis is affected
Partial thickness – includes epidermis and dermis
Full thickness – all parts of skin along with muscles, bones with blood vessels and nerves

15. Surgical wounds Clean surgical wounds – no inflammatory reaction
Clean -contaminated surgical wounds – high risk for developing inflammation, infection. Ex – chest procedures
Contaminated wounds – wounds come in contacts with contaminants
Infected surgical wounds – wounds delayed treatment ex- traumatic wounds, wound contact with pus, fecal matters

16. Origin
Internal – due to impaired immune system or decrease in blood oxygen and nutrients to specialized cells or due to any external force internal organs are being injured
External – by penetrating / non- penetrating causes the external part is being injured or due to miscellaneous causes.

17. Miscellaneous
Thermal wounds – extreme hot or cold ex- burns
Chemical wounds – exposure / inhalation to chemical. Ex- acids or alkali
Bites and stings
Electrical – passage of high electrical voltage through body

18. Wound healing
Fundamental property of all living tissues in all species
Nursing role – florence nightinale’s definition
Preparing a client for the most favorable conditions for healing.

19. If the wound involves:-
Mucus membrane – regeneration will be complete
Partial /Full thickness – scar will form as a result of healing
CNS tissue – no regeneration

20. Definition of wound healing
Wound healing is a complex and dynamic (active, changing and adapting ) process that results in the restoration of anatomic continuity of structure and function.
Components – oxygen, nutrition and growth factors in blood

21. Phases of wound healing
Hemostasis (the process of keeping blood inside a damaged vessel to stop bleeding) and vascular response
Inflammatory phase or process
Proliferative or resolution phase
Maturation/ reconstruction phase

22. Hemostasis and vascular response
Starts within seconds after an injury
There will be Vasoconstriction immediately after the injury -to stop bleeding
Clot formation - with the help of platelets and stops bleeding
Plasma protein – forms fibrous mesh work around wound
Combination of clot with platelets with the mesh work occurs to minimize bleeding

23. Capillary dilation / vasodilation
Dilation of vessels for supply of more blood to the area. And plasma will also be supplied
Plasma – phagocytes (macrophages, leukocytes , mast cells, neutrophills )
Dilute toxins
Carry oxygen and nutrients
Due to all these, redness, warmness occurs

24. Inflammatory phase or process
Starts within 4-6 days
This phase is a defense mechanism produced by cells or tissues against the microorganisms
It limits or eliminate the effects microorganisms

25. Walling off effect –in the wounded area, there will be presence of microorganism. It can spread through the lymph vessels around it. So The wounded area develops fibrinogen clots around it and these will block the lymph vessels and thus reduce the spreading

26. WBC’S role
They gets activated in inflammation and infection
Neutrophills – vital role
More neutrophills are transported to the wound area.
Blood vessels are made of endothelium (closely packed) and the neutrophills reaches and marginate around the area – marginating / pavementing

27. Histamine will produce and they dilate the vessels and create the space in between the endothelium in that area.
Through theses spaces, nutrients and all needed factors pass to the wound area along with neutrophills
The transport of neutrophills though the endothelial space created is called as diapedesis
Chemotaxis – the process of movement of neutrophills towards the affected area

28. Neutrophills (60% of WBC) are also called as poly morphonucleus neutrophills- polys
These are secreted either mature (segmented – segs ) Or immature (banded – bands )
The mature ones are phagocytotic
If more segs are seen in blood tests, indicated increased phagocytosis
If immature or bands is high – less phagocytosis and the problem can be from the bone marrow.

29. Macrophage –
Phagocytosis
Activate within 48 hours after injury
Removes dead cells or dying cells through phagocytosis
Eosinophills and basophills
Migrate towards the wounded area
basophills – secrete histamine
Antihistamines produced by eosinophills

30. Mediators of phase II
Mast cells (produced by plasma cell [antibody producing cells]) – mast cells get activated if any injury occurs and produces :-
Histamine
Serotonin
Leukotrines
Prostaglandins – responsible for pain – managed with aspirin(NSAID’S).
These are vasodilators

31. Kinins - Kind of plasma proteins.
Bradykinin – action same as prostaglandins and produce pain
It increases vascular permeability also
Cytokines - Generally for growth and maturation of cells along with immunity development
Interleukins – growth and development of cells
Interferones – immunity

32. Proliferative or resolution phase
This is an overlapping phase Fibroplasia and Development of granulation tissue – Fibroblasts – the cells that synthesizes the extracellular matrix and collagen and plays a critical role in wound healing By the end of first week, fibroblast are the main cells in the wound area Granulation tissue – they are new connective tissues consist of tiny blood vessels, fibroblasts, inflammatory cells, endothelial cells.

33. Collagen deposition
Collagens are proteins which helps in generation of new cells
Angiogenesis (neovascularisation) – development of new blood vessels
Wound contraction
Ability of wound edges to come together and to contract

34. Epithelialization
Migration of normal epithelial cells from the edge of wounds towards the centre
Basal epithelial cells at the wound margin flatten (mobilize) and migrate into the open wound
Basal cells at margin multiply (mitosis) in horizontal direction

35. Epithelialization/Contraction

36. Epithelialization

37. Cells activates during IIIrd phase
Fibroblast – helps in collagen deposition and granulation tissues
Myofibroblast – helps in wound contraction
Macrophages – helps in angiogenesis
It secretes / stimulate certain factors
PDGF – platelet derived growth factor
AGF – angiogenitc growth factors
TGF- transforming growth factors

38. Maturation / reconstruction phase
It will take weeks, months, years or more
Formation of scar and its remodeling
Initially scar will be very tight and dark
Then thins and becomes white
In this phase the disorganized collagen fibers are rearranged and cross linked
As the phase progress the tensile (ability to stretch) strength of the wound increases

39. Wound healing intention
Probable process of healing. These are
Primary intention – with suturing of wound. Can heal the wound without inflammation. ex -incision and lacerations
Secondary intention – keeping wound open. By the time proliferation and maturation occurs slowly and healing occur by scar tissue formation eventually – diabetic wound

40. Tertiary intention(delayed primary intension) – the contaminated wounds cant kept closed. So cant use primary intension. Only after removing the debris (dead cells) and contaminants primary intension can adopt.

41. Factors delaying wound healing
Disease conditions
Diabetes – hyperglycemia can delay developments of collagen
Immunosuppressive conditions
Oxygen deficit – anemia, inadequate blood supply, foreign body
Increased Moisture
Increase age – decrease healing
Increased mobility
Drugs – anticoagulants, - bleeding cant stop

42. Lack of Personal hygiene
Inadequate dressing – too short / too tight
Nutritional deficiency – vit c – collagen development
protein – repair and development of new cells
Zinc – epitheliazation
Smoking – o2 saturation will decrease and nicotine is a vasoconstrictor

43. Edema – increased interstitial pressure thus vasoconstriction
Hypovolemia – decreased oxygen, nutrient by decrease blood volume
Hemorrhage – blood loss, accumulation in internal bleeding favor microbes multiplication.