• Made up of the skin and its appendages

• “integument” – covering
• Adult skin covers 3000 sq. inches of the
surface area of the body
• Weighs around 6 lbs.
(twice the weight of the brain and liver)
• Receives around 1/3 blood of the body
• It is flexible and has the capacity to
regenerate itself
Injury to any of the tissues of the body,
especially that caused by physical
means and with interruption of
continuity is defined as a wound.
DISRUPTION IN THE INTEGRITY OF BODY TISSUE
Tissue is defined as a collection of
similar cells and the intercellular
substances surrounding them. Four
basic tissues in the body:
1)epithelium
2)connective tissues, including blood,
bone and cartilage
3)muscle tissue
4)nerve tissue.
CLASSIFIED AS:
1. OPEN or CLOSED
2. ACUTE or CHRONIC
3. ACCORDING TO SEVERITY (superficial /
deep)
4. ACCORDING TO RISK OF INFECTION (clean /
contaminated / infected)
a. Contusion
: is a bruise
• the most common type of closed wound
(blood trapped under the surface of the
skin.)
• The epidermis remain intact, but cells and
blood vessels in the dermis are damaged.
• There is pain, swelling (a collection of
blood), and discoloration at the wound site.
• May indicate of internal injuries and related
internal bleeding.
b. Hematoma
: involves a larger amount of tissue
damage, including damage to larger blood
vessels with greater blood loss.
• Tumor like mass of blood trapped under the
skin
1. Manage the victim airway, breathing, and
circulation. Apply high- concentration
oxygen by non-re breather mask.
2. Manage as if there is internal bleeding
and provide care for shock(assess for any
possibility of internal injuries)
3. Splint extremities that are painful, swollen,
or deformed.
4. Stay alert for the victim to vomit.
5. Continue to monitor the victim for the
development of shock and transport as
soon as possible. 10
a. Abrasion
: includes a simple scrapes and
scratches in which the outer layer of
the skin is damaged
- usually the least serious type of
open wound.

11
b. Laceration:
• occurs when Sharp or
pointed object tears tissues
• results in wound with jagged
(irregular) edges
•May also result in tissue
avulsion
c. Puncture:
•when a sharp, pointed object
passes through the skin or
other tissue
•a puncture wound has
occurred.
Stab
Incision of the skin with well
defined edges, usually
caused by a sharp
Cut
instrument
• Deeper than long incision of the
skin with well defined edges,
usually longer than deep
d. Avulsion:
• in an avulsion, flaps of skin
and tissues are torn loose or
pulled off completely.
• tearing away from
supporting structures

22
 e. Amputation
the extremities are sometime
subject to amputation.
•Control bleeding.
•Treat for shock.
•Recover amputated part.
•Wrap part in gauze, place in a bag,
and keep bag cool.
•Transport the part with the victim.
f. Crush injury
• A crush injury occurs when force or
pressure is put on a body part. This type of
injury most often happens when part of the
body is squeezed between two heavy
objects.

• may be closed wound, but also can be

open wound.
Wound representing the outline of the
object causing the wound
G. Dehiscence and Evisceration
DEHISCENCE
• PARTIAL OR TOTAL SEPARATION OF WOUND
EDGES (most likely to occur 4 – 5 days
postoperatively)
EVISCERATION
• PROTRUSION OF AN INTERNAL ORGAN
THROUGH THE INCISION
YOU MUST STAY CALM !
Stay with client;
have MD notified immediately
Cover wound with normal saline soaked sterile
dressing
• Keep the protruding organ moist,
using gauze with sterile NSS
• Do not attempt to put back the
omentum inside the stomach
• Treat for shock
• Maintain sterility to prevent infection
• Many kinds of objects can become
impaled and cause significant internal
damage:
• Pencils Screwdrivers
• Knives Glass
•Steel rods Fence posts
• DO NOT remove the
object.
• Stabilize the object.
1. Expose the wound area.
2. Control profuse bleeding by direct
pressure if possible. (do not put pressure
on the object)
3. Stabilize the impaled object with a bulky
dressing.
4. Secure the dressing in place.
5. Care of shock. Provide oxygen at the
highest possible concentration.
6. Keep the victim at rest.
7. Transport the victim carefully and as
soon as possible. 38
• A bullet causes injury
in two ways:
• Laceration and
crushing
• Shock and
temporary
cavitation
• Initial care for
gunshot wounds is
roughly the same as
for any other wound.
• Can be painful and irritating
• Usually easily removed with tweezers
• After removal, clean with soap and water
and apply adhesive strip.
• Special cases:
• Cactus spines: Use white wood-working glue
• Fishooks: Use pliers with tempered jaws or
fishline method
• RED: normal granulation/ proliferative
phase/ need to protect & keep moist
• YELLOW: either fibrinous slough or
purulent bacterial exudate/ need to
remove slough
• BLACK: contain necrotic tissue/ need
debridement
1. Expose the wound.
2. Clean the wound surface.
3. Control bleeding. Start with direct pressure,
or direct pressure and elevation. When
necessary, employ pressure point
procedures.
- Remember a tourniquet is used only as a last
resort.
4. For all serious wounds, provide care for
shock.
- Including administration of high- concentration
44
5. Prevent further contamination. Use
sterile dressing. When none is
available, use the cleanest cloth
material at the scene.
6. Bandage the dressing in place after
bleeding has been controlled.
7. Keep the patient lying still. This help
reduce the bleeding rate.
8. Reassure the victim.
9. Transport the victim to the nearest
hospital. 45
• Tetanus bacterium enters a wound
that contains little oxygen and
produces powerful toxin.
• No known antidote to the toxin
once it enters bloodstream.
• A tetanus vaccine can completely
prevent the disease.
 Most cases of open wound care require
application of
a dressing and a bandage.
 Dressing is any material applied to a
wound in an effort to control bleeding and
prevent further contamination.
- Dressing should be sterile.
 A bandage is any ,material used to hold a
dressing in
place. Bandage need not be sterile.
47
• Closing of the wound
• WHAT DO YOU DOCUMENT ??
1. LOCATION
2. SIZE (in centimeters cm)
3. COLOR
4. SURROUNDING SKIN
5. DRAINAGE
6. TEMPERATURE
7. PAIN
8. WOUND CLOSURES
9. ODOR
• MONITOR CLIENT (ASSESSMENT)
• SKIN CLEANSING
• NUTRITION (MULTIDISCIPLINARY EFFORT)
• POSITIONING
• HEALTH TEACHING
• WOUND CARE / SKIN PROTOCOL

HANDWASHING – staff &

patient
• Ensure proper hygiene & skin care
• Proper positioning
• Consults as needed
• Apply complementary therapies
• Precautions if necessary
• Specialty beds
• HANDWASHING – staff & patient
1. AGE
• both skin and muscle tissue lose their tone
and elasticity.
• Metabolism slows, and circulation may be
impaired.
• Aging and chronic disease states often go
together, and both delay repair processes
due to :
• delayed cellular response to the stimulus of
injury,
2. WEIGHT
• Obese patients of any age have
excess fat at the wound site that may
prevent securing a good closure.
• In addition, fat does not have a rich
blood supply, making it the most
vulnerable of all tissues to trauma and
infection.
3. NUTRITIONAL STATUS
• Overall malnutrition associated with
chronic disease or cancer, or specific
deficiencies in
carbohydrates, proteins, zinc, and
vitamins A, B,
and C can impair the healing process.

• Adequate nutrition is essential to

support cellular activity and collagen
4. DEHYDRATION
• If the patient's system has been
depleted of fluids , it can affect
cardiac function, kidney function,
cellular metabolism, oxygenation of
the blood, and hormonal function.
• These effects will not only impact
upon the patient's overall health
status and recovery from surgery but
may also impair the healing process.
5. INADEQUATE BLOOD SUPPLY TO
THE WOUND SITE

• Oxygen is necessary for cell survival

and, therefore, healing.
• Skin healing takes place most rapidly
in the face and neck, which receive
the greatest blood supply, and most
slowly in the extremities.
• IMMUNE RESPONSES — Because the
immune response protects the patient
from infection, immunodeficiencies may
seriously compromise the outcome of a
surgical procedure.

• CHRONIC ILLNESSES
• RADIATION THERAPY
• TISSUE HANDLING — Keeping tissue trauma to a
minimum promotes faster healing.
• MAINTAINING MOISTURE IN TISSUES
• REMOVAL OF NECROTIC TISSUE AND FOREIGN
MATERIALS — Adequate debridement of all
devitalized tissue and removal of inflicted foreign
materials are essential to healing, especially in
traumatic wounds. The presence of fragments of dirt,
metal, glass, etc., increases the probability of infection.
 CLEAN WOUND
• Seventy-five percent of all wounds (which
are usually elective surgical incisions)
• An uninfected operative wound in which
no inflammation is encountered and the
respiratory, alimentary, genital, or
uninfected urinary tracts are not entered.
• These elective incisions are made under
aseptic conditions and are not predisposed
to infection.
 Clean-contaminated wounds
• wounds in which the respiratory, alimentary, genital, or
urinary tracts are entered under controlled conditions
and without unusual contamination.
• Specifically, operations involving the biliary tract,
appendix, vagina, and oropharynx are included in this
category provided no evidence of infection or major
break in technique is encountered.
• Appendectomies, cholecystectomies, and
hysterectomies fall into this category, as well as
normally clean wounds which become
contaminated
 Contaminated wounds
• include open, traumatic wounds or
injuries such as soft tissue lacerations,
open fractures, and penetrating
wounds;
• operative procedures in which gross
spillage from the gastrointestinal tract
occurs; genitourinary or biliary tract
procedures in the presence of infected
urine or bile;
• M.V.A