The skin is the body's largest organ, accounting for 15% of the total body weight:

SKIN PROVIDES:
- A protective barrier against disease-causing organisms
- A sensory organ for pain, temperature, and touch
- Vitamin D synthesis

THE SKIN HAS TWO LAYERS:

1. Epidermis- Top layer of the skin
2. Dermis -Inner layer of skin that provides tensile strength and mechanical support and protection to
underlying muscles, bones, and organs. Made of collagen, blood vessels, and nerves.
Collagen -Tough, fibrous protein
Fibroblasts (which are responsible for collagen formation)

A wound is a disruption of the integrity and function of tissues in the body. It is classified by the extent
of tissue loss.

Types or Classifications of Wounds:

A. Closed wounds are those where the skin is not broken. Tissue damage and any bleeding occur
below the surface.
a. Contusions – blunt trauma causing pressure damage to the skin and/or underlying
tissues
b. Blisters - are small pockets of fluid that usually form in the upper layers of skin after
it's been damaged.
c. Seroma – a fluid-filled area that develops under the skin or tissue
d. Hematoma – a blood-filled area that develops under the skin or tissue (occurring when
there is internal blood vessel damage to an artery or vein)

B. Open wounds -the skin is split, cut or cracked open in some way. Open wounds leave underlying
tissue – and sometimes bone and muscle – exposed to the air, as well as to dirt and bacteria.

A. Abrasions: These are shallow, irregular wounds on the upper layers of skin, due to
contact with a rough or smooth surface.
B. Punctures: are small and usually round. They’re caused by objects like needles, nails
or teeth, such as in the case of a human or animal bite.
C. Penetrations: takes place when an object or force breaks through the skin and
damages underlying tissue, muscle or organs. Penetrations have different sizes, shapes
and levels of severity depending on the cause, and can be life-threatening.
D. Lacerations: are tears in the skin with irregular, torn edges. They’re usually deeper
than abrasions and cause more pain and bleeding, and they’re often caused by trauma
or are the result of an accident.
E. Incisions: generally a result from surgical procedures or from the skin being cut with a
sharp object like a scalpel, knife or scissors. Incisions usually have sharp, smooth edges
and lines.
F. Gunshot wounds: These are penetrating wounds caused by bullets from a firearm.
Entrance wounds may have burn marks or soot on the edges and surrounding tissue. If
a bullet goes completely through the body, the exit wound will be larger and more
irregular than the entrance wound. The fast, spinning movement of a bullet can cause
serious damage to tissue, vital organs and blood vessels as it passes through the body.

Wound Classifications: (according to thickness)

- Partial-thickness wounds are shallow in depth, moist, and painful, and the wound base
generally appears red.
Ex. Scrape or Abrasion

- A full-thickness wound extends into the subcutaneous layer and the depth and tissue type
will vary depending on body location. It heals by forming new tissue, a process that can take longer
than the healing of a partial-thickness wound.
 Ex. Pressure Ulcers

A clean surgical incision is an example of a wound with little tissue loss. The surgical incision heals
by Primary Intention: Wound that is left closed (approximated) by epithelialization with minimal scar
formation. Healing occurs quickly.

A wound involving loss of tissue, such as a burn, pressure ulcer, or severe laceration, heals by
Secondary Intention: Wound is left open until it becomes filled with scar tissue; chance of infection is
greater

Three components are involved in the healing process of a partial-thickness wound:

- Inflammatory response
- Epithelial proliferation (reproduction)
- Migration with reestablishment of the epidermal layers.

Stages of Wound Healing

Phase 1: Hemostasis:
Injured blood vessels constrict, and platelets gather to stop bleeding; clots form fibrin
matrix for cellular repair
Phase 2: Inflammatory
Damaged tissues and mast cells secrete histamine (vasodilates) with exudation of
serum and WBC into damaged tissues.
Phase 3: Proliferative
With appearance of new blood vessels as reconstruction progresses, the proliferative
phase begins and lasts from 3-24 days. The main activities during this phase are the filling of
the wound with granulation tissue, contraction of the wound, and resurfacing of the wound by
epithelialization.
Phase 4: Maturation
The collagen scar continues to reorganize and gain strength for several months. May
take up to one year

Complications of wound healing:

 Hemorrhage-Bleeding from a wound site that occurs after hemostasis indicates a slipped
suture, a dislodged clot, infection, or erosion of a blood vessel by a foreign object (internal or
external)
 Hematoma-Localized collection of blood underneath the tissue
 Health care-associated infection- Second most common nosocomial infection; purulent
material drains from the wound (yellow, green, or brown, depending on the organism)
 Dehiscence- A partial or total separation of wound layers; risks are poor nutritional status,
infection, or obesity.
 Evisceration- Total separation of wound layers with protrusion of visceral organs through a
wound opening requiring surgical repair

Wound Appearance: Whether the wound edges are closed, the condition of tissue at the wound base;
look for complications and skin coloration.

Character of wound drainage: Amount, color, odor, and consistency of drainage, which depends on
the location and the extent of the wound

Types of Wound Drainage:

Serous - a clear drainage
Sanguineous - a bloody drainage
Serosanguineous - a clear, blood-tinged drainage
Purulent - a thick yellow, brown, green or grey drainage

The Braden Scale was developed for assessing pressure ulcer risks.

Pressure Ulcer - localized injury to the skin and underlying tissue over a bony prominence as a result
of pressure or pressure in combination of shear and/or friction.
Ex. sacrum, greater trochanter
Blanching - Occurs when normal red tones of skin are absent. Does not occur in dark-skinned patients.

Risk Factors That Predispose a Patient To Pressure Ulcer Formation

1) Impaired sensory perception
2) Impaired mobility
3) Alteration in level of consciousness (LOC)
4) Shear
5) Friction
6) Moisture

Stages of pressure ulcers based on the depth of tissue destroyed

Stage I: Intact skin with non-blanchable redness
Stage II: Partial-thickness skin loss involving epidermis, dermis, or both
Stage III: Full thickness tissue loss with visible fat
Stage IV: Full-thickness tissue loss with exposed bone, muscle, or tendon

Factors that place a patient at risk for a pressure ulcer.

 Mobility -Potential effects of impaired mobility; muscle tone and strength
 Nutritional Status -Malnutrition is a major risk factor; A loss of 5% of usual weight, weight
less than 90% of ideal body weight, and a decrease of 10 pounds in a brief period are all
signs of actual or potential nutritional problems.
 Body Fluids:Continuous exposure of the skin to body fluids, especially gastric and
pancreatic drainage, increases the risk for breakdown
 Pain: Maintaining adequate pain control and patient comfort increases the patient's
willingness and ability to increase mobility, which in turn reduces pressure ulcer risk.

Wound Closures:
Surgical wounds are closed with staples, sutures, or wound closures. Look for irritation
around staple or suture sites and note whether the closures are intact.

Purpose of dressings:
- Protects a wound from microorganism contamination
- Aids in hemostasis
- Promotes healing by absorbing drainage and deriding a wound
- Supports or splints the wound site
- Promotes thermal insulation of the wound surface
- Provides a moist environment

Principles of packing a wound

1. Assess the size, depth, and shape of the wound; dressing (moist) needs to be flexible and in
contact with all of the wound surface; do not overlap the wound edges (maceration of the tissue)
2. Briefly describe how the wound vacuum-assisted closure (wound VAC) device works:
3. Applies localized negative pressure to draw the edges of a wound together by evacuating wound
fluids and stimulating granulation tissue formation, reduces the bacterial burden of a wound, and
maintains a moist environment.
4. Identify three principles that are importance when cleaning an incision:
- Cleanse in a direction from the least contaminated area to the surrounding skin
- Use gentle friction when applying solutions locally to the skin
- When irrigating syringe to flush the area with a constant low-pressure flow of solution of
exudates and debris. Never occlude a wound opening with a syringe.

Principles of wound irrigation:

1. Use of an irrigating syringe to flush the area with a constant low-pressure flow of solution of
exudates and debris. Never occlude a wound opening with a syringe.
2. Explain the purpose for drainage evacuation:
3. Portable units that connect tubular drains lying within a wound bed and exert a safe, constant low-
pressure vacuum to remove and collect drainage.
4. Explain the benefits of binders and bandages:
 - Creating pressure over a body part
- Immobilizing a body part
- Supporting a wound
- Reducing or preventing edema
- Securing a splint
- Securing dressings

Nursing responsibilities when applying a bandage or binder:

- Inspecting the skin for abrasions, edema, discoloration, or exposed wound edges.
- Covering exposed wounds or open abrasions with a sterile dressing
- Assessing the condition of underlying dressings and changing if soiled
- Assessing the skin for underlying areas that will be distal to the bandage for signs of
circulatory impairment

Physiological responses
- Heat application: Improves blood flow to an injured part; if applied for more than 1 hour,
the body reduces blood flow by reflex vasoconstriction to control heat loss from the area

- Cold application: Diminishes swelling and pain, prolonged results in reflex vasodilation

WOUND CARE/DRESSING

Definition: Wound care refers to specific types of treatment for pressure sores , skin ulcers and other
wounds that break the skin.

A dressing is a sterile pad or compress applied to wound to promote healing and protect the wound
from further harm. Dressing is used to have direct contact with a wound but bandage is used to hold a
dressing in place.

Safety considerations:
a. Perform hand hygiene.
b. Check room for additional precautions.
 c. Introduce yourself to patient.
d. Confirm patient ID using two patient identifiers (e.g., name and date of birth).
e. Explain process to patient; offer analgesia, bathroom, etc.
f. Listen and attend to patient cues.
g. Ensure patient’s privacy and dignity.
h. Perform point of care risk assessment for PPE
i. Sanitize your working surface.

ACTION RATIONALE
1. Assess current dressing. Assess dressing for signs of bleeding, type and
size of dressing used. Apply non-sterile gloves
2. Perform hand hygiene. Hand hygiene reduces risk of spread of
microorganisms.
3. Gather necessary equipment. Dressing supplies must be for single patient use
only. Use the smallest size of dressing for the
wound.
4. Prepare environment; position patient; adjust Ensure patient’s comfort prior to and during the
height of bed; and turn on lights. procedure. Proper lighting allows for good
visibility to assess wound.
5. Perform hand hygiene. Hand hygiene prevents spread of microorganisms.
6. Prepare sterile field. Sterile field ensures an area free of
microorganisms and other contaminants.
7. Add necessary sterile supplies. Add necessary supplies
8. Pour cleansing solution. Pour sterile cleansing solution into sterile tray.

Normal saline or sterile water containers must be

used for only one client, and they must be dated
and discarded within at least 24 hours of being
opened.
9. Prepare patient and expose dressed wound. Prepare patient and expose wound
10. Apply non-sterile gloves. Use non-sterile gloves to protect yourself from
contamination.
Apply non-sterile gloves.
11. Remove outer dressing with non-sterile gloves Remove outer dressing with non-sterile gloves.
and discard as per agency policy. The rationale for non sterile gloves is to protect
you from exposure.
12. If necessary, remove inner dressing with Remove inner dressing with transfer forceps
transfer forceps.
13. Discard transfer forceps & gloves.
14. Assess wound Are the wound edges approximated? Are the
staples / sutures intact? Is there evidence of
complications?
14. Cleanse wound remembering principles of Clean to dirty; one wipe one way discard; fluids
asepsis flow in the direction of gravity.
15. Cleanse around the drain if present Using a circular motion, clean the area
immediately next to the drain and work outward
still following principles of asepsis.
16. Apply new sterile dressing. The type of dressing applied will depend on the
needs of the wound and the supplies available in
the agency. Secure dressings and drains with tape.

Write the date and time on the outside of the

dressing as a way to inform others.
17. Ensure the patient is comfortable before Discard used equipment according to agency
leaving the bedside. policy.

Perform hand hygiene.

 Prevents spread of infection.
18. Document according to agency policy. Documentation example:

date / time: abdominal dressing changed.

Moderate sanguinous drainage from distal end of
Consider the progression of wound healing. If incision. Wound well approximated. Staples
concerned notify the physician. intact. Cleansed with 0.9% NS. Dressed with
medipore dressing. Patient tolerated well.

——- B. Dage RN

BANDAGING

DEFINITION
A bandage is any gauze or cloth material used for any of the purpose to support or to hold or
to immobilize the body part. Bandaging is a technique of application of specific roller bandages to
different parts of body. Three types of bandages are the Kerlex bandage, the gauze bandage, and the
elastic bandage.

PURPOSE
1. To control bleeding by pressure
2. To immobilize sprained or fractured limb
3. To hold a dressing or compress in place
4. To secure splints in case of fracture of deformity
5. To protect open wound from contaminants
6. To provide support and aid in case of varicose veins or impaired circulation

ROLLER BANDAGE
 A roller bandage is a strip of gauze or cotton material prepared in a roll. Roller bandages can
be used to immobilize injured body parts (sprains and torn muscles), provide pressure to control
internal or external bleeding, absorb drainage, and secure dressings.

TYPES
1. Circular bandage: the bandage is wrapped around the part with complete overlapping of the
previous bandage turn. This is used primarily for anchoring a bandage where it is begun and
where it is terminated
2. Spiral bandage: the bandage ascends in a spiral manner so that each turn overlaps the
preceding one by one half or two-thirds the width of the bandage. The spiral turn is useful
for the wrist, the finger and the trunk
3. Figure-of-eight: the figure-of-eight turn consists of making oblique overlapping turns that
ascend and descend alternatively. It is effective for use around joints, such as the knee, the
elbow, and the ankle.
4. Recurrent-stumps bandage: after a few circular turns to anchor the bandage the initial end
of the bandage is placed in the center of the body part being bandaged, well back from the
tip to be covered. Recurrent bandages are used for gingers for the hand and for the stump of
an amputated limb
5. T-bandage: it is used to secure rectal or perineal dressing. The double “T” bandage is used
for males and single “T” bandages is for the females. The strips of the “T” bandage are
brought between the patients leg and is pinned to the waist band in front.

Triangular Bandage
The triangular bandage is one of the most standard contents of a first aid kit. It has plenty of
uses, such as a sling to support an injury to the upper body, padding for major wounds and a bandage
for immobilization purposes. It is quite easy to make and they are as follows:
 Stretch the piece of fabric that will be used. Opt to use a long stretch to create more
triangular bandages, which can be used in the fracture
 Cut the fabric into a square, approximately 3 ft multiply 3 ft. cut the square diagonally into
two equal halves, creating two triangle
 There are two ways to sterilize the bandages (sterilizing will reduce infection risk). First
option is to pull the bandage in boiling water. The second option is to soak the bandage in
hydrogen peroxide or any other disinfectant. Dry before use
 If possible, iron the triangular bandage, so it can be easily used during a time of need

SPECIAL BANDAGES
 Eye bandage (monocular): bandage of 1.5-2 width is required. Place the free end of
bandage at temporal region on the same side of eye to be bandaged. A piece of tape is
passed under bandage on side of eye and tie so as to prevent bandage from sliding over
good eye.
 Binocular bandage: figure-of-eight technique is used. Start from right temporal region
take one turn. Around head, down over the left eye, under right ear right eye to right to left
temple. Repeat around heal to right temple following previous pattern until both eyes are
covered.
 Ear-mastoid bandage: bandage with 2 feet width and 5 yards length is required make
circular turns around head above ears, beginning on affected side. Follow with circular
turns. The first turn is taken beneath occiput, and carried high over to opposite side of
head below ear.
 Jaw Barton bandage: used in fracture of lower jaw and to hold dressing on chin.
Bandage of 2 inches width and 5-6 yards length is required. Begin at nape of neck below
occiput, carry bandage obliquely up, behind and close to ear, then under chin and up in
front of left ear to top of head.
 Cape line bandage (head bandage): a double roller bandage of 2 feet width and 8 yards
length is required. Place center of bandage in middle of forehead and carry roller in
opposite direction to occipital. Cross rollers one over other. The roller in inferior position
in brought over head to middle of forehead.
 Shoulder spica: a bandage of 2 ½ inches width and 8 yards is required. The spica may be
either descending or ascending. The ascending type is most commonly used. While
applying bandage, stand at side which is to be bandage. A pad must be placed in axilla.
GENERAL PRINCIPLES
1. The patient should be placed in a comfortable position and it should convenient for the
nurse.
2. The position of the part to be bandaged should be well supported and elevated if necessary.
3. The nurse should stand directly in front of the patient or facing part to be damaged.
4. Apply and fix bandage at least two circular turns around part is its smallest diameter, so that
it can stay in place.
5. Skin surfaces should be separated. They may be separated by either gauze or cotton. In the
application of casts, special padding is used over bony prominences.
6. Always bandage to the right.
7. Exert even pressure as far as possible. The bandage should be done in the direction of the
venous circulation.
8. Do not cover the ends of the finger or toes, unless it is necessary in order to cover the injury.
It is necessary to observe circulatory changes.
9. Never apply a wet bandage. When wet bandage applied, terms to shrink and become tight as
it dries.
10. Do not apply a bandage too loosely because it may slip and expose the wound.
11. All turns of bandage should be made clockwise unless there is some special reason for doing
otherwise the roll should be held in the palm of the hand, with the free end of the bandage
coming from the part of the roll.
12. Applying bandage, secure terminal extremity by pinning with safety pins or strapping
adhesive.
13. Remove bandages by gathering folds in a loose mass. Passing mass from one hand to the
other.
14. Examine the bandage part frequently for pain, swelling, etc.

ASSESSING BEFORE APPLYING BANDAGE

1. Inspect and palpate the area for swelling
2. Inspect for the presence of and status of wounds
3. Note the presence of drainage (amount, color, odor, and velocity)
4. Inspect and palpate for adequacy of circulation (skin temperature, color and sensation)
5. Ask the patient about any pain experienced (location, intensity, onset and quality)
6. Assess the ability of the patient to reapply the bandage when needed
7. Assess the capabilities of the patient regarding activities of daily living (to dress, comb hair,
bath)

MATERIALS
 Gauze  Flannel
 Muslin  Crinoline for plaster
 Rubber  Adhesive
 Elastic

PROCEDURE
1. Introduce yourself to the patient. Explain the procedure to the patient.
2. Provide privacy and place patient in a comfortable position.

3. Make sure that the area to be bandaged is clean and dry.

4. Stand opposite to the patient if possible.

5. Support the affected part adequately ensuring correct body alignment to prevent deformity
and impair circulation.

6. Keep bandage roll uppermost with free and above site to be bandaged.

7. Bandage from below to upward.

8. Cover two – thirds of previous turn, avoid loose edges.

9. Take requires number of turns so that purpose is achieved.

10. Secure the end of the bandage with tape. Metal clips or a safety pin over an uninjured area.

11. Document the site and type of bandage used.