Download Wound Dressing

WOUNDS AND WOUND
CARE
 Learning Objectives:
At the end of the lecture-discussion the
student’s will…
 List & differentiate classification of wounds
 Understand the process of wound healing
and wound management.
 Performing proper wound care and its
related interventions
 Demonstrate care of a draining wounds
 Know wound complication and its
management
WOUND DEFINITION
Any break in the external or internal
surfaces of the body involving a
separation of tissue, and caused by
external injury or force.
WOUNDS
 Incised or cut
produced by a sharp instrument or
object
 Puncture
if the instrument is pointed and narrow
 Lacerated
if accompanied by a tearing of the
tissue
 Contused
if a substantial amount of tissue is
bruised
 Penetrating
Wound passes completely through
a part of the body
 Subcutaneous
involves deep destruction of tissue with a
relatively small opening, or none at all,
in the surface.
Compromised Wounds
 Septic, or infected, wounds are
those in which the area is
contaminated by bacteria, which
can cause suppuration or
shedding of tissue.
WOUND
CLASSIFICATION OF WOUNDS
 Incision- open wound; painful;deep;shallow
 Contusion-closed wound, skin appears
ecchymotic (bruised).
 Abrasion-open wound involving the skin;
painful
 Puncture-open wound which penetrates the
skin and underlying tissues.
 laceration-made by object that tears
tissues
 Penetrating wounds-open wound that
penetrates the skin and the underlying
tissues.
Description According to Depth
 Partial thickness- confined to the skin
 Full-thickness- involving the dermis,
epidermis, subcutaneous tissues and
possibly muscle and bone.
Decubitus Ulcer
Gunshot wound
Stab wound
Lacerating wound
Degree of Contamination
a) Clean-an aseptically made wound, that does
not enter the alimentary, respiratory or genitourinary tracts.
b) Clean contaminated-are surgical wounds in which
the alimentary, respiratory and genitals or urinary
tract has been entered.
c) Contaminated- wounds exposed to excessive
amount’s of bacteria
d) Dirty or infected-wounds containing dead tissues
and with evidence of clinical infection (purulent
discharge).
TYPES OF WOUND DRAINAGE
1. Serous-clean, watery
2. Purulent- thick, yellow, green, tan or
brown.
3. Serosanguineous-pale, red, watery
mixture of serous and sanguineous.
4. Sanguineous- bright red, indicative of
active bleeding.
PHASES OF WOUND HEALING
FIRST PHASE
INFLAMMATORY PHASE-starts
immediately after injury and lasts 3-6 days
or 4-6 days.
2 major processes occur during this phase …
HEMOSTATIS AND PHAGOCYTOSIS
Hemostatis- blood vessels constrict,
platelets aggregates and bleeding stops,
scabs forms, preventing entry of infectious
organisms.
Inflammation-increase blood flow, to wound
resulting localized redness and edema,
attracts WBC and wound growth factors.
 WBC arrive-clear debris from wound.
SECOND PHASE
PROLIFERATIVE PHASE
extends from day 3 to about day 21 post
injury.
collagen synthesis establishment of
new capillaries  creation of granulation
tissue wound contraction
epitheliazation.
THIRD PHASE
REMODELLING OR MATURATION PHASE
-final healing stage may continue for I year
or more.
Remodeling of scar tissue to provide wound
strength.
TYPES OF WOUND HEALING
 FIRST INTENTION HEALING-partial
thickness wounds.
- a clean incision is made with primary
closure, minimal scarring.
-expected when the edges of clean surgical
incisions are sutured together, tissue loss
is minimal or absent if the wound is not
contaminated with microorganism.
-e.g.-abrasion or skin tear.
 SECOND INTENTION HEALING-
granulation
-accompanies traumatic open wounds with
tissues loss or wounds with a high
microorganisms count.
-go though a process involving scar tissue
formation a, heal slowly because of the
volume of tissue needed to fill the defect.
-e.g.-contaminated surgical wound,
pressure ulcer.
FACTORS AFFECTING WOUND HEALING
 Developmental considerations
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(healthy children and adults)
Nutrition
Lifestyle
Medications
Contamination and infection
COMPLICATIONS OF WOUND HEALING
 1. HEMORRRHAGE
-risk of hemorrhage is greatest during the
first 48 hours after surgery.
-emergency -should apply pressure dressing
to the wound and monitor vital signs.
 2. INFECTION
-surgical infection is apparently 2-11 days
post operatively.
Observe for presence of changed in wound
color, pain or drainage-culturing of the
wound.
 3. DEHISCENCE WITH POSSIBLE
EVISCERATION
-may occur 4-5 days postoperatively.
-involves an abdominal wound in which the
layers below the skin separates.
Observe for an increase in flow of
serosanguinous drainage into the dressing
can indicate impending dehiscence
- If occurs should be quickly supported by
sterile dressing soaked in sterile normal
saline.
-position? Patient in bed with knees
bent…why? To decrease pull on the
incision. and? Notify physician……
Wound evisceration from stab
wound
Wound dehiscence
Infected wound dehiscence
WOUND ASSESSMENT PARAMETERS
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Etiology
Location of the wound
Stage of wound/extent of tissue loss
Phase of healing
Wound size
Presence of undermining, sinus tracts or tunnels
Condition of the wound bed
Volume of exudates
Condition of periwound skin
Presence of pain
WOUND MANAGEMENT
 1. DRESSINGS - material applied to wound
with or without medication, to give
protection and assist in healing.
-what are the purposes?
a) To protect the wound from mechanical
injury
b) Splint or immobilized the wound.
c) Absorbs dressing
d) Prevent contamination from bloody
discharges
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Promote homeostasis,(pressure dressing)
Debride the wound
kill or inhibit microorganism
provide a physiologic environment
conducive to healing
 provide mental and physical comfort for
the patient.
Pressure dressing
What are the types of dressings?
a. DRY TO DRY DRESSINGS
-used primarily for wounds closing by
primary intention.
>advantage-offers good protection,
absorption & provide pressure
>disadvantage-they adhere to the wound
surface when drainage dries.
- when removed can cause pain and
disruption of granulation tissue.
 b. WET TO DRY DRESSINGS
-used for untidy or infected wounds that must
be debrided and closed by secondary
methods.
>how can it be done?
-gauze saturated with sterile saline or
antimicrobial solution is packed into the
wound, the wet dressing are then covered by
dry dressings
>when to change
-when it becomes dry
 b. WET TO WET DRESSINGS
-used on clean open wounds or on
granulating surfaces.
>advantage-provide a more physiologic
environment (warmth moisture) which can
enhance the local healing processes and
assure greater patient comfort.
>disadvantage-surrounding tissues can
become ulcerated. high risk for infection.
 2. DRAINS- device or a tube used to draw
fluids from an internal body cavity to the
surface.
-what are the purposes?
a) placed in the wounds only when
abdominal fluid collections are present.
b) placed near the incision site
> wound drainage-drains placed within the
wounds are attached to a portable
suction with a collection container.
e.g. hemovac, jackson-pratt, penrose drain.
 3. BINDERS AND BANDAGES
-what are the purposes?
a) Creates pressure over the body parts
b) Immobilize body parts
c) Reduce or prevent edema
d) Secure a splints
e) Secure dressing
UNEXPECTED OUTCOMES &
RELATED INTERVENTIONS
1. Inflamed and tender wounds which show
evidence of drainage and foul odor.
a. Monitor clients for signs of infection
(fever, pain, increase in WBC count).
b. notify physician
c. obtain wound culture as ordered.
2. Increase wound drainage
a. changed dressing frequently
b. notify physician
3. Wound bleeds during dressing change
Dehiscence with possible
evisceration is a complication
of large abdominal wounds
A.) True
B.) False
Hemmorhage is a risk 1-3 weeks
after surgery
A.) True
B.) False
Lifestyle & current medications
are two factors that might
affect wound healing
A.) True
B.) False
The first phase of wound healing
is
A.) Proliferative
B.) Inflammation
C.) Remodeling
Bob has a pale red, watery
drainage coming from a leg
wound. What describes this type
of drainage
A.) Sanguineous
B.) Purulent
C.) Serous
D.) Serosanguinous
Gregg has his appendix removed.
What degree of contamination is
this?
A.) Clean
B.) Clean Contaminated
C.) Contaminated
D.) Dirty
A stab wound is classified as a
A.) Puncture wound
B.) Laceration
C.) Penatrating wound
D.) Subcutaneous
You stepped on a nail. What type
of wound is this?
A.) Incision
B.) Abrasion
C.) Puncture
D.) Lacerated
A contused wound would have
ecchymosis present
A.) True
B.) False
A disadvantage to wet to wet
dressings is
A.) high risk of infection
B.) Adheres to wound surface & causes pain when
removed
An advantage of Dry to Dry
Dressings is
A.) Offers good protection
B.) Provides good physiologic environment