Wound Is break or disruption in the normal

Wound Is break or disruption in the normal integrity of the skin and tissues.

Wound Classification Intentional wounds Result of planned invasive therapy or treatment. Example → Result from surgery. T. V therapy or treatment- lumber puncture.

Characteristic → Wound edges is clean –bleeding is usually controlled. The risk for infection is decreased because it is under sterile condition. With sterile supplies and skin preparationhealing is facilitated.

Unintentional wound Result from unexpected trauma. Example →Accident –forcible injury (stabbing or gunshot)-burns. Characteristic →wound edges are usually jagged, multiple trauma is common, and Bleeding is uncontrolled. High risk for infection and longer healing time.

Open and closed wound: Open: Occur from intentional or unintentional trauma. Characteristic→ Skin surface broken, portal of entry for microorganisms, bleeding, tissue damage. Increase infection, and delayed heeling.

Closed Result of blow, force, or strain caused by trauma such as fall, motor crash. Characteristic →Skin surface not broken, but soft tissue is damaged. Internal injury and hemorrhage may occur.

Acute and Chronic wounds: Acute As surgical incisions usually heal with days to weeks. Characteristic→ the edge are well approximated and the risk of infection is lessened.

Chronic As pressure ulcer. Characteristic→ the edge are often not approximated. The risk of infection is increased , and the normal healing time is delayed.

Factor affecting wound healing Age Children and health adults heal more rapidly than older adlts.

Circulation and oxygenation Adequate blood flow to deliver nutrients and oxygen and to remove local toxins, bacteria, and other debris is essential for wound healing.

-Decrease circulation→ older adult, vascular disease. - Decrease circulation→ anemia, chronic respiratory disorder. - Decrease circulation→ smoke

Nutritional status: Wound heals need→ adequate proteins, carbohydrate, fat, vitamin, and minerals. Vit. A and C →re-epithelialization and collagen synthesis. Zinc → proliferation of cell. Fluid →necessary for function of cell.

Wound condition Lang- contaminated- infection→ decrease healing process. Health status Patient’s with chronic illness→ cardio vascular diseases , diabetes mellitus.

Goal of wound care: Is to promote tissue repair and regeneration so that skin integrity is restored.

Providine iodine (Betadine) Indication: 1 -Medical and surgical aseptic technique. 2 -Clean wound. 3 -Septic wound. 4 -Vaginal douche. 5 -Mouth washes & gargle.

Contraindication: Patient sensitive to iodine Drug Interaction: Alcohol & Hydrogen peroxide.

Alcohol Indication: 1 -Medical and Surgical Aseptic Technique. 2 -Clean Wound. 3 -Umbilical Cord Care

Contraindication: 1 -Septic Wound. 2 -Deep Wound. Drug Interaction: Hydrogen peroxide & Providine Iodine.

Hydrogen Peroxide Indication: 1 -Mouth Wash. 3 -Septic Wound. Contraindication: 1 -Deep Wound. 2 -Clean Wound. 2 -Ear Wash.

Side Effects: 1 -Pulmonary embolism when used in deep wound. 2 -Tongue atrophy. Drug Interaction: Alcohol & Providine Iodine.

Nursing Intervention: After using hydrogen peroxide rinse the wound using normal saline because hydrogen peroxide lead to delay wound healing.

-Sterile Gloves. -Sterile Basin. -Gauze Dressings or Squares. -Clean Disposable gloves. -Sterile Dressing Set or Suture set (Contains scissors and forceps).

- Plastic bag for Soiled Dressing. -Additional Dressing Supplies as needed or ordered. -Cleaning Solution.

Steps Rationale 1 -Explain -Explanation encourages procedure to client cooperation and client. reduces apprehension 2 -Gather equipment -This provides for organized approach to task.

Steps Rationale 3 -Wash your Hands. -Hand Washing deters spread of microorganisms 4 -Chech physician’s -This clarifies order for dressing type of dressing. change. Note if drain is present. 5 -Close door or -This provides curtain. for privacy and comfort

Steps 6 -Assist client to Rationale -This provides comfortable position for comfort. that provides easy access to wound area.

Steps Rationale 7 -Place opened -Soiled dressing may plastic bag near be placed in disposal working area. bag without contaminating outside surfaces of bag.

Steps 8 -Loosen tape on Rationale -It is easier to dressing. If tape is loosen tape before soiled. Done gloves. putting on gloves.

Steps 9 -Don clean disposable gloves an removes soiled dressing carefully in a clean to less clean direction. Do not reach over wound. Check position of drains before removing dressing. If dressing is adhering to skin surface pouring a small amount of sterile saline onto it may moisten it. Keep soiled side of dressing away from client’s view.

Rationale -This protects the nurse from handling contaminated dressings. Caution removal of dressing is more comfortable for client and ensures that drain is not removed if one is present. Sterile saline provides for easier removal dressing.

Steps Rationale 10 -Assess amount, -Wound healing type, and odor of process or presence drainage. of infection should be documented. 11 -Discared dressings in plastic disposal bag. Pull off gloves inside out drop it in bag. -This prevents spread of microorganisms by contaminated dressings.

Steps Rationale 12 -Wash your hands. -Hand washing deters spread of microorganisms. 13 -Using aseptic technique. Open sterile dressings and supplies on work area. -Supplies are within easy reach, and sterility is maintained.

Steps Rationale 14 -Open sterile cleaning solution, -Sterility of dressings and pour over sponges placed in solution is maintained. sterile basin. 15 -Don sterile gloves. -Maintain surgical asepsis.

Steps Rationale 16 -Clean wound or surgical incision. Use sterile forceps if desired. Ⓐclean from top to bottom or from center outward. -Clean from least to most contaminated area.

Steps Rationale -Previously cleaned Ⓑuse one gauze area is not square for each recontaminated. wipe. Discarding each square by dropping into plastic bag. Do not touch bag with forceps.

Steps Rationale ⒸClean around drain, if present. Moving from center outward in a circular motion. Use one gauze square for each circular motion. -Move from least to most contaminated area.

Steps Rationale Ⓓdry wound using -Moisture provides gauze sponge and medium for growth some motion. of microorganisms.

Steps Ⓔapply antiseptic Rationale -Growth of ointment if ordered. microorganisms may be retarded and healing process improved.

Steps Rationale 17 -Apply a layer of -Primary is dry, sterile absorbed and dressings over surrounding skin wound. Use sterile area is protected. forceps if desired.

Steps Rationale 18 -Use sterile scissors to cut -Drainage is absorbed and sterile 4╳ 4 gauze surrounding skin area is protected. square to place under and around drain if one is present.

Steps 19 -Apply second gauze layer to wound site. 20 -Remove gloves from inside out. And discard them in plastic waste bag. Apply tapes to secure dressings. Rationale -Tape is easier to apply after gloves have been removed.

Steps Rationale 21 -Wash hands. -This prevents Remove all spread of equipment, and microorganisms. make client comfortable.