WOUNDS AND WOUND CARE Learning Objectives At the

WOUNDS AND WOUND CARE

Learning Objectives: At the end of the lecture-discussion the student’s will… v List & differentiate classification of wounds v Understand the process of wound healing and wound management. v Performing proper wound care and its related interventions v Demonstrate care of a draining wounds v 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 HEALINGgranulation -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 (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 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

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 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 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