WOUND DRESSING : By: RAIN S. NOLASCO RN WOUND DRESSING Slide 2: Learning Objectives:
At the end of the lecture-discussion the student’s will…
Enumerate & 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 the wound complication and its management Slide 3: Required Readings:
Fundamentals of nursing (human health and function) Lippincot…chapter 40
Fundamentals of nursing (clinical concepts) Erb and Kozier…chapter 34
Search the net. www.medstuff.com
Basic wound care (video tapes)
Defining related terms
Paper and pencil test
Return demonstration Slide 4: Wound, any break in the external or internal surfaces of the body involving a separation of tissue, and caused by external injury or force. Wounds are classified as incised, or cut, if they are 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, if the wound passes completely through a part of the body; and subcutaneous, if it involves deep destruction of tissue with a relatively small opening, or none at all, in the surface. Septic, or infected, wounds are those in which the area is contaminated by bacteria, which can cause suppuration or shedding of tissue. WOUND : WOUND : CLASSIFICATION OF WOUNDS
1.Mechanism of injury
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. Slide 7: e) laceration-made by object that tears tissues
f) Penetrating wounds-open wound that penetrates the skin and the underlying tissues. Slide 8: 2. According to depth
Partial thickness- confined to the skin
Full-thickness- involving the dermis, epidermis, subcutaneous tissues and possibly muscle and bone. Decubitus ulcer : Decubitus ulcer Gunshot wound : Gunshot wound Stab wound : Stab wound Lacerating wound : Lacerating wound Slide 13: 3. Degree of contamination
a) Clean-an aseptically made wound, that does
not enter the alimentary, respiratory or genito-urinary 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 discharged). TYPES OF WOUND DRAINAGE : TYPES OF WOUND DRAINAGE Serous-clean, watery
Purulent- thick, yellow, green, tan or brown.
Serosanguineous-pale, red, watery mixture of serous and sanguineous.
Sanguineous- bright red, indicative of active bleeding. PHASES OF WOUND HEALING : PHASES OF WOUND HEALING 1. 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. Slide 16: Inflammation-increase blood flow, to wound resulting localized redness and edema, attracts WBC and wound growth factors.
WBC arrive-clear debris from wound. Slide 17: 2. 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. Slide 18: 3. 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 : 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. Slide 20: 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 : FACTORS AFFECTING WOUND HEALING Developmental considerations
(healthy children and adults)
Contamination and infection
e COMPLICATIONS OF WOUND HEALING : COMPLICATIONS OF WOUND HEALING 1. HEMORRRHAGE
-risk of hemorrhage is greatest during the ist 48 hours after surgery.
-emergency -N@- should apply pressure dressing to the wound and monitor vital signs.
-surgical infection is apparently 2-11 days post operatively. Slide 23: N@- watched 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.
N@- an increase in flow of serosanguinous drainage into the dressing can indicate Slide 24: impending dehiscence.
If occurs N@ should be quickly supported by sterile dressing soaked in sterile normal saline.
-position? Client in bed with knees bent…why? To decrease pull on the incision. and? Notify physician…… Wound evisceration from stab wound : Wound evisceration from stab wound Wound dehiscence : Wound dehiscence Infected wound dehiscence : Infected wound dehiscence WOUND ASSESSMENT PARAMETERS : WOUND ASSESSMENT PARAMETERS Etiology
Location of the wound
Stage of wound/extent of tissue loss
Phase of healing
Presence of undermining, sinus tracts or tunnels
Condition of the wound bed
Volume of exudates
Condition of periwound skin
Presence of pain WOUND MANAGEMENT : WOUND MANAGEMENT 1. DRESSINGS - material applied to wound with or without medication, to give protection and assist in healing.
-what are the purposes?
To protect the wound from mechanical injury
Splint or immobilized the wound.
Prevent contamination from bloody discharges Slide 30: e.) Promote homeostasis,(pressure dressing)
f.) Debride the wound
g.) to kill or inhibit microorganism
h.) provide a physiologic environment conducive to healing
i.) provide mental and physical comfort for the patient. Pressure dressing : Pressure dressing Slide 32: What are the types of dressings?
a. DRY TO DRY DRESSINGS
-used primarily for wounds closing by primary intention.
>adv-offers good protection, absorption & provide pressure
>dadv-they adhere to the wound surface when drainage dries.
- when remove can cause pain and disruption of granulation tissue. Slide 33: b. WET TO DRY DRESSINGS
-used for untidy or infected wounds that must be debrided and closed by secondary intention.
>how can it be done?
-gauze saturated with sterile saline or antimicrobial sol’n. is packed into the wound, the wet dressing are then covered by dry dressings
>when to changed?
-when it becomes dry Slide 34: b. WET TO WET DRESSINGS
-used on clean open wounds or on granulating surfaces.
>adv-provide a more physiologic environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort.
>dadv-surrounding tissues can become ulcerated. high risk for infection. Slide 35: 2. DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface.
-what are the purposes?
placed in the wounds only when abdominal fluid collections are present.
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. Slide 36: 3. BINDERS AND BANDAGES
-what are the purposes?
Creates pressure over the body parts
Immobilize body parts
Reduce or prevent edema
Secure a splints
Secure dressing UNEXPECTED OUTCOMES & RELATED INTERVENTIONS : UNEXPECTED OUTCOMES & RELATED INTERVENTIONS Inflamed and tender wounds which evidence of drainage and foul odor.
N@ a. Monitor clients for signs of infection
(fever, increase in WBC count).
b. notify physician
c. obtain wound culture as ordered.
Increase wound drainage
N@ a. changed dressing frequently
b. notify physician
3. Wound bleeds during dressing change PAPER AND PENCIL TEST : PAPER AND PENCIL TEST PART 1
Based on your readings, dressings may be used for what 6 reasons?
During dressings changes, wounds and surrounding tissues must be inspected for?
What will be the assessment data you must collect prior to any dressing?
Describe on how to set-up, prepare materials needed for dressing thus, maintaining sterility. Draw a picture to help explain your answer. Slide 39: PART 2
Explain what should be done in each of the following situations to avoid contamination during wound dressing.
You are in the middle of a sterile dressing change with the wound exposed and realize that you need more dressings from the CSR.
You begin to sneeze prior to beginning a sterile procedure.
A patient with abdominal wound is walking in the hall when his dressing falls onto the floor.
When removing the cap from any sterile solution bottle, be sure the cap is placed with the inner side up. Why is this critically important? THANK YOU : THANK YOU