WOUND CARE

WOUND - disruption of the integrity and function of tissues in the body

TYPES OF WOUND
According to Mechanisms of Injury:

Incised wounds -Made by a clean cut of a sharp instrument.

TYPES OF WOUND
According to Mechanisms of Injury:

Contused wounds -Made by blunt force

causing tissue damage with bruising and swelling, typically not breaking the skin.

TYPES OF WOUND
According to Mechanisms of Injury:

Lacerated wounds -Made by an object

that tears tissues, producing jagged, irregular edges.

TYPES OF WOUND
According to Mechanisms of Injury:

Puncture wounds - Made by a pointed instrument,

TYPES OF WOUND
According to Mechanisms of Injury:

Avulsion wounds - Made by strong shearing forces and

friction that can result in significant tearing and destruction of tissues

TYPES OF WOUND
According to Mechanisms of Injury:

Burn wounds - Caused by thermal, chemical, or electrical

injury to the skin.

TYPES OF WOUND
Classification of Surgical Wounds:

Class I: Clean Wounds

uninfected operative wound in which no inflammation is encountered and the alimentary, respiratory, or genitourinary tracts have not been entered. primarily closed wounds

TYPES OF WOUND
Classification of Surgical Wounds:

Class II: Clean-Contaminated

aseptically-made wound that enters the respiratory, alimentary, or genitourinary tracts. surgical operations involving the biliary tract, appendix, vagina, oropharynx,

TYPES OF WOUND
Classification of Surgical Wounds:

Class III: Contaminated

- open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the GIT - w/ evidence of inflammation

TYPES OF WOUND
Classification of Surgical Wounds:

Class IV: Dirty or infected

containing dead tissue and wounds with evidence of a clinical infection, such as purulent discharge

Types of Wound Exudate

Serous exudate consists chiefly of serum derived from blood and the serous membranes of the body looks watery and has few cells (fluid in a blister from a burn)

Types of Wound Exudate

Purulent exudate thicker than serous exudate because of the presence of pus, which consists of leukocytes, liquified dead tissue debris, and dead and living bacteria.

Types of Wound Exudate

Sanguinous exudate consists of large amount of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of RBC to plasma.

Types of Wound Exudate

Mixed Types Serosanguinous consisting of clear and blood-tinged drainage (surgical incisions)

Purulosanguinous consists of blood and pus (infected wounds)

Choosing a Cleaning Agent

Antiseptic Solution
Acetic Acid
Used to treat pseudomonas infection Verify active infection by culture before use.

Antiseptic Solution
Hydrogen Peroxide
Used to clean or irrigate mechanical debridement aid. Promotes vasodilation through warmth of foaming action. Reduces inflammation Commonly used half-strength

Antiseptic Solution
Sodium hypochlorite
(Dakins Solution) Used to kill gram negative bacteria per culture. Slightly dissolves necrotic tissue.

Antiseptic Solution
Povidone-Iodine Used to kill broad spectrum of bacteria May dry and stain the surrounding skin; protect from contact Toxic with prolonged use or over large areas

Antiseptic Solution
Chlorhexidine
Used to kill gram-positive and gramnegative Must be diluted.

BASIC WOUND CARE

Equipment: Sterile dressing and dressing materials Sterile irrigation set or individual supplies that include
Sterile syringe (30 60mL syringe) Sterile graduated container for irrigating solution Basin for collecting the used irrigation solution Moisture-proof sterile drape

BASIC WOUND CARE

Irrigating Solution, usually 200mL of solution warmed to body temperature. (or as ordered) Goggles, gown, mask Clean gloves Sterile gloves Impervious plastic trash bag

Cleaning Wounds
Preparation: Assemble the equipment at the patients bedside. Cut tape into strips for securing dressings Loosen lids on cleaning solutions and medications for easy removal Attach the impervious plastic trash bag to the over bed table to hold used dressings. Check the irrigating fluid if at the proper temperature.

Cleaning Wounds
PROCEDURE: 1. Assist the client to a position in which the irrigating solution will flow by gravity from the upper end to the lower end then into the basin. 2. Place the waterproof drape over the client and the bed.

Cleaning Wounds
3. Put on clean gloves and gently roll or lift an edge of the soiled dressing to obtain a starting point. Support adjacent skin while gently releasing the soiled dressing from the skin. When possible remove the dressing in the direction of hair growth. 4. Discard soiled dressing and your contaminated gloves in the impervious plastic trash bag to avoid contaminating sterile field then wash hands.

Cleaning Wounds
5. Put on clean gloves. 6. Inspect the wound. 7. Clean the wound. Moisten gauze pads either by dipping the pads in wound cleaning solution and wringing excess or by using a spray gun bottle to apply solution to the gauze.

Cleaning Wounds
For a linear shaped wound, such as an incision, gently wipe from top to bottom in one motion, starting directly over the wound and moving outward.

Cleaning Wounds

Cleaning Wounds

Cleaning Wounds
For an open wound such as pressure ulcer, gently wipe in concentric circles, again starting directly over the wound and moving outward.

Cleaning Wounds

Cleaning Wounds
8. Use a separate swab for each stroke, and discard each swab after use. This prevents the introduction of microorganisms to the wound area. 9. Dry the wound with 4x4 gauze pads, using the same procedure as for cleaning.

Cleaning Wounds
10. Dress the wound.
Carefully smooth out wrinkles and avoid stretching the dressing; if the dressing edges need to be secured with tape, apply a skin sealant to the intact skin around the wound. Remove and discard clean gloves.

11. Document wound and the clients response.

Dressing Wounds
Dressings are applied for the following purposes:
To protect the wound from mechanical injury To protect the wound from microbial contamination. To provide or maintain moist wound healing. To provide thermal insulation. To absorb drainage or debride a wound or both. To prevent hemorrhage. To splint and immobilize the wound site.

Types of Dressings
Transparent Dressings are often applied to wounds including ulcerated or burned skin areas.

Types of Dressings
Hydrocolloid Dressings are frequently used over pressure ulcers.

Types of Dressings
Gauze Dressing can stick to the wound surface & disrupt the wound when removed

Securing Dressings

Securing Dressings

Securing Dressings

Securing Dressings

Securing Dressings

Securing Dressings
Montgomery straps, or tie tapes -are used to secure large dressings that require frequent changing.

Drainage Devices
Penrose Soft tube that applies no suction.

Drainage Devices
Jackson-Pratt
Portable, self-contained unit that provides constant low-pressure suction and collects drainage. Used when small volumes of exudate (100-200 ml per 24 hours) are anticipated.

Drainage Devices
Hemovac
used for larger amounts of exudate (up to 500 ml per 24 hours).

Debridement of Acute Wounds

- to remove devitalized and highly-contaminated tissues while preserving critical structures such as nerves, blood vessels, tendons, and bone.

When to seek consultation:

Failure to achieve wound closure as anticipated. Wound complications. Scar management and revision. Significant infection.

End of lecture.