Wound It is a break in the continuity of the skin, mucous membranes, bone, or any body organ
TYPES OF WOUNDS
INCISION It is cause by sharp instrument. Ex knife or scalpel.
CONTUSION Cause by blow From a blunt Object. Closed wound Skin appears ecchymotic
ABRASION Surface scrape, either Unintentional or Intentional. It is an open wound Involving the skin, Painful.
PUNCTURE Penetration of the Skin and often, the Underlying tissues From a sharp Instrument.
LACERATION Tissues torn apart, Often from accidents.
PENETRATING WOUND Penetration of the Skin and the Underlying tissues.
KINDS OF WOUNDS DRAINAGE Exudate - is material, such as fluid and cells, that has escaped from blood vessel during the inflammatory process and is deposited in tissue or on tissue surfaces.
Serous exudate - consist chiefly of serum or the clear portion of the blood derived from the blood and serious membranes. 2. Purulent Exudate - It is thicker than serous exudate due to presence of pus.
3. Sanguineous exudate - Consist of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape or red blood cells.
THE RYB COLOR CODE This concept is based on the color of an open wound - Red, Yellow, Black.
Red wound - are usually in the late regeneration phase of tissue repair and are clean and uniformly pink in appearance this type of wound needs to be protected.
Protect the Red wound a. gentle cleansing b. avoiding the use of dry gauze or wet to dry saline dressings. c. applying a topical antimicrobial agent. d. changing the dressing as infrequent as possible.
YELLOW WOUNDS - Characterized by primarily by liquid to semiliquid “slough” that is often accompanied by purulent discharges.
CLEANSETHE YELLOWWOUNDS Yellow wounds should be Cleanse to absorb drainage and remove nonviable tissue. Apply wet to wet dressing. Hydrogel dressings Exudate absorbent dressings
BLACK WOUNDS This type of wound is covered with necrotic tissue. BLACK WOUNDS requires debridement ( removal of infected and necrotic material)
GUIDELINES IN WOUND CLEANING
Use Isotonic saline or lactated ringers solution to clean or irrigate the wound.
Warm the solution to body temperature before use.
If wound is grossly contaminated by foreign material, bacteria, or necrotic tissue, clean the wound at every dressing change.
If wound is clean, has little exudate, and reveals healthy tissue avoid repeated cleaning.
Use gauze squares. Avoid using cotton balls and other products that shed fibers onto the wound surface. The fibers become embedded in the granulation tissue and act as a foci for infection
Consider cleaning superficial noninfected wounds by irrigating them rather than by mechanical means.
Purpose of wound Dressings
To protect the wound from mechanical injury
To protect the wound from microbial contamination
To provide or maintain high humidity of the wound
To provide thermal insulation
To absorb drainage or debride the wound
To prevent haemorrhage
To splint or immobilize the wound site and prevent further injury