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WOUND
DEFINITION OF WOUND
A wound is a break or cut in the continuity of any body structure,
internal or external caused by physical means.
CLASSIFICATION OF WOUND
According to severity of injury
INCISED Wound
CONTUSED wound
LACERATED wound
PUNCTURED /stab wound
• Incised wounds:
These are made by a clean cut with a sharp instrument, e.g , those made by the
surgeon in every surgical procedure. Clean wounds (those made aseptically) are
usually closed by sutures after all bleeding vessels have been ligated carefully.
• Contused wounds:
• These are made by blunt force and are characterized by considerable injury of the
soft part, hemorrhage, and swelling
• Lacerated wounds:
• These are with jagged, irregular wire. edges, such as would be made by glass or
barbed
• Puncture wounds:
• These result in small openings in the skin, e.g. those made by bullets or knife
steps.
According to cleanliness / contamination
Clean wound
Clean Contaminated wound
Contaminated wound
Dirty or infected wound
• Clean wounds:
These are uninfected surgical wounds in which there is no inflammation
and the respiratory, alimentary, genital, or uninfected urinary tracts are
not entered.
Clean wounds are usually sutured closed; if necessary, a closed
drainage system (e.g.Jackson Pratt) is inserted. The relative probability
of wound infection is 1 to 5%.
• Clean-contaminated wounds:
These are surgical wounds in which the respiratory, alimentary, genital
and urinary tract are entered under controlled conditions; there is no
unusual contamination. The relative probability of wound infection is 3 to
11%.
Contaminated wounds:
These include open, fresh, accidental wounds, and surgical
procedures with major breaks in aseptic technique or gross spillage
from the gastrointestinal tract; Included in this category are incisions
in which there is acute, nonpurulent inflammation.
The relative probability of wound infection is 10 to 17%.

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WOUND.pptx

  • 2. DEFINITION OF WOUND A wound is a break or cut in the continuity of any body structure, internal or external caused by physical means. CLASSIFICATION OF WOUND According to severity of injury INCISED Wound CONTUSED wound LACERATED wound PUNCTURED /stab wound
  • 3. • Incised wounds: These are made by a clean cut with a sharp instrument, e.g , those made by the surgeon in every surgical procedure. Clean wounds (those made aseptically) are usually closed by sutures after all bleeding vessels have been ligated carefully. • Contused wounds: • These are made by blunt force and are characterized by considerable injury of the soft part, hemorrhage, and swelling • Lacerated wounds: • These are with jagged, irregular wire. edges, such as would be made by glass or barbed • Puncture wounds: • These result in small openings in the skin, e.g. those made by bullets or knife steps.
  • 4. According to cleanliness / contamination Clean wound Clean Contaminated wound Contaminated wound Dirty or infected wound
  • 5. • Clean wounds: These are uninfected surgical wounds in which there is no inflammation and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. Clean wounds are usually sutured closed; if necessary, a closed drainage system (e.g.Jackson Pratt) is inserted. The relative probability of wound infection is 1 to 5%. • Clean-contaminated wounds: These are surgical wounds in which the respiratory, alimentary, genital and urinary tract are entered under controlled conditions; there is no unusual contamination. The relative probability of wound infection is 3 to 11%.
  • 6. Contaminated wounds: These include open, fresh, accidental wounds, and surgical procedures with major breaks in aseptic technique or gross spillage from the gastrointestinal tract; Included in this category are incisions in which there is acute, nonpurulent inflammation. The relative probability of wound infection is 10 to 17%.
  • 7. Dirty or infected wounds: These are those in which the organisms that caused postoperative infection were present in the operative field before surgery. These include old traumatic wounds with retained devitalized tissue and those that involve existing clinical infections or perforated viscera. The relative probability of wound infection is over 27%.
  • 8. According to status of skin integrity Open wound Closed wound According to the cause of the wound Intentional or surgical wound Unintentional wound
  • 9. WOUND HEALING PROCESS Stage 1 Inflammatory phase Stage 2 Destructive phase Stage 3 Proliferative phase Stage 4 Maturation phase
  • 10. Inflammatory phase • Within few seconds after injury, inflammation begins and lasts for about 3 days. • Injured tissues and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and exudation of serum and while blood cells into damaged tissues.
  • 11. Leukocytes reach the wound within few hours. The neutrophil begins to ingest bacteria and small debris. The neutrophil dies in a few days. • During this period the monocyte which transforms into macrophages cells clean the wound bacteria, dead cells and debris. • This process continues for about 48 hours. Finally a thin layer of epithelial tissue forms over the wound, which is later absorbed.
  • 12. Destructive phase • This begins before the inflammatory phase ends and lasts for about 2 to 5 days. • Macrophages continue its cleaning process and stimulate the formation of fibroblast.
  • 13. Proliferative phase This phase begins with the appearance of the new blood vessels and lasts from 3 to 24 days. Fibroblasts appear alongside the capillaries. These two together constitute the granulation tissue. Subsequently there is epithelization. All the cells forming the surface epithelium undergoes rapid division and migrates as a thin film covering the wound. The wound appears pink owing to the new capillaries in the granulation tissue and the area is soft and tender.
  • 14. Maturation phase This final phase may take more than one year there is scar formation by the fibroblasts. The capillaries and lymphatic endothelial buds in the new tissues disappear and the scar then shrinks. The collagen scar continues to regain strength over several months.
  • 15. FACTORS AFFECTING HEALING PROCESS Nutrition Age Blood supply Hormones Drugs Extent of the injury Infection Chronic diseases Smoking Obesity Radiation Wound stress
  • 16. COMPLICATION Hemorrhage Infections Wound dehiscence Wound evisceration Fistula Abscess formation Cellulitis Necrosis or Gangrene Keloids Pain Fluid collection Interference with organ function
  • 17. DEFINITION OF WOUND DRESSING It is a sterile protective covering applied to a wound/incision with aseptic technique with or without medications.
  • 18. TYPES OF DRESSINGS Dressings are vary by type of material and mode of application. Gauze dressings Non-antiseptic dressings Antiseptic dressings Wet dressings Pressure dressings Non-adherent gauze dressings Self-adhesive transparent film
  • 19. PURPOSES OF WOUND DRESSINGS • To prevent infection. • To prevent further tissue damage. • To promote healing. • To absorb inflammatory exudate and to promote drainages. • To convert the contaminated wound into a clean wound. • To prevent hemorrhage. To prevent skin excoriation. To apply medication in place. To restore the function of the part. To provide physical and mental comfort to the patient. To promote thermal insulation to the wound surface area. To provide maintenance of high humidity between the wound and dressing.
  • 20. DRESSING: SUTURE CARE Wound care is defined as cleaning, monitoring and promoting healing in a wound that is closed with sutures, clips or staples. Purpose of Dressing • Provide physical, psychological and aesthetic comfort. • Remove necrotic tissue. • Prevent, eliminate or control infection. • Absorb drainage.
  • 21. • Maintain a moist wound environment. • Protect the wound from further injury. • Protect the skin surrounding the wound. • Promote homeostasis as in a pressure dressing. • Prevent contamination from feces, urine, vomitus, etc. • For splinting or immobilization of wound.
  • 22. Types of Dressing • Dry dressing: Clean wounds are dressed by the application of 4 to 8 layers of gauze folded into suitable size and shape. The surrounding of the wound is cleaned by some antiseptic and dried and dry dressing is applied after the application of medicine to the wound.
  • 23. • Wet dressing: It is used if wounds are infected and there is pus. The wet dressing compresses the hot, it stimulated the supportive process. The dressing is made of many layers of gauze or cotton pad covered with gauze. • Pressure dressing: It is done when there is bleeding or oozing from the wound. The dressing consists of thick pad and binder of sterile gauze applied over the wound with a firm bandage
  • 24. General Instructions • Maintain aseptic technique to prevent cross infection to the wound and to the ward. • All the material touching the wound should be sterile. • Wash hands before and after each dressing to avoid cross infection. • All equipment should be thoroughly disinfected, so that they will be free from pathogens. • Use masks, sterile gloves and gown for large dressing to minimize the wound contamination.
  • 25. • Dressing is changed at least 15 minutes after the room has been cleaned and avoids meal timings. • Clean wound should be dressed before infected or discharging wounds. • Wounds that are draining freely should be dressed frequently, according to the doctor's order. • Avoid coughing, sneezing and talking when the wound is opened. • While dressing avoid contamination with patient’s skin. Clothing and bed linen with soiled instruments and dressings.
  • 26. • Clean the wound from cleanest area to the least clean area, e.g. clean the wound from is center to the periphery. • If the dressings are adherent to the wound due to drying of the secretions or blood, wet it with normal saline before it is removed from the wound. • While dressing, keep the wound edges as close as possible to promote healing. • Measure the amount of discharge from the wound. Note the color, amount, and consistency of the drainage. • Before doing the dressing, inspect the wound for any complication and if it is present, report immediately to avoid further complications.
  • 27. Preliminary Assessment • Check the doctor's order for specific instructions. • Identify the correct patient, bed number and general condition. • Check the nurse's record to note the condition of the wound in previous dressing. • Check the abilities of the patient for self-help understanding and limitation. • Check the availabilities of the equipment.
  • 29. •Equipment: • A sterile tray containing: •Artery forceps-1, • Dissecting forceps-2, •Scissors-1, •Sinus forceps-1. •Probe-1, •Small bowl-1, •Safety pin-1, •Gloves, Masks and Gowns, cotton balls, gauze pieces, cotton pads and dressing towels
  • 30. A sterile tray containing: Artery forceps-1, Dissecting forceps-2, Scissors-1, Sinus forceps-1. Probe-1, Small bowl-1, Safety pin-1, Gloves, Masks and Gowns, cotton balls, gauze pieces, cotton pads and dressing towels
  • 31. A trolley containing: Cleaning solutions as necessary, ointments and powders as ordered, Vaseline gauze in sterile containers, Roller gauze in sterile container, Chittle forceps in a solution, sterile gauze, cotton and pad drum, bandages, adhesive plaster, pins and scissors, Mackintosh and draw a covered bucket to put soiled dressing.
  • 32. Procedure • Explain the procedure to the patient, using sensory preparation. • Inspect the wound for redness, swelling or signs of dehiscence or evisceration. • Observe the characteristics of any drainage. • Clean the area around the wound with an appropriate cleansing solution. • Swab from clean area towards the less clean area. (Clean the wound from the center to periphery). • Apply medications if ordered.
  • 33. • Apply sterile dressing - apply gauze pieces first and then the cotton pads. • Remove the gloves and discard it in the bowl with lotion. • Secure the dressing with bandage or adhesive tapes.
  • 34. AFTER CARE • Assess the patient to dress up and to take a comfortable position. Change the garments if soiled with drainage. • Remove the mackintosh and towel. Replace the bed linen. • Take all equipment to the utility room. Discard the soiled dressing in a covered container and send for incineration. • Wash hands and record the procedure on the nurse's record with date and time. • Teach the patient/family about wound care and signs and symptoms of infection.
  • 35. SUTURING THE WOUND • Materials and equipment: Suture materials can conveniently be divided into two broad groups: absorbable and non-absorbable. Two major mechanisms of absorption result in the degradation of catgut, are gradually digested absorbable sutures. Sutures of biological origin, such as catgut, are gradually digested by tissue enzymes. Sutures manufactured from synthetic polymers are mainly broken down by hydrolysis in tissue fluids and are the preferred material.
  • 36. • Non-absorbable sutures, such as nylon, are made from a variety of non-biodegradable materials, and are ultimately encapsulated or walled off by fibroblasts. • The sizes and tensile strengths of all suture materials are standardized. Size denotes the diameter of the material the smaller the diameter, the less tensile strength it will have. Stated numerically, the higher the first number, the smaller the diameter of the suture. • Examples of suture size used are: Trunk and lower limbs 3/0, Scalp 2/0, 3/0 or 4/0, Upper limbs 4/0, Most wounds 4/0, Face 5/0, 6/0.
  • 37. SURGICAL DRESSING A dressing is a protective covering applied to a wound. • The goal of a wound care is to promote tissue repair and regeneration, so that skin integrity is restored. • Dressing is used as a protective cover over the wound which helps meet the goal of wound care. • Most dressings especially for the surgical wounds consist of three layers. • The dressings applied directly over the wound called contact layer, allows drainage to pass into the middle layer. • This layer should be able to remove without causing further tissue damage. • This middle layer dressing absorbs the drainage and the outer layer keeps the two inner layers in place.
  • 38. Purposes of dressings: There are many different types of dressings, but all have essentially the same purposes as follows: • Remove necrotic tissue • Prevent, eliminate, or control infection • Absorb drainage of discharge • Control bleeding Apply medication • Maintain a moist wound environment • Promote quick healing • Provide comfort • Protect the wound from further injury • Protect the skin surrounding the wound.
  • 39. Advantages of Dressings Dressings have advantages and disadvantages. The advantages of wound dressing are as follows: • Dressings absorb drainage to help promote wound healing • Dressings protect the wound from mechanical injury • Dressings when used as a pressure dressing or with elastic bandages promote homeostasis help prevent hemorrhage, and aid in wound edge approximation
  • 40. • Dressing splint or immobilize the wound, facilitating healing and preventing further trauma • Dressings prevent contamination from the external environment • Dressings provide physical, psychological and esthetic comfort.