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Wound Care and Dressing

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Regulates body temperature. Prevents loss of essential body fluids, and penetration of

toxic substances. Protection of the body from harmful effects of the sun and

radiation. Excretes toxic substances with sweat ( waste removal). Mechanical support. Immunological function mediated by Langerhans cells. Sensory organ for touch, heat, cold, socio-sexual and

emotional sensations. Vitamin D synthesis from its precursors under the effect of

sunlight and introversion of steroids.

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- A loss of continuity of the skin or mucous membrane which may involve soft tissues, muscles, bone and other anatomical structures.

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- Any disruption to layers of the skin and underlying tissues due to multiple causes including trauma, surgery, or a specific disease state.

Classification of wound healing(According to the amount of tissue loss)

Primary intention healing (e.g closed surgical

incision)

Secondary intention healing (e.g pressure

ulcer)

Tertiary intention healing (wounds left open

for 3-5 days & then closed with sutures, staples, etc…)

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Healing is a quality of living tissue; it is also referred to as

regeneration (renewal) of tissue.

A. The inflammatory phase: initiated immediately after

injury & lasts 3-6 days.

B. The regenerative (Proliferative) phase (day 4-day21)

C. The maturation (Remodeling) phase (day 21- 1 or 2

yrs)

(Manley, Bellman, 2000)

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Two major processes occur during the inflammatory phase:

1. Hemostasis (cessation of bleeding) which is achieved by a. vasoconstriction of the blood vessels in the affected area, b. deposition of fibrin, c. formation of the blood clot from the platelets.

2. Phagocytosis: Macrophages which arise from the blood monocytes engulf microorganisms and cellular debris.

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1. Fibroblasts (connective tissue cells) begin to synthesize collagen which is a protein substance that adds strength to the wound.

2. Granulation tissue & neovascularization.

3. Contraction: wound edges pull together to reduce defect .

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Begins about day 21 and can extend up to 6 months up to one or two years after the injury.

Fibroblasts continue to synthesize collagen

The collagen fibers recognized into a more orderly structure

The scar become a thin ,less elastic, white line

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Developmental consideration/Age Nutrition Life-style Medication Infection Wound perfusion

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TypeCauseDescription and Characteristics

IncisionSharp instrument eg. KnifeOpen wound; painful

ContusionBlow from a blunt instrumentClose wound, skin appears ecchymotic (bruised) because of damaged blood vessels

AbrasionSurface scrape, either unintentional (eg, scraped knee from fall) or intentional (eg, dermal abrasion to remove pockmarks)

Open wound; involving the skin ; painful

PuncturePenetration of the skin and, often the underlying tissues from a sharp instrument

Open wound; can be intentional or unintentional

LacerationTissues torn apart, often from accidents (eg, machinery)

Open wound; edges are often jagged

Penetrating wound

Penetration of the skin and the underlying tissues

Open wound; usually accidental ( bullet or metal fragments) 11

Clean wounds: Operations in which a viscus is not opened. This category includes non- traumatic, uninfected wounds where is no inflammation encountered and no break in technique has occurred.

Clean-contaminated: A viscus is entered but without spillage of contents. This category included non- traumatic wounds where a minor break in technique has occurred but no evidence of infection.

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Contaminated: Gross spillage has occurred or a major break in the sterile technique has occurred. Contaminated wounds shows evidence of inflammation.

Dirty or infected : Old traumatic wounds from a dirty source, with delayed treatment, devitalised tissue, clinical infection, fecal contamination or a foreign body.

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I. Partial-thickness: Confined to the skin, the dermis and epidermis.

II. Full-thickness : Involve the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone.

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Partial Thickness Full Thickness

A complex process.

Involve examination of the entire wound.

Nurses visually assess wounds and

document their findings to monitor and

evaluate the progress of wound healing.

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What to assess?1.Location2.Dimensions/Size3.Tissue viability4.Exudates/Drainage5.Peri-wound condition6.Pain7.Stage or extent of tissue damage ,

dictates how often a wound is re-assessed8.Swelling

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Risk for Impaired Skin IntegrityImpaired Skin Integrity Impaired Tissue Integrity Risk for InfectionPain

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A- Intrinsic risk factors:1. Extremes age: Defined as “ Children aged 1

year and under, and people aged 65 years and over’.

2. Underling Conditions/DisordersA.DiabetesB.Respiratory disordersC.Blood disorders

3. Smoking4. Nutrition and build

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B- Extrinsic risk factors:1. Drug therapy as a risk factor: e.g.

Cytotoxic drugs2. Break in the integrity of the skin3. Items such as foreign bodies4. Bypassing of defense mechanisms

through devices e.g. Intubations

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Wound is swollen. Wound is deep red in color. Wound feels hot on palpation. Drainage is increased and possibly purulent. Foul odor may be noted. Wound edges may be separated with

dehiscence present. Fever High WBC count

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Exudate is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and deposited in or on tissue surfaces. The Nature and amount of exudate vary according to: Tissue involved, Intensity and duration of the inflammation, and the presence of microorganisms.

1. Serous Exudate Mostly serum Watery, clear of cells E.g., fluid in a blister

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2. A purulent Exudate Is thicker than serous exudate because of the

presence of pus. It consists of leukocytes, liquefied dead tissue

debris, dead and living bacteria. The Process of pus formation is referred to as

suppuration, and the bacteria that produce pus are called pyrogenic bacteria.

Purulent exudate vary in color, some acquiring tinges of blue, green, or yellow. The color may depend on the causative organism.

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3. A sanguineous (hemorrhagic) Exudate It consists of large amount of blood cells,

indicating damage to capillaries that is very severe enough to allow the escape of RBCs from plasma

This type of exudate is frequently seen in open wounds.

Nurses often need to distinguish whether the exudate is dark or bright. Bright indicate fresh blood, whereas dark exudate denotes older bleeding.

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Infection Hemorrhage Dehiscence and possible evisceration Fistula formation (opening between an

organ and the skin).

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This concept is based on the color of the open wound rather than the depth or size of the wound.

On this scheme, the goal of wound care is to protect ( cover) the red, cleanse the yellow, & debride black.

The RYB code can be applied to any wound allowed to heal by secondary intention.

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R=Red Y=Yellow B= Black

Usually in the late regeneration phase of tissue repair (ie, developing granulation tissue) and are clean and uniformly pink in appearance

They need to be protected to avoid disturbance to regenerating tissue. Examples are superficial wounds, skin donor sites, and partial- thickness or second – degree burns.

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Gentle cleansing

Avoid the use of dry gauze or wet- to-dry saline

dressings.

Applying a topical antimicrobial agent.

Appling a transparent film or hydrocolloid

dressing.

Changing the dressing as infrequently as

possible.

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Characterized primarily by liquid to semi-liquid ”slough” that is often accompanied by purulent drainage.

The nurse cleanses yellow wounds to absorb drainage and remove nonviable tissue. Methods used may include . Applying wet-to-dry dressing; irrigating the wound; using

absorbent dressing material such as impregnated non-adherent, hydrogel dressing, or other exudate absorbers; and consulting with the physician about the need for a topical antimicrobial agent to minimize bacterial growth.

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Covered with thick necrotic tissue or Eschar.

e.g.. third degree burns and gangrenous ulcer.

Required debridement . When the eschar is removed, the

wound is treated as yellow, then red.

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1. To protect the wound from mechanical injuries.

2. To protect the wound from microbial contamination.

3. To provide or maintain high humidity of the wound.

4. To provide thermal insulation.

5. To absorb drainage and /or debride a wound.

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6. To prevent hemorrhage (when applied as a pressure dressing or with elastic bandages).

7. To splint or immobilize the wound site and thereby facilitate healing and prevent injury.

8. To provide psychological (aesthetic) comfort.

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The aim: Guarantee the safety of the equipment

used (cleaning/disinfection/sterilization). Reduce the level of microbial

contamination of the site requiring manipulation (antisepsis).

Ensure that no microorganisms are introduced (asepsis).

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Cleaning : Is the removal of dirt, debris and organic material.

Disinfection: Removes or destroys harmful microorganisms but not bacterial spores or slow viruses.

Sterilization: is the complete destruction or removal of all living microorganisms including bacterial spores.

Antisepsis: is the reduction of the number of microorganisms already present on the body site prior to a procedure.

Asepsis: Procedure designed to prevent any introduction of microorganisms to the site achieved by a non-touching technique and use of sterile gloves.

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1. Use physiologic solution, such as isotonic Normal saline or lactated ringer solution.

2. When possible , warm the solution to body temperature before use.

3. If the wound is grossly contaminated by foreign material , bacteria, slough, or necrotic tissue clean the wound at every dressing change.

4. If a wound is clean , has little exudate , and reveals healthy granulation tissue , avoid repeated cleaning. 34

5. Use gauze squares . 6. Consider cleaning superficial non-

infected wound by irrigating them with normal saline rather than using mechanical means.

7. To retain wound moisture , avoid drying a wound after cleaning it.

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Supplies Infection prevention Wound healing Appearance of the skin/recent changes Activity/mobility Nutrition Pain Elimination

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