Wounds and Wound Care

Wound Classification     

Incision Clean Clean-contaminated Contaminated Dirty/Infected

CLASS I/CLEAN WOUNDS

-an uninfected surgical wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed and, if necessary, drained with closed drainage. Surgical wound incisions that are made after nonpenetrating (ie, blunt) trauma should be included in this category if they meet the criteria.

CLASS II/CLEANCONTAMINATED WOUNDS

-a surgical wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, surgical procedures involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection is encountered and no major break in technique occurs.

CLASS III/CONTAMINATED WOUNDS

-open, fresh, accidental wounds. In addition, surgical procedures in which a major break in sterile technique occurs (eg, open cardiac massage) or there is gross spillage from the gastrointestinal tract and incisions in which acute, nonpurulent inflammation is encountered are included in this category

CLASS IV/DIRTY OR INFECTED WOUNDS-

old traumatic wounds with retained or devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the wound before the surgical procedure.

Wound Healing 

The entire wound healing process is a complex series of events that begins at the moment of injury and can continue for months to years.

I. Inflammatory Phase       

A) Immediate to 2-5 days B) Hemostasis Vasoconstriction Platelet aggregation Thromboplastin makes clot C) Inflammation Vasodilation Phagocytosis

II. Proliferative Phase        

A) 2 days to 3 weeks B) Granulation Fibroblasts lay bed of collagen Fills defect and produces new capillaries C) Contraction Wound edges pull together to reduce defect D) Epithelialization Crosses moist surface Cell travel about 3 cm from point of origin in all directions

III. Remodeling Phase 

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A) 3 weeks to 2 years B) New collagen forms which increases tensile strength to wounds C) Scar tissue is only 80 percent as strong as original tissue

Process of Wound Healing   

Primary intention Secondary intention Tertiary intention (delayed primary intention)

Primary Intention   

Clean surgical wounds Minimum cell damage Minimal scarring

Secondary Intention 

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Irregular gaping wound Purulent wound Cavity fills from below

Tertiary Intention    

Delayed primary intention Delayed suturing of wound Contaminated wounds Large, deep scar

Factors that Affect Wound Healing    

Nutritional status Preexisting conditions Infection Fluid balance

Wound Closure      

Sutures Staples Steri-Strips Butterfly strips Transparent Sprays/Films Skin Glue

Sutures 

Stitches (also called sutures) are used to close cuts and wounds in skin. They can be used in nearly every part of the body, internally and externally. Doctors literally "sew" the skin together with individual sutures and tie a secure knot. Stitches then allow the skin to heal naturally when it otherwise may not come together. Stitches are used to close a variety of wound types. Accidental cuts or lacerations are often closed with stitches. Also, surgeons use stitches during operations to tie ends of bleeding blood vessels and to close surgical incisions. 

Sutures are divided into 2 general categories, namely, absorbable and nonabsorbable. 

Absorbable sutures rapidly break down in the tissues and lose their strength within 60 days. This type of suture does not have to be removed. These are used internally or in special areas such as inside of the mouth.

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Non-absorbable sutures, on the other hand, maintain their strength for longer than 60 days. These sutures are used to close skin or external wounds and require removal once the wound has healed

Surgical staples 

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Are useful for closing many types of wounds. Staples have the advantage of being quicker, more economical, and causing fewer infections than stitches. Disadvantages of staples are permanent scars if used inappropriately and imperfect aligning of the wound edges, which can lead to improper healing. Staples are used on scalp lacerations and commonly used to close surgical wounds

Suture and Staple removal   

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7-10 days after surgery Cleanse wound Remove every other staple and replace with a steri-strip Carefully remove sutures—be sure to note if they are continuous or interrupted.

Skin closure tapes 

The advantages of skin closure tapes are plenty. The rate of wound infection is less with adhesive strips than with stitches. Also, it takes less time to apply skin closure tape. For many people, there is no need for a painful injection of anesthetic when using skin closure tapes. Disadvantages of using skin closure tapes include less precision in bringing wound edges together than suturing. Not all areas of the body can be taped. For example, body areas with secretions such as the armpits, palms, or soles are difficult areas to place adhesive strips. Areas with hair also would not be suitable for taping

Adhesive agents 

Skin adhesives can also be used to close a wound. This material is applied to the edges of the wound somewhat like glue and should keep the edges of the wound together until healing occurs. Adhesive glue is the newest method of wound repair and is becoming a popular alternative to stitches, especially for children

Nursing Care of Incisions  

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Inspect dressings Q2-4 hours minimally Inspect dressings and wounds with each change of care-giver Document wound condition and drainage   

Sanguineous Serosanguineous Serous

Drainage Systems 

Closed 

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Jackson Pratt

Open 

Penrose Drain

Wound VAC    

Vacuum Assisted Closure Increases granulation Vacuum must be on at all times Pulls exudate and bacteria away from wound

Wet-to-Dry Dressings    

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Purpose: debridement Moist gauze put into a wound to dry. Gauze adheres to wound Removing gauze mechanically removes dead (and living) tissue Now illegal and should never be done.

Irrigations 

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Gentle washing of an area with a stream of solution Use sterile technique Using a syringe, keep tip 1” from wound Irrigate gently from least contaminated to most contaminated area Position patient for optimum drainage

Complications of Wound Healing     

Watch for signs of internal bleeding Monitor for excessive bleeding Dehiscence Evisceration Infection

Pressure Ulcers 

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Areas of tissue destruction caused by the compression of vessels in soft tissue over bony prominences and an external surface Form in as little as 2 hours

Pressure Ulcer Sites

Pressure Ulcer Risk Factors

Preventing Pressure Ulcers · Help the patient change position every one to two hours. · Keep the patient well nourished. See that he or she gets enough calories, protein and vitamin C. · Keep the patient clean. If the skin is not clean, bacteria will collect and make pressure sores develop more quickly. · Keep the patient dry. Moisture from urine and perspiration helps pressure sores to form. · Keep bedding clean and free of wrinkles. This will reduce friction, which also leads to pressure sores. · If necessary, use a foam rubber pad or soft mattress. This will reduce the pressure on bony parts of the body such as the back of the pelvis (sacrum). . Raising the heels makes them less likely to develop sores.

Preventing Pressure Ulcers 

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Every time you give care to a patient who is on bed rest or has limited mobility, check bony parts of the body for the signs of pressure sores, so that you can begin treatment. Early signs include red or pale skin or local swelling and a tingling or burning sensation. Encourage the patient to change position as often as possible if any of these signs are present, and exercise the area to stimulate blood circulation.

Pressure Ulcer Staging

Bandages  

Are narrow strips of fabric, gauze, or elastic Used on wounds to promote healing

Bandages: 

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Cover wounds, hold dressings in place & reduce edema. Used to supply pressure or support to an area with out compromising circulation, alignment or mobility. Can control hemorrhaging Used for immobilization

Assessment before applying 

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Assess the wound & rationale for bandaging. Assess Circulation Inspect skin for temp, color, pulses, abrasions, edema, discoloration, or exposed wound edges

Assessment 

Assess the condition of underlying dressings and change them if soiled

Assessment 

Cover exposed wounds or open abrasions with a sterile dressing

Assessment 

Assess the skin of underlying body parts and parts that will be distal to the bandage for sings of circulatory impairment to provide a basis for comparison

Assessment 

Assess level of consciousness (LOC). 

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Can client report if bandage is too tight.

If decreased LOC use interventions to ensure dressing is not too tight.

Elastic Bandages

Elastic Bandages A p 1341 

Elastic bandages can be used on any body part and to apply compression to any area, with the exception of the neck.

Principles of Bandaging 

Position the body part to be bandaged in a comfortable position of normal anatomical alignment

Principles of Bandaging Prevent friction between against skin surfaces by applying gauze or cotton padding  Never secure skin to skin 

Principles of Bandaging 

Apply bandages securely to prevent slippage during movement

Principles of Bandaging 

When bandaging extremities, apply bandage first at the distal end and progress toward the trunk

Applying Bandages Apply bandages firmly, with equal tension exerted over each turn or layer  Avoid excess overlapping of bandage layers 

Applying Bandages 

Position pins, knots, or ties away from wound or sensitive skin areas

Evaluation & Reassessment Assess circulation 20 minutes after application then every 2 hours thereafter  Remove and reapply bandages and binders every 8 hours 

Applying an Abdominal Binder    

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Step 1 Have the patient in a supine position, with the bed flat Step 2 Place the binder under the person's back. Make sure the back of the binder is placed where it would wrap around the person's stomach once closed. Step 3 Stretch out one end of the binder. This will ensure that the abdominal binder provides the maximum amount of compression to the person. Step 4 Grab one end of the binder and stretch it over the person's stomach. Use your hand to hold this end of the binder in place. Step 5 Take the other end of the binder and stretch it over the first end of the binder. Step 6 Fasten the binder by gently pressing the two areas of the abdominal binder together, making sure that the stretch of the binder is maintained.

Scultetus Binders 

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Straight abdominal and Scultetus binders are used to support the abdomen. Place patient in supine position and place the abdominal binder under client with upper border of the binder at the waist and the lower border at the level of the gluteal fold.

Scultetus Binder 

a many-tailed binder or bandage with an attached central piece. The tails are overlapped. The last two, tied or pinned, act to secure the others. A Scultetus binder may be opened or removed without moving the bandaged part of the body.

Assessment after applying abdominal binder 

Assess respiratory rate 20 minutes and PRN after application of abd binder.

Arm Sling 

What conditions is a sling used for? 

To immobilize an arm or shoulder injured by sprain, dislocation, or FX

Arm Sling 

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Arm sling will prevent dependent edema, promote rest & support upper extremity. Often used with arm cast or as first aid to prevent further damage.

Arm Sling 

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May be lg triangular piece of fabric or commercially made Assessment:   

Assess arm, clavicle & shoulder If possibility of neck injury do not use sling Assess skin integrity

Arm Sling   

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Teach pt. how to apply & remove the sling. Keep hand just above the elbow Remove sling once or twice per day to do ROM as ordered Check neurovascular status of fingers and hand.

Knot tied at side of neck