3 wound care

WOUND CARETYPES OF WOUNDS

Incision = sharp instrument (knife)

Contusion = blow from blunt instrument

Abrasion= surface scrape

Laceration = tissues torn apart

Penetrating = deeper penetration: from bullet

Puncture = shallow penetration

WOUND CAREDEGREE OF WOUND

CONTAMINATIONa. Clean wounds

Uninfected, no inflammation; respiratory, genital and urinary tracts are not entered

b. Clean contaminated wounds Surgical wounds and respiratory, genital

and urinary tracts has been enteredc. Contaminated wounds

Open, fresh, major break in sterile technique, signs of inflammation

d. Dirty or infected old, accidental wounds with dead tissue,

with infection, purulent drainage

WOUND CARE

CLASSIFICATION OF WOUND BY DEPTH:

a. Partial thickness Confined to skin Epidermis and dermis

b. Full thickness Dermis, epidermis, subcutaneous, muscle

and bone

WOUND CAREWOUND HEALING

quality of living tissue; regenerationTHREE PHASES: (IPM)

1. Inflammatory phase- initiated immediately and lasts 3-4 days- marked with HEMOSTASIS and PHAGOCYTOSIS

2. Proliferative phase- until day 21 post injury- Collagen formation – whitish protein substance that adds to tensile strength of wound; eschar formation

3. Maturation phase- begins at day 21 until 1 - 2 years; scar formation

WOUND CARETYPES OF HEALING

1. Primary Intention; FIRST INTENTION- tissue surfaces have been closed and

minimal tissue loss; - SURGICAL INCISION

2. Secondary Intention- extensive and with tissue loss, edges cannot be

approximated; - PRESSURE ULCERNote: repair time is longer

scarring is greatersusceptibility to infection is

greater

WOUND CARETYPES OF HEALING:

3. Tertiary intention healing; - DELAYED or secondary closure- indicated when there is reason to delay a

suturing wound- ABDOMINAL WOUND THAT IS LEFT OPEN FOR DRAINAGE AND IS LATER CLOSED

WOUND CAREKINDS OF WOUND DRAINAGE

1. Serous:= serum; from clear portion of the blood,

clear to brownish2. Sanguineous:

= bloody, BRIGHT red3. Serosanguineous

= combination of blood and serum, pinkish

4. Purulent:= pus, YELLOW OR yellow-green

WOUND CARECOMPLICATIONS OF WOUND HEALING

H = HEMORRHAGEI = INFECTIOND = DEHISCENCE = openingE = EVISCERATION = coming out

C = CALL for help and assistanceC = COVER wound with saline

soaked sterile OS

K = KEEP MOISTD = DON’T REINSERT protruding

organsD = DORSAL RECUMBENT positionD = DO VSQ5M and prepare for

surgery

WOUND CARERYB COLOR CODE OF WOUNDS

- Based on the color of an open wound rather than depth and size of wound

- Can be applied to wound allowed to heal by SECONDARY INTENTION

Goals of wound care:a. RED : Protect (cover)b. YELLOW : Cleansec. BLACK : Debride


a. RED : PROTECT- Gentle cleansing- Avoiding use of dry-gauze or wet to dry saline

dressings- Application of topical antimicrobial agent- Transparent film or hydrocolloid dressing- Change dressing infrequently


b. YELLOW : CLEANSE To absorb drainage and remove nonviable

tissue Apply wet-wet dressing Irrigating the wound Use of absorbent dressing material Consult MD as to use of antimicrobial agent


c. BLACK : DEBRIDEMENT full thickness or third degree burns, gangrene Covered with occlusive dressing to provide

moist environment Eschar removal

WOUND CARENURSING INTERVENTIONS

a. Wound dressingb. RYB color codec. Surgical dressingd. Wound drainse. Wound irrigationf. Suturesg. Heat and cold applicationh. Supporting and immobilizing wounds

a. bandages and binders

3 wound care

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