wound dressing. wound it is a break in the continuity of the skin, mucous membranes, bone, or any...

WOUND DRESSING

Wound It is a break in the continuity of the skin, mucous membranes, bone, or any body organ

TYPES OF WOUNDSAccording to

descriptors of wound

INCISION

It is cause by sharp instrument. Ex knife or scalpel.

CONTUSIONCause by blowFrom a blunt Object. Closed woundSkin appears ecchymotic

ABRASION Surface scrape, eitherUnintentional orIntentional. It is an open wound Involving the skin, Painful.

PUNCTURE

Penetration of theSkin and often, the Underlying tissuesFrom a sharp Instrument.

LACERATION

It is a wound with tearing of tissues with irregular wounds edges, Often from accidents.

PENETRATING WOUND• Penetration of the skin and the underlying

tissues. It is caused by a foreign object or instrument entering deep into body tissue

TYPES OF WOUNDSAccording to degree of

contamination

Surgical Wound Classifications

Type I Clean WoundType II Clean-contaminated WoundType IIIContaminatedType IVDirty/Infected

Wound Types

Type I - Clean Wound (Potential infection rate 1%-

5%)

No inflammation No break in sterile

technique Wound primarily

closed/Not drained Wound has no

pathogenic organisms

Wound Types

Type II - Clean-contaminated Wound(Potential infection rate 8% - 11%)

No inflammation/Infection present Wound primarily closed/Not drained It is caused by a surgical wound entering

gastrointestinal, genital or urinary tract under controlled conditions

Wound Types

Type III - Contaminated Wound (Potential infection rate 15% - 20%) Traumatic wound (less than 4

hours old) Acute inflammation present Major break in asepsis technique Wound that exists under

conditions in which presence of microorganisms is likely

Wound Types

Type IV - Dirty/Infected Wound (Potential infection rate 27% - 40%)

Wound in which bacterial organisms are present

Wound doesn’t properly heal and grows organisms, old traumatic wound

Organisms present at surgical site prior to procedure/Existing infection

KINDS OF WOUNDS DRAINAGE

Exudate - is material, such as fluid and cells, that has escaped from blood vessel during the inflammatory process.

1. Serous exudate - consist chiefly of serum or the

clear.2. Purulent Exudate - It is thicker, yellow, green

consist of WBC exudates 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 of red blood cells.

4. Sero-sanguineous exudate - mixture of serous and

sanguineous pale-red watery.

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 restoration phase of tissue repair and are clean and 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 that is often accompanied by purulent discharges.

CLEANSE THE YELLOW WOUNDS

Yellow wounds should be Cleanse to absorb drainage and remove nonviable tissue.

1. Apply wet to wet dressing.2. Hydrogel dressings3. 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 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 into the wound surface. The fibers become embedded in the granulation tissue and act as a source 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 absorb drainage or debride the wound

To prevent haemorrhageTo splint or immobilize the

wound site and prevent further injury