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