wound healing, wound types, wound dressings, & drainage devices

Wound Healing, Wound Types, Wound Dressings, & Drainage Devices

ST230Concorde Career College

Wound Types & Wound Healing

Objectives:

List and define the four types of wound classifications and provide examples of wound types for each category.

List and describe the types of wounds and provide examples of each.

List and describe the types of wound healing and explain the mechanism for each type.

Objectives:

Identify the factors that influence wound healing and understand how to implement techniques that promote optimal wound healing.

Describe Halsted’s principles of tissue handling and explain the relationship of those principles to today’s methods of suturing.

List and describe the techniques used for suturing and provide examples of when each may be utilized.



Objectives:

Outline the dressing application process and identify the optimal time for dressing placement.

Identify basic abdominal incisions and identify the tissue layers of the abdominal wall.


Wound Classifications


Surgical Wound Classifications

Type I Clean WoundType II Clean-contaminated WoundType III ContaminatedType IV Dirty/Infected


Type I - Clean Wound (Potential infection rate

1%-5%)

No inflammation No break in sterile

technique Wound primarily

closed/Not drained Aerodigestive and

genitourinary tract not entered


Type II - Clean-contaminated Wound

(Potential infection rate 8% - 11%)

No inflammation/Infection present

Minor break in technique Wound primarily

closed/Not drained Aerodigestive or

genitourinary tract entered under controlled circumstances


Type III - Contaminated Wound


Traumatic wound (less than 4 hours old)

Acute inflammation present

Major break in technique Gross

spillage/contamination from respiratory, gastrointestinal, biliary, or genitourinary tracts


Type IV - Dirty/Infected Wound


Traumatic wound (more than 4 hours old)

Organisms present at surgical site prior to procedure/Existing infection

Perforation (Gastrointestinal, biliary, respiratory, genitourinary tract)


Types of Wounds


Types of Wounds

Intentional (Surgical)

Accidental (Traumatic)

Chronic


Intentional (Surgical)

Incision Purposeful cut

through intact tissue for the purpose of exposure or excision

Wounds

Excisional Removal of tissue


Six Types of Accidental

Closed

Simple

Clean

(Traumatic) Wounds

Open

Complicated

Contaminated


Closed Traumatic WoundSkin Intact / Underlying tissue damaged

Examples:

Blister Simple Fracture


Open Traumatic WoundSkin Disrupted

Examples:

Laceration Compound Fracture


Simple Traumatic WoundSkin Disrupted/No loss or destruction of

tissue/No foreign body implanted

Examples:

Minor penetration Cut with sharp object


Complicated Traumatic WoundSkin

disrupted/Underlying tissue lost or

destroyed/Foreign body implanted

Examples:

Severe burn Stab or bullet wound


Clean Traumatic WoundSimple wound caused by a sharp edged object

Expected to be sutured and heal by first

intention without infectionExample:

Laceration


Contaminated Traumatic Wound

Complicated wound caused by a dirty object

May need debridement and has a high potential for becoming infected

Examples: Crush Type Injury Foreign Body

Implantation


A SINGLE WOUND MAY BE CLASSIFIED IN MORE THAN ONE CATEGORY


Chronic Wound - Wound that fails to heal over an extended period of time

Examples: Decubitus ulcer

(Pressure sore) Wound caused by

inadequate circulation or in which healing is delayed as a result of vascular compromise

Infected wounds


Wound Healing


Types of Wound Healing

First Intention (Primary Union)

Second Intention (Granulation)

Third Intention (Delayed Primary Closure)


First Intention (Primary Closure)

Wound is sutured closed

Healing occurs from side-to-side

Healing occurs rapidly with little inflammation and minimal scarring

Wound heals in three phases


Phases of Wound Healing by First Intention

Phase I - Lag Phase or Inflammatory Response Phase

Phase II - Proliferation Phase Phase III - Maturation or Differentiation Phase


Phase I - Lag Phase or Inflammatory Response Phase

Begins within minutes of the injury and lasts 3-5 days

Inflammation is present (manifested by heat, redness, swelling, pain, loss of function)

Inflammation is a result of increased blood flow to the area caused by arterial dilation


Phase I (continued)

Bleeding controlled by platelet aggregation Oxygenated blood delivered to the site Epithelial cells for repair formed Scab formed Phagocytosis occurs


Phase I (continued)

Basal cells seal wound surface

Fibroblasts begin reconstruction of nonepithelial tissue


Phase II - Proliferation Phase

Begins about the 3rd postoperative day and continues up to 20 days

Fibroblasts multiply (proliferate) and bridge wound edges

Collagen secreted from fibroblasts


Phase II (continued)

Collagen fibers begin to restore tensile strength of tissue

Capillary networks established and lymphatic networks reformed


Phase II (continued)Definition:Tensile Strength: Ability to resist rupture

During the proliferation phase (phase II) of wound healing by first intention the wound regains 25%-30% of its original tensile strength


Phase III - Maturation or Differentiation Phase Begins on the 14th postoperative day and

lasts until the wound is completely healed, (may take up to 12 months)

Tensile strength increased by interweaving of collagen fibers


Phase III (continued)

Collagen density increases and formation of new blood vessels decreases

Cicatrix is formed


Second Intention (Granulation)

Wound is intentionally left open

Healing occurs from the bottom - up

High risk of infection (if not already present)

Union is weak and scar formation extensive


Second Intention (Granulation) (continued)

Granulation tissue containing myofibroblasts forms in the wound

Gaps in tissue fill from bottom upward closing the wound by contraction

Epithelial growth is secondary


Third Intention (Delayed Primary Closure)

Two granulated surfaces are approximated

Wound is left open to heal by second intention for 4-6 days

Then, wound is closedEquation 2+1=3

(Second Intention plus First Intention equals

Third Intention)


Factors Affecting Wound HealingThree main factors influence wound healing:

Physical condition of the patient Intraoperative tissue handling Application of the principles of asepsis


Physical Condition

Age

Nutritional Status

Disease (Chronic or Acute)

of the Patient

Smoking

Radiation Exposure

Immunocompromised or Immunosuppressed Patients


Intraoperative

Length and direction of the incision

Dissection technique (sharp or blunt)

Length of surgery

Hemostasis

Tissue Handling

Minimal and gentle tissue handling

Precise tissue approximation

Elimination of dead space

Secure wound closure


Halsted's Methods of Tissue Handling Strict aseptic technique Gentle handling of tissue Use of the finest suture material Small stitches and low tension on the tissue Complete closure of wounds whenever

possible


These basic procedures had a far-reaching effect on the practice of surgery, making it safer and more effective than it had been previously.

William S. Halsted


Dead Space Dead space is a separation of wound edges,

which have not been closely approximated or air that has become trapped between tissue layers. This space may allow for serum or blood to collect and provide a medium for microbial growth that may result in infection.


Dead SpaceReduce or eliminate

dead space with the use of:

Proper suturing techniques

Wound drains Pressure

dressings


Application of the Principles of Asepsis Through the Use of Sterile Technique

A sterile field is created for each surgical procedure

Sterile team members must be appropriately attired prior to entering the sterile field

Movement in and around the sterile field must not compromise the sterile field


Complications of

Dehiscence Evisceration Hemorrhage Infection Adhesions

Wound Healing

Herniation Fistula Sinus tract Suture complications Keloid scar formation


Knot Tying Basics

Knot Security Knot Tying Principles Square Knot (Two

Hand Technique) Surgeon’s Knot


Knot SecurityKnot security is of utmost importance in

preventing wound complications

Use the most simple; secure knot possible


Knot Tying Principles

Knot must be firm Tie knot as small as possible and trim ends as

close as possible When tying, avoid “sawing” motion or

excessive tension, which may damage the integrity of the suture


Two Simple Knots(Over 1,000 types of knots available)

Square Knot - Easiest and most reliable

Surgeon’s Knot - Provides extra security


NO GRANNIES!!!! A Granny knot is a

slip knot and is NOT acceptable as a surgical knot!


Square Knot (Two Hand Technique)

Right over left (first throw)

Left over right (second throw)


Surgeon’s KnotFirst step

Right over left

Repeat right over left

Then tighten


Surgeon’s KnotSecond Step

Left over right

Tighten

DONE!!It should look like

this...


Tissue Approximation


Suturing Techniques

Primary Suture Line Holds wound edges

together Heals by first

intention May be continuous or

interrupted


Suturing Techniques

Secondary Suture Line Supports and

reinforces primary suture line

Also called retention sutures

Usually interrupted


Primary and Secondary Suture Lines


Continuous Suture Line

Also called “running” stitch

Series of stitches placed with one continuous suture


ContinuousPROS

Quick placement Less foreign body in

wound Tension evenly

distributed

Suture LineCONS

Over tensioning can cause suture failure leading to wound disruption

Can allow fluid to travel along suture line - may spread infection


Interrupted Suture Each suture strand is

placed individually Individual suture

strands are tied and cut

Key concept in Halsted’s suturing principles - still employed today


InterruptedPROS

Secure closure Remaining sutures

should hold wound edges together if one stitch fails

Microbes less likely to move along interrupted suture line

Suture LineCONS

Time consuming More foreign body

in wound


Continuous Suturing

Techniques

Over and Over Running Stitch


Continuous Suturing

Techniques

Interlocking Stitch


Interrupted Sutures

Simple Interrupted Evenly spaced Equal depth Ends uniformly cut


Interrupted Sutures

Vertical Mattress


Interrupted Sutures

Horizontal Mattress


Dressing Application


Dressing Application

Last step of the sterile procedure


Basic Abdominal Incisions


Layers of the Abdominal Wall

Wound Healing, Wound Types, Wound Dressings, & Drainage Devices

ST230Concorde Career College

Laparotomy Tapes, packs, laps

Ray-Tec ray

Cottonoids Patties

Tonsil Kittner Peanut ** must be counted**

Sponges

78

Sponges

Lap sponge

Tonsil

Peanut

Ray-Tec

Have a radiopaque strip so they can be located by X-ray

Sponges

Dirty sponges are placed in kick bucket or sponge tree

Discarded

81

Dressing Choice determined by several factors:

Type, size, and location of the wound Amount of drainage expected Surgeon preference Age and size of the patient Underlying medical conditions Condition of the surrounding skin Comfort of the patient

82

Dressing One-layer Three-layer Pressure Bulky Rigid Specialty Packing

83

Dressing One-layer dressing

Cover small incisions Frequently used to cover IV access Transparent polyurethane film/adhesive backing

84

Dressing One-layer dressing

OP-site Collodion Aerosol adhesive sprays, foams, gels Skin closure tapes

85

Dressing Three-layer dressing

Inner (contact) layer Intermediate (absorbent) layer

Absorbs drainage 4X4, kerlix, fluffs

Outer ( securing) layer Tape, stockinette

Nonpermeable Occlusive xeroform

Semipermeable Semi-occlusive Exu-derm, aqua-gel

Permeable Nonocclusive Telfa, adaptic Wicking action

3 layer dressing/ Contact Layer

87

Dressing Pressure dressing

Immobilization of an area Support Absorption of excessive drainage Even pressure distribution Elimination of dead space Reduced edema Reduced hematoma formation

88

Dressing Bulky dressing

Three-layer dressing Additional material is added to the intermediate

layer Used to immobilize an area Provide support Absorb excessive drainage

89

Dressing Rigid dressing

Casts Encircles Provide support Prevent movement Often incorporates the joint

Splints Applied to one side of a structure Support Prevent unidirectional movement

Bolster Wet-to-dry Wet-to-wet Drain Ostomy Peri-pad

Specialty Dressing

Packing Assist with hemostasis Provide pressure Provide support Eliminate dead space

Dressing

92

Catheters• Used to remove fluid

or other objects• Used to monitor body

functions • Insert fluids

93

Catheters• Remove air and fluids• Decompression• Maintain patency• Administration of

oxygen, anesthetic, medications, fluids

Cystostomy catheter

Passive Drains air or fluid moves from an area of high pressure to

one of lower pressure. Penrose Cigarette T-tube Gastrostomy Cystostomy Nephrostomy

Drains

Penrose Drain

Active Drains Negative pressure Connected to a collection device

Hemovac Jackson-Pratt Stryker

Drains

Jackson Pratt(JP) drain

Hemovac Drain with trocar

Used to remove air and fluids Decompression Maintain patency of a lumen Administer oxygen, anesthetics, and other

gases Administer medications

Tubes

Gastrostomy tube

Nephrostomy tube

Hypodermic Used to withdraw fluid from medication or tissue 12g-30g; ½-4 inches long

Arterial Used to place plastic indwelling catheter

Intravenous Biopsy

Non-suture Needles

Insufflation Heparin

Irrigate vessels Spinal

3-4 inches Beveled stylet within the cannula

Non-suture needles

Luer lock Luer slip ( slip tip) 3-60 cc Three ring or control syringe Bulb Asepto

Syringes