Wound Care in Fundamentals of Nursing .pptx
- 1. Wound care
- 2. Wound is disruption in the continuity of cells. a. Acute wound b. Chronic wound
- 3. Acute wound An acute wound is the result of tissue damage by trauma. Ex: surgical wound heat, electricity, chemicals or friction
- 6. Chronic wound A chronic wound fails to progress or respond to treatment over the normal expected healing time.
- 7. Layers of the skin Epidermis 1. Outer layer and epithelial cells 2. A vascular layer 3. Regenerated every 2-4 weeks
- 8. Dermis 1. Middle layer of the skin thickness 0.5mm 2. It is very vascular 3. It contains nerves, connective tissue, collagen, elastin and specialized cells such as fibro blasts and most cells. 4. Contains receptors for heat, cold, pain and pressure
- 9. Hypodermis 1. It is the inner most layer of the skin and is referred to as the subcutaneous layer 2. It is compromised of adipose tissue, connective tissue and blood vessels. 3. The function of this layer is to store lipids, protect underline organs, provide insulation and regulate temperature
- 10. Classification 1. According to the way it happened 2. According to the degree of contamination
- 11. According to the way a) Incised clean cut with sharp instrument b) Contused wounds due to blunt force c) Lacerated with irregular boarders d) Puncture wound Ex: sharp injuries
- 12. According to the degree of contamination 1. Clean wounds surgical wounds without infections. The rate of infection is very low. 2. Clean contaminated wounds the rate of infection is more than in clean wounds 3. Contaminated wounds open fresh accidental wounds. The rate of infection is relatively high. 4. Dirty or infected wounds old traumatic wounds
- 13. Clean Wound Chronic Wound https://watch?v=S6hWkScUssg
- 14. Phases of wound healing 1) Phase 1 inflammatory phase (0-3 days) This phase activates vasodilation leading to increased blood flow causing heat, redness, pain, swelling and loss of function. Ooze may be present.
- 15. Phase 2 Proliferative phase (3-24 days) The time when the wound is healing. The body makes new blood vessels which cover the surface of the wound.
- 16. 3) Phase 3 maturation phase (24-365days) This is the final phase of healing. Scar tissue is formed.
- 17. Mechanism of wound healing 1. Healing by primary intention Most clean surgical wounds and recent traumatic injuries are managed by primary closure.
- 18. 2. Healing by delayed primary intention This is defined as the surgical closure of a wound 3-5 days after the debri of the wound bed. This is used for traumatic wounds and contaminated surgical wounds. 3. Secondary intention In this method healing occurs slowly by granulation contraction (& re epithelialization) and results in scar formation. Ex: pressure sores and leg ulcers
- 19. 4. Skin graft Removal of partial or full thickness segment of epidermis and dermis from its blood supply transplanting it to another site to speed up healing and reduce the risk of infection.
- 20. Factors affecting wound healing 1. Age 2. Haemorrhage 3. Malnutrition Ex: protein, vit c and Zn 4. Reduced blood supply 5. Medication 6. Chemotherapy Ex: immune suppress 7. Presence of foreign bodies in the wound 8. Collection of drainage
- 21. 9. Radiotherapy Ex: damage cells 10. Obesity 11. Psychological stress 12. Infection 13. Underline disease condition Ex: diabetic mellitus 14. Abuse Ex: smoking, alcohol 15. Use of anticoagulants
- 22. Journal article for Wound Healing Factors https://journals.lww.com/aswcjournal/fulltext/2011/04000/ checklist_for_factors_affecting_wound_healing.10.aspx#:~:text=Wound %20healing%20can%20be%20delayed%20by%20systemic%20factors%20that %20bear,Age.
- 23. Improve wound healing 1) Careful gentle handling when performing wound care 2) Maintain fluid and electrolyte balance 3) Maintain adequate nutrition 4) Use correct methods in dressing change 5) Observe the patency of the drain tubes when present 6) Take measures to prevent infections 7) Encourage the patient to have adequate rest
- 24. Purposes of dressing 1. To provide suitable environment for wound healing 2. To facilitate absorption of drainage 3. To protect new epithelial cells on the wound 4. To prevent invasion of micro-organisms 5. To prevent contamination Ex: urine, feces 6. To control bleeding 7. To provide physical and psychological comfort
- 25. Wound assessment parameters 1. Etiology 2. Location of the wound 3. Stage of wound 4. Phase of healing 5. Size of wound 6. Presence of pain
- 26. Methods of wound care 1. Open methods 2. Closed methods Open method o Keep open to the environment Ex: burns patients
- 27. Closed method o After cleaning and application of medication on the wound is covered with dressings. Wound management Dressing dressing are materials applied to wound with or without medication to protection and assist healing. 1. Cotton swabs to clean the wounds 2. Gauze swabs to cover the wounds 3. Gauze towels to cover large wounds 4. Gauze plugs prepared with various length Ex: ear, nose, vagina 5. Lint dressing covered the wounds
- 28. Types of dressings 1) Dry to dry dressing 2) Wet to dry dressing 3) Wet to wet dressing 4) Pressure dressing
- 31. Dry to dry dressings Used primarily for wounds closing Advantage : Good protection absorption Provide pressure Disadvantage : Adhere to wound
- 32. Wet to dry dressings Used to infected wounds. Wet to wet dressing Used on clean open wound. Advantages 1. Provide more physiologic environment for wound. 2. Enhance the local healing process.
- 33. Disadvantages 1. Can become ulcerated 2. Infection Pressure dressings Used to control bleeding and edema Solution:- Used to clean wounds Surgical spirit 70% alcohol Hydrogen peroxide Hibitane Normal saline
- 34. Materials used for securing dressings 1. Leucoplaster 2. Adhesive plaster 3. Bandages 4. Binders 5. Micropro
- 35. Special considerations in preparing for apply dressings 1. Preparation of the ward 2. Preparation of equipment and supplies 3. Preparation of the patient 4. Preparation of the nurse Ward preparation Restrict the visitors Complete cleaning and wet mopping of the floor of ward half and hour before starting the procedure. Switch off the electrical fans
- 36. Preparation of the equipment Check the availability of adequate amount of sterile equipment and supplies for dressing. Wash hand and prepare the trolley following aseptic techniques. Preparation of the patient 1. Complete the preliminary assessment of the patient a) Identify the patient b) Check the general condition of the patient and the wound c) Check the physicians order d) Check the level of consciousness of the patient and ability to follow instructions.
- 37. 2. Explain the procedure to the patient. 3. Observe the personal hygiene of the patient. 4. Ensure whether the patient has meals. 5. Fulfilling elimination needs of the patient if necessary. 6. Administer painkillers if prescribed 7. Keep the patient in comfortable position. 8. Screen and protect the privacy of patient.
- 38. Preparation of the nurse 1. Wash hands 2. Wear mask 3. Prepared trolley to the unit of the patient 4. Position the patient 5. Put the small mackintosh and cover under the wound area 6. Remove the outer layer of the dressing 7. Do surgical hand washing 8. Wipe hands with sterile towel and put a towel around the wound and to create the surgical field.
- 39. Get the support of another nurse if necessary to complete the dressing procedure. **DRESSING PROCEDURE** SPECIAL CONSIDARATIONS Assess the followings about the patient and wound. a)the location of the wound b)the nature of the wound c)size the wound d)amount and character of the drainage
- 40. Position the patient -to expose the wound properly. Protect bed linen -by using small mackintosh and cover. Remove plaster towards the wound & remove dressing keeping only one layer on top of the wound. Do surgical hand washing , wipe the hands with sterile G.S towel & make a sterile field with that towel , by applying it around the wound.
- 41. Remove the layer of the dressing remaining on the wound with a sterile forceps & discard the forceps into in to a tray with soapy water. Clean the wound with an antiseptic solution with the help of a new forceps. a) Clean wound -from the center to outer area in a circular motion. b) infected wound -first clean the outer area then clean the center.
- 42. For clean wounds put dry dressings Infected wound soaked with medication solution and put dry dressing on it and apply plaster or bandages Keep the patient in a comfortable position. Remove the equipment Clean and dry the equipment Documentation
- 43. Drainage tubes and wound drainage The wound healing the inflammatory process causes drainage of exudates. It classified as follows; 1. Serous clear watery plasma 2. Sanguineous bright red in colour fresh bleeding dark colour old bleeding 3. Serosanguinous pale, watery drainage 4. Purulent thick, yellow, green or brown drainage
- 45. That a drain tube is inserted into close to a surgical wound. It is necessary to observe the amount, colour, odor and consistency of the drainage. Indications for surgical drains 1) To prevent the accumulation of fluid. ( blood, pus and infected fluids) 2) To prevent accumulation of air. ( dead space)
- 46. Drain Tube Note https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Surgical_ Drains_(Non_Cardiac)/
- 47. Types of surgical drains 1) Open 2) Closed Open drains open drains drain fluid on to a gauze pad, to increase the risk of infection. Closed drains they are formed by tubes draining into a bag or bottle. Less risk of infection.
- 48. Common types of drain 1. Corrugated drain - incision and drainage of an abscess. 2. Rubber tubes - usually used after chest surgery. Ex: Intra costal tube, IC tube 3. T Tubes - used after cholecystectomy to drain bile 4. Hemovac / Redivac - closed drainage system
- 49. Corrugated drain
- 53. Sutures 皰Sutures are threads made of organic materials, cotton, silk, linen, wire, nylon and dlacron 皰Staples are made wire or silverhttps://www.youtube.com/watch?v=64z0fFFMrfM 皰Skin sutures are small and run through the top layers of skin. 皰They are removed 7 to 10 days after the procedure.
- 54. 皰Prior to the actual removal of sutures, the nurse 1. Carefully assesses the healing of the wound. 2. Observe any infection. 3. Appearance of wound 皰First remove every other sutures or staples, moving from proximal to distal. 皰Sutures or staple, moving from proximal to distal.
- 55. 皰 Sutures are clipped on one side with a sterile scissors, just next to the skin surface and then pulled out of the skin with a forceps. 皰 Staples are removed with a surgical staple remover. 皰 Types of sutures, 1. Plain interrupted 2. Mattress interrupted 3. Plain continuous 4. Mattress continuous 5. Blanket continuous
- 58. Plain continuous
- 62. THANK YOU!