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WOUNDS
GROUP 2 PRESENTATION What is a wound? Types of wound classification
• According to Morphological characteristics
• According to etiology • According to duration of wound healing • According to wound depth • According to degree of contamination • According to severity CLASSIFICATION according to morphological characteristics
damaged Infection can occur Bleeding is limited due to rupture of small veins and capillaries Avulsions Forcible separation or tearing of tissue from the body Bleeding occurs immediately Incision
Wound with smooth
sides/edges Caused by sharp object Severe bleeding can exist Laceration
Jagged, irregular tear
of soft tissue Punctures A small hole in tissue Object pierces the skin External bleeding limited Internal damage may cause bleeding Blisters
Develop with friction
to an area Typical to foot or hand Fluid accumulates under the skin Blood vessels broken; “blood blister” forms According to bacterial contamination • 1) Clean Wound: – Operative incisional wounds that follow nonpenetrating (blunt) trauma. • 2) Clean/Contaminated Wound: – uninfected wounds in which no inflammation is encountered but the respiratory, gastrointestinal, genital, and/or urinary tract have been entered. • 3) Contaminated Wound: – open, traumatic wounds or surgical wounds involving a major break in sterile technique that show evidence of inflammation. • 4) Infected Wound: – old, traumatic wounds containing dead tissue and wounds with evidence of a clinical infection (e.g., purulent drainage). Depth of injury
Superficial Partial thickness Full thickness Deep wound The wound management
1- To promote wound healing by primary intention .
2- To prevent infection . 3- To assess the healing process 4- To protect the wound from mechanical trauma . 5- To absorb drainage. 6- To prevent contamination from bodily discharge. Performance (procedures) Explain procedure to the client .1 Wash hands .2 Provide for client privacy .3 Remove binder and tape -4 . remove binder if used and place them aside-
If adhesive tape used , remove it by holding down the skin and pulling - . the tape toward the wound . Use solvent to loose the tape if required - . Remove and dispose of soiled dressing - 5 4
. Put on clean gloves to remove outer dressing or surgipad -
. Place outer dressing away from client -
. Place the soiled dressing in moisture proof bag without touch the outside the bag -
Remove the under dressing , taking care not to dislodge any drains , if the gauze sticks to - the drains , support the drain with one hand and remove the gauze with other - . Assess the location , type and odor of the wound drainage and number of gauzes saturated -Discard the soiled dressing in the bag as before -Remove clean gloves -Wash hands or clean with antiseptic solution
. emo binder if used and place them aside
. If adhesive tape used , remove it by holding down the skin and pulling the tape toward the wound - . Use solvent to loose the tape if required - Setup sterile supplies -6 . Open the sterile dressing set using aseptic technique - . Place the sterile drape beside the wound - Open the sterile cleaning solution pour it over the - . gauze sponges Put on sterile gloves - 7- Irrigate the wound : -Instill a steady stream of irrigating solution into the wound . - Position the basin below the wound to receive the irrigating -Use either a syringe with a catheter attached or with irrigating tip to flush the wound -Continue irrigating until the solution becomes clear. -Dry the area around the wound. 8- Clean the wound . - Clean the wound using your gloved hands or forceps and gauze swabs moisture with cleaning solutions. - Use the cleaning method . - Use a separate swab for each stroke and discard each swab after use . 9- Apply dressing to the drain site and incision. -Place a precut 4 in 4 gauze around drain .
-Apply the sterile dressing one at a time over the drain and incision .
-Apply surgipad , remove gloves and dispose of them .
-Secure the dressing with tape or tie.
- Wash your hands.
-Document the procedure and all nursing assessment .
OTC products and antiseptics used to treat wounds Povidone iodine solution and ointment 10% Mercurochrome solution 1% Tetracycline ointment Flamazine (SSD cream) Potassium permanganate 1% Alum salts Glycerol and Itchamol ( G and I ) When do you refer
Wounds that are extensively contaminated with enmeshed, difficult to
remove foreign matter or particles Bites (either human or animal) Necrotic wounds, like those seen in diabetes Wounds that tend to develop into chronic wounds Wounds with nerve, tendon, bone, muscle, duct, or organ damage Wounds that need stiches
