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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 1
CHAPTER 13Surgical Wound Care
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 2
Phases of Wound Healing
1. Hemostasis• Termination of bleeding• Clotting soon after the injury occurs
2. Inflammatory Phase• An initial increase in blood elements and water flow out
of the blood vessel into the vascular space• Causes cardinal signs and symptoms of inflammation:
erythema, heat, edema, pain, and tissue dysfunction
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 3
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 4
Wound Healing
3. Reconstruction Phase• Collagen formation occursa glue-like protein
substance that adds tensile strength to the wound and tissue.
• Appearance changes to an irregular, raised, purplish, immature scar.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 5
Wound Healing
4. Maturation Phase• Fibroblasts begin to exit the wound.• The wound continues to gain strength, although healed
wounds rarely return to the strength the tissue had before surgery.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 6
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 7
Process of wound healing
Primary Intention• Wound is made surgically with little tissue loss.• Skin edges are close together.• Minimal scarring results.• It begins during the inflammatory phase of healing.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 8
Review the Phases of Healing
• 1. Hemostasis• 2. Inflammatory Phase • 3. Reconstruction Phase• 4. Maturation Phase • 5. Primary Intention
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 9
3 TYPES OF WOUND HEALINGFirst type is called Primary Intention
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.)
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 10
Example of Primary Intention Wound
Wound closure with staples.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 11
2. Secondary IntentionSkin edges are not close togetherThe necrotized (dead) tissue decomposes and escapes.The cavity begins to fill with granulation tissue.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 12
Another Example of Secondary intention Cavity Type Wound, Significant drainage, Left Open to heal
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 13
3. Tertiary Intention Occurs when a surgically contaminated wound is left
open and sutured closed after the infection is controlled
Or a primary wound becomes infected, is opened, allowed to drain and granulate, then sutured.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 14
Factors that Effect Healing
Nutritional Needs• If the patient cannot tolerate food or fluids, total
parenteral nutrition or nasogastric feedings can be provided.
Fluids• Offer hourly; encourage 2000 to 2400 ml in 24 hours.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 15
Factors that Affect Wound Healing
Rest and Activity• Rest is vital to facilitate healing
• Activity is also encouraged to decrease venous stasis.
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 16
Surgical Wound Care Principles
• The PT should inspect dressings PRN or as ordered.
• Exudate: term to describe broadly any fluid drainage • Exudate can be described of as small, medium to large
amounts.•• Sanguineous exudate: Bright red, indicates active bleeding
• Serosanguineous exudate: pale, light red, pinkish, watery
• Serous: clear and watery
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 17
Figure 13-2
Types of dressings.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 18
Cleaning
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 19
Care of the Incision
• Dry Dressings (primary wound) May be chosen for management of a wound with little
exudate/drainage
Protects the wound from injury, prevents introduction of bacteria, reduces discomfort, and speeds healing
Most commonly used for abrasions and nondrainingpostoperative incisions
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 20
Care of the Incision
• Wet-to-Dry Dressing (secondary & tertiary wounds)
Primary purpose is to debride a wound. (debridement)
The moistened contact layer of the dressing increases the absorptive ability of the dressing to collect exudate and wound debris.
As the dressing dries, it adheres to the wound and debrides it when the dressing is removed.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 21
Care of the Incision
• Transparent Dressings Advantages
• Adheres to undamaged skin to contain exudates and minimize wound contamination
• Serves as a barrier to external fluids and bacteria yet still allows the wound to breathe
• Permits visualization of the wound
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 22
Skill 13-3: Steps 11a & 11b
Applying a transparent dressing.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 23
Care of the Incision
• Irrigations
A cleansing solution is introduced directly into the wound with a syringe, syringe and catheter, shower, or whirlpool.
Promote wound healing by removing debris from a wound surface, decreasing bacterial counts
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 24
Care of the Incision
Principles of Basic Wound Irrigation• Cleanse from the least contaminated area
to the most contaminated area.• When irrigating, all of the solution flows
from the least contaminated area to the most contaminated area.
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 25
Skill 13-4: Steps 10 & 13
Performing sterile irrigation.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 26
Complications of Wound Healing
• Dehiscence Wound layers separate. It may result after periods of sneezing, coughing, or
vomiting. Patient should remain in bed and given reassurance . Place a warm, moist sterile dressing over the area
until the physician evaluates the site.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 27
Complications of Wound Healing
• Evisceration Abdominal organs protrude through an opened
incision. The wound and contents should be covered with
warm, sterile saline dressings. The surgeon is notified immediately. This is a medial emergency, and the wound requires
surgical repair.
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 28
Complications of Wound Healing
• Wound Infection CDC labels a wound “infected” when it contains
purulent (pus) drainage.
A patient with an infected wound displays a fever, tenderness, and pain at the wound; edema; and an elevated _ _ _ count.
Purulent drainage has an odor and is brown, yellow, or green, depending on the pathogen.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 29
Staple and Suture Removal
• Sutures and staples are generally removed within 7 to 10 days after surgery, or sooner if healing is adequate.
• The physician determines and orders removal of sutures or staples
• Replaced with a Steri-Strip as the first phase, with the remainder removed in the second phase.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 30
Staple and Suture Removal
• Sutures Sutures are threads of wire or other materials used to
sew together body tissues.
Sutures are placed within tissue layers in deep wounds and superficially as the final means of wound closure.
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 31
Skill 13-5: Step 17
Removing sutures.
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 32
Staple and Suture Removal
• Staples Staples are made of stainless steel wire are quick to
use, and provide ample strength. They are popular for skin closure of abdominal
incisions and orthopedic surgery when the appearance of the incision is not critical.
Removal of staples requires a sterile staple extractor and maintenance of aseptic technique.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 33
Skill 13-5: Step 9
Removing staples.
(From Perry, A.G., Potter, P.A. (1998). Clinical nursing skills and interventions. (4th ed.). St. Louis: Mosby.)
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 34
Exudate/Drainage: Need to know
• Serous Clear, watery fluid that has been separated from its
solid elements
• Sanguineous Fluid that contains blood
• Serosanguineous Thin and red; composed both of serum and blood
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 35
Figure 13-7
Jackson-Pratt drains have a wide, flat area brought through the stab wound with great force.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 36
Figure 13-8
Jackson-Pratt drainage device. A, Drainage tubes and reservoir. B,Emptying drainage reservoir.
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 37
Exudate/Drainage
• Drainage Systems
Requires close monitoring• Note the color, consistency, and
amount of drainage.• Note patency of tube; it should not be
kinked or occluded. • If blood clots or exudate have slowed
drainage, record and report.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 38
Skill 13-6: Step 6
Maintaining Hemovac/Davol suction and T-tube drainage.
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 39
Figure 13-10
Wound VAC system using negative pressure to remove fluid from area surrounding the wound.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 40
Skill 13-7: Step 2
Wound Vacuum-Assisted Closure.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 41
Skill 13-7: Step 12
Wound Vacuum-Assisted Closure.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 42
Skill 13-7: Step 16
Wound Vacuum-Assisted Closure.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 43
Documentation
• After a bandage is applied, the PT should Date, time and initial on the edge of the dressing Assess comfort level of the client (use pain scale) Document in the IDN’s (clients chart) the following:Status of the woundDescription of exudate and quantityType of dressings appliedClient’s response to the procedurePatient teaching
Immediately report changes in circulation, skin integrity, comfort level, or accidential removal of a drain.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 44
Thursday morning you begin wound care principals, good luck, class is over