Surgical Wound Care

8/6/2019 Surgical Wound Care

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Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 1

CHAPTER 13

Surgical Wound Care

CHAPTER 13

Surgical Wound Care


Phases of Wound HealingPhases of Wound Healing

1. Hemostasis

Termination of bleeding

Begins as soon as the injury occurs

2. Inflammatory Phase

An initial increase in blood elements and water flow outof the blood vessel into the vascular space

Causes cardinal signs and symptoms of inflammation:erythema, heat, edema, pain, and tissue dysfunction



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Wound HealingWound Healing

3. Reconstruction Phase

Collagen formation occursa glue-like proteinsubstance that adds tensile strength to the wound andtissue.

Appearance changes to an irregular, raised, purplish,immature scar.

Wound dehiscence most frequently occurs during thisphase.


Wound HealingWound Healing

4. Maturation Phase

Fibroblasts begin to exit the wound.

The wound continues to gain strength, al though healedwounds rarely return to the strength the tissue hadbefore surgery.


Reviewing the Phases of HealingReviewing the Phases of Healing

1. Hemostasis

2. Inflammatory Phase

3. Reconstruction Phase

4. Maturation Phase 5. Primary Intention


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Process of wound healingProcess 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.


Figure 13-1Figure 13-1

Types of wound healing. A, Primary intention.B, Secondary intention. C, Tertiary intention.

(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment andmanagement of clinical problems. [6th ed.]. St. Louis: Mosby.)


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Process of Wound HealingProcess of Wound Healing

Secondary Intention Healing occurs when skin edges are not close together

If wound has purulent exudates, the surgeon provides ameans for its release via drainage system or by packingthe wound.

The necrotized tissue decomposes and escapes.

The cavity begins to fill with granulation tissue.

The amount of granulation tissue required depends onthe size of the wound.


Tertiary Intention

Occurs when a contaminated wound isleft open and sutured closed after theinfection is controlled

or a primary wound becomes infected,is opened, allowed to granulate, andthen sutured.


Factors that Effect HealingFactors 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.


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Factors that Affect Wound HealingFactors that Affect Wound Healing

Rest and Activity

Rest is vital to facilitate healing

Activity is also encouraged to decreasevenous stasis.


Surgical WoundSurgical Wound

The surgeons goal is to enter the cavity involved,repair the injured or diseased area, and minimizetrauma as quickly as possible.

Many options are available to the surgeon for closingthe surgical incision.

Sutures, staples, Steri-Strips, butterfly strips, andtransparent sprays and films

Binder or bandage used to support the incision ofsecure dressings without the use of adhesivematerials



Sutures. A, Interrupted, or separate. B, Continuous. C, Blanket. D,Retention.

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.Louis: Mosby.)


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Wound closure with staples.




Steri-Strips placed over incision for closure.

(From Potter, P.A., Perry, A.G. [2003].Basic nursing: Essentials for practice. [5th ed.]. St. Louis:Mosby.)



The PT should inspect dressings every 2 to 4 hoursfor the first 24 hours, PRN, or as ordered.

On the day of surgery, most wounds will have

sanguineous or serosanguineous exudates.

As the exudate subsides, it becomes serous.


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Types of dressings.




The inflammatory response depends on the level ofinjury inflicted, size of the area involved, andphysical condition of the patient.

Phagocytosis occurs when exudate from the injuredcell is surrounded, engulfed, and digested byleukocytes.

An infectious process would be evidenced by anelevated _ _ _ count.


Care of the IncisionCare of the Incision

Surgical wounds, because they are asepticallycreated, generally heal well and quickly.


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Removing Dressings An analgesic may need to be given at least 30

minutes before exposing a wound.

Sterile technique is followed whenever the wound ordressing is handled.

A gown, mask, and protective goggles are worn ifsoiling or splashing of wound exudate is expected.


Skill 13-1: Steps 9 & 11Skill 13-1: Steps 9 & 11

Changing a sterile dry dressing.

(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)



Dry Dressings May be chosen for management of a wound with little

exudate/drainage

Protects the wound from injury, prevents introductionof bacteria, reduces discomfort, and speeds healing

Most commonly used for abrasions and nondrainingpostoperative incisions


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Wet-to-Dry Dressing

Primary purpose is to debride awound.

The moistened contact layer of the dressingincreases the absorptive ability of the dressing tocollect exudate and wound debris.

As the dressing dries, it adheres to the wound anddebrides it when the dressing is removed.



Transparent Dressings Advantages

Adheres to undamaged skin to contain exudates andminimize wound contamination

Serves as a barrier to external fluids and bacteria yetstill allows the wound to breathe

Promotes a moist environment that speeds epithelialcell growth

Permits visualization of the wound


Skill 13-3: Steps 11a & 11bSkill 13-3: Steps 11a & 11b

Applying a transparent dressing.



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Irrigations

A cleansing solution is introduced directly into thewound with a syringe, syringe and catheter, shower,or whirlpool.

Promote wound healing through removing debris froma wound surface, decreasing bacterial counts



Irrigations

Principles of Basic Wound Irrigation

Cleanse in a direction from the leastcontaminated area to the mostcontaminated area.

When irrigating, all of the solution flowsfrom the least contaminated area to themost contaminated area.


Skill 13-4: Steps 10 & 13Skill 13-4: Steps 10 & 13

Performing sterile irrigation.



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Complications of Wound HealingComplications of Wound Healing

De-his-cence Wound layers separate.

It may result after periods of sneezing, coughing, orvomiting.

It may be preceded by serosanguineous drainage.

Patient should remain in bed and given reassurance .

Place a warm, moist sterile dressing over the areauntil the physician evaluates the site.



Evisceration Abdominal organs protrude through an opened

incision.

The wound and contents should be covered withwarm, sterile saline dressings.

The surgeon is notified immediately.

This is a medial emergency, and the wound requiressurgical repair.



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 anelevated _ _ _ count.

Purulent drainage has an odor and is brown, yellow,or green, depending on the pathogen.


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Staple and Suture RemovalStaple and Suture Removal

Sutures and staples are generally removed within 7to 10 days after surgery, or sooner if healing is

adequate.

The physician determines and orders removal ofsutures or staples

Replaced with a Steri-Strip as the first phase, withthe remainder removed in the second phase.



Sutures Sutures are threads of wire or other materials used to

sew together body tissues.

Sutures are placed within tissue layers in deepwounds and superficially as the final means of woundclosure.


Skill 13-5: Step 17Skill 13-5: Step 17

Removing sutures.



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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 theappearance of the incision is not critical.

Removal of staples requires a sterile staple extractorand maintenance of aseptic technique.



Removing staples.

(From Perry, A.G., Potter, P.A. (1998). Clinical nursing skills and interventions.(4th ed.). St. Louis:Mosby.)


Exudate/DrainageExudate/Drainage

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


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Jackson-Pratt drains have a wide, flat area brought through the stabwound with great force.




Drainage Systems Closed Drainage

System of tubing and other apparatus attached to thebody to remove fluid in airtight circuit that preventsenvironmental contaminants from entering the wound orcavity

Open Drainage

Drainage that passes through an open-ended tube intoa receptacle or out onto the dressing

Suction Drainage

Use of a pump or other mechanical device to helpextract a fluid



Jackson-Pratt drainage device. A, Drainage tubes and reservoir. B,

Emptying drainage reservoir.



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Drainage Systems

Requires close monitoring

Note the color, consistency, andamount of drainage.

Note patency of tube; it should not bekinked or occluded.

If blood clots or exudate have sloweddrainage, record and report.



Maintaining Hemovac/Davol suction and T-tube drainage.




Wound VAC system using negative pressure to remove fluid fromarea surrounding the wound.

(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)


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Wound Vacuum-Assisted Closure.











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Bandages and BindersBandages and Binders

Bandage A strip or roll of cloth or other material that may be

wrapped around a part of the body in a variety of waysfor multiple purposes.

Bandages are available in rolls of various widths andmaterials, including gauze, elasticized knit, elastic

webbing, flannel, and muslin.

Binders A binder is a bandage that is made of large pieces of

material to fit a specific body part, such as anabdominal binder or a breast binder.


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Skill 13-9: Step 5cSkill 13-9: Step 5c

Applying a binder, arm sling, and T-binder.



Bandages and BindersBandages and Binders

After a bandage is applied, the PT should Assess, document, and immediately report changes in

circulation, skin integrity, comfort level.

Assess to be sure it is properly applied and isproviding therapeutic benefit; soiled bandages shouldbe replaced.


The EndThe End


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Surgical Wound Care