WOUND CARETYPES OF WOUNDS
Incision = sharp instrument (knife)
Contusion = blow from blunt instrument
Abrasion= surface scrape
Laceration = tissues torn apart
Penetrating = deeper penetration: from bullet
Puncture = shallow penetration
WOUND CAREDEGREE OF WOUND
CONTAMINATIONa. Clean wounds
Uninfected, no inflammation; respiratory, genital and urinary tracts are not entered
b. Clean contaminated wounds Surgical wounds and respiratory, genital
and urinary tracts has been enteredc. Contaminated wounds
Open, fresh, major break in sterile technique, signs of inflammation
d. Dirty or infected old, accidental wounds with dead tissue,
with infection, purulent drainage
WOUND CARE
CLASSIFICATION OF WOUND BY DEPTH:
a. Partial thickness Confined to skin Epidermis and dermis
b. Full thickness Dermis, epidermis, subcutaneous, muscle
and bone
WOUND CAREWOUND HEALING
quality of living tissue; regenerationTHREE PHASES: (IPM)
1. Inflammatory phase- initiated immediately and lasts 3-4 days- marked with HEMOSTASIS and PHAGOCYTOSIS
2. Proliferative phase- until day 21 post injury- Collagen formation – whitish protein substance that adds to tensile strength of wound; eschar formation
3. Maturation phase- begins at day 21 until 1 - 2 years; scar formation
WOUND CARETYPES OF HEALING
1. Primary Intention; FIRST INTENTION- tissue surfaces have been closed and
minimal tissue loss; - SURGICAL INCISION
2. Secondary Intention- extensive and with tissue loss, edges cannot be
approximated; - PRESSURE ULCERNote: repair time is longer
scarring is greatersusceptibility to infection is
greater
WOUND CARETYPES OF HEALING:
3. Tertiary intention healing; - DELAYED or secondary closure- indicated when there is reason to delay a
suturing wound- ABDOMINAL WOUND THAT IS LEFT OPEN FOR DRAINAGE AND IS LATER CLOSED
WOUND CAREKINDS OF WOUND DRAINAGE
1. Serous:= serum; from clear portion of the blood,
clear to brownish2. Sanguineous:
= bloody, BRIGHT red3. Serosanguineous
= combination of blood and serum, pinkish
4. Purulent:= pus, YELLOW OR yellow-green
WOUND CARECOMPLICATIONS OF WOUND HEALING
H = HEMORRHAGEI = INFECTIOND = DEHISCENCE = openingE = EVISCERATION = coming out
C = CALL for help and assistanceC = COVER wound with saline
soaked sterile OS
K = KEEP MOISTD = DON’T REINSERT protruding
organsD = DORSAL RECUMBENT positionD = DO VSQ5M and prepare for
surgery
WOUND CARERYB COLOR CODE OF WOUNDS
- Based on the color of an open wound rather than depth and size of wound
- Can be applied to wound allowed to heal by SECONDARY INTENTION
Goals of wound care:a. RED : Protect (cover)b. YELLOW : Cleansec. BLACK : Debride
WOUND CARERYB COLOR CODE OF WOUNDS
a. RED : PROTECT- Gentle cleansing- Avoiding use of dry-gauze or wet to dry saline
dressings- Application of topical antimicrobial agent- Transparent film or hydrocolloid dressing- Change dressing infrequently
WOUND CARERYB COLOR CODE OF WOUNDS
b. YELLOW : CLEANSE To absorb drainage and remove nonviable
tissue Apply wet-wet dressing Irrigating the wound Use of absorbent dressing material Consult MD as to use of antimicrobial agent
WOUND CARERYB COLOR CODE OF WOUNDS
c. BLACK : DEBRIDEMENT full thickness or third degree burns, gangrene Covered with occlusive dressing to provide
moist environment Eschar removal
WOUND CARENURSING INTERVENTIONS
a. Wound dressingb. RYB color codec. Surgical dressingd. Wound drainse. Wound irrigationf. Suturesg. Heat and cold applicationh. Supporting and immobilizing wounds
a. bandages and binders