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  2. DEFINITION OF WOUND  A wound is a break or cut in the continuity of any body structure, internal or external caused by physical means.
  3. CLASSIFICATION OF WOUND According to status of skin integrity  Open wound  Closed wound According to the cause of the wound  Intentional or surgical wound  Unintentional wound
  4. CON… According to severity of injury  Superficial (Abraded) wound  Penetrating wound  Perforated wound  Puncture or stab wound According to cleanliness / contamination  Clean wound  Contaminated wound  Infected or septic wound  Colonized wound
  5. WOUND HEALING PROCESS Stage 1 Inflammatory phase Stage 2 Destructive phase Stage 3 Proliferative phase Stage 4 Maturation phase
  6. Inflammatory phase • Within few seconds after injury, inflammation begins and lasts for about 3 days. • Injured tissues and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and exudation of serum and while blood cells into damaged tissues. • Leukocytes reach the wound within few hours. The neutrophil begins to ingest bacteria and small debris. The neutrophil dies in a few days. • During this period the monocyte which transforms into macrophages cells clean the wound bacteria, dead cells and debris. • This process continues for about 48 hours. Finally a thin layer of epithelial tissue forms over the wound, which is later absorbed.
  7. Destructive phase  This begins before the inflammatory phase ends and lasts for about 2 to 5 days.  Macrophages continue its cleaning process and stimulate the formation of fibroblast.
  8. Proliferative phase  This phase begins with the appearance of the new blood vessels and lasts from 3 to 24 days. Fibroblasts appear alongside the capillaries. These two together constitute the granulation tissue.  Subsequently there is epithelization. All the cells forming the surface epithelium undergoes rapid division and migrates as a thin film covering the wound.  The wound appears pink owing to the new capillaries in the granulation tissue and the area is soft and tender.
  9. Maturation phase  This final phase may take more than one year there is scar formation by the fibroblasts. The capillaries and lymphatic endothelial buds in the new tissues disappear and the scar then shrinks. The collagen scar continues to regain strength over several months.
  10. FACTORS AFFECTING HEALING PROCESS  Nutrition  Age  Blood supply  Hormones  Drugs  Extent of the injury  Infection  Chronic diseases  Smoking  Obesity  Radiation  Wound stress
  11. COMPLICATION  Hemorrhage  Infections  Wound dehiscence  Wound evisceration  Fistula  Abscess formation  Cellulitis  Necrosis or Gangrene  Keloids  Pain  Fluid collection  Interference with organ function
  12. DEFINITION OF WOUND DRESSING  It is a sterile protective covering applied to a wound/incision with aseptic technique with or without medications.
  13. TYPES OF DRESSINGS  Dressings are vary by type of material and mode of application.  Gauze dressings  Non-antiseptic dressings  Antiseptic dressings  Wet dressings  Pressure dressings  Non-adherent gauze dressings  Self-adhesive transparent film
  14. PURPOSES OF WOUND DRESSINGS  To prevent infection.  To prevent further tissue damage.  To promote healing.  To absorb inflammatory exudate and to promote drainages.  To convert the contaminated wound into a clean wound.  To prevent hemorrhage.  To prevent skin excoriation.  To apply medication in place.  To restore the function of the part.  To provide physical and mental comfort to the patient.  To promote thermal insulation to the wound surface area.  To provide maintenance of high humidity between the wound and dressing.
  15. PRINCIPLES INVOLVED IN WOUND DRESSINGS  Micro-organisms are present in environment, on the articles and on the skin. Pathogenic organisms are transmitted from the source to the new host directly or indirectly.  Bacteria travel along with the dust particles.  Cleaning the area where there is less number of organisms, before cleaning an area where there is more organisms. Minimize the spread of organisms to the clean area.  A break in the skin and mucus membrane acts as the portal of entry for the pathogenic organisms.
  16. CON..  Respiratory tract harbors micro-organisms that can enter the wound.  Nutrients and oxygen are carried to the wound via blood stream and are essential for collagen formation.  Moisture facilitates growth and movement of micro- organisms.  Fluid moves downwards as a result of gravitational pull.  Fluids move through materials by capillary action.  Unfamiliar situations produce anxiety.  Systematic ways of working saves time, energy and material.
  17. GENERAL INSTRUCTIONS FOR THE WOUND DRESSING  Practice strict aseptic technique to prevent cross infection to the wound and from the wound. All materials touching to the wound should be sterile.  All articles should be disinfected thoroughly to make sure that they are free from pathogens. Special care must be taken when there is any reason to suspect the presence of pathogenic spores particularly those causing the dreaded wound infections of gas gangrene and tetanus. These spores are destroyed only by the sterilization with steam under pressure.  Wash hands thoroughly before and after procedure.  Instruments used for one dressing can not be used for another until they have been re-sterilized.  Use masks, sterile gloves and gowns for large dressings to minimize the wound contamination.
  18. CON..  Dressings are not changed for at-least 15 minutes after the room has been swept or cleaned. Sweeping and dusting of the room will raise the dust and the wound will be contaminated.  Use individually wrapped sterile dressings and equipment for the greatest safety of the wound. The practice of storing dressings and instruments in large trays and drums and opening them every now and then should be condemned.  Create a sterile field around the wound by spreading sterile towels.  Avoid talking, coughing and sneezing when the wound is opened.  During the procedure the nurse works carefully to avoid contaminating the patient’s skin. Clothing and bed linen with soiled instruments and dressings. All the soiled dressings and contaminated instruments should be carefully collected and disposed safely.
  19. CON…  Cleaning of the wound should be done from the most clean area to the less clean area. Consider the wound area cleaner than the skin area even if the wound is infected. Therefore clean the wound from its center to the periphery. When cleaning the circular wound, start from the center of the wound and go to the periphery. When cleaning a linear wound, the first swab cleanses the wound line and the subsequent swabs cleanse the skin on either side of the wound.  If the dressings are adherent to the wound due to the drying of the secretions or blood, wet it with physiologic saline before it is removed from the wound.  When dressing the wound, keep the wound edges as near as possible to promote healing.  When drains are in place, anticipate drainage and re-enforce the dressings accordingly. The dressings over the drains should not combined with the dressings on the wound line. This enables a nurse to change the dressings over the drains without disturbing the wound dressings and thereby minimizing the wound infections.
  20. CON..  The amount of discharge from the wound should be accurately measured by recording the number and size of the dressings changed. Note the colour, odour, amount and consistency of the drainage.  When the wound drainage is diminished the drains are to be shortened. This should be done in consultation with the doctor. Usually the doctor gives a written order.  Before doing the dressings, inspect the wound for any complications such as dehiscence and evisceration. If present, report it immediately to the surgeon and immediate steps are to be taken.  Avoid meal timing.  Give an analgesics prior to the painful dressings.
  21. PREPARATION OF ARTICLES Articles Purpose A sterile tray containing Artery forceps - 1 To clean the wound Dissecting forceps – 2 Scissors - 1 For the debridement of the wound if necessary or to cut the gauze pieces to fit around the drainage tubes etc. Sinus forceps - 1 To open the sinus tract or to pack the sinus tract if necessary. Small bowl - 1 To take the cleaning solution. Safety pins - 1 To fix the drain in case the drains are cut short. Gloves, mask and gown To use when large wounds are dressed. Cotton balls, gauze pieces, cotton pads etc. as necessary To clean and dress the wound. Slit or dressing towel To create a sterile field around the wound.
  22. CON.. An unsterile tray containing Cleaning solution as necessary To clean the wound and surrounding skin area. Ointment and powders as ordered To apply on the wound. Vaseline gauze in sterile containers To prevent the dressing adhering to the wound. Ribbon gauze in sterile containers To pack the sinus tract or a penetrating wound. Swab stick in a sterile containers To apply the medication if necessary. Transfer forceps in a sterile containers To handle the sterile supplies. Bandages, binders, pins, adhesive plaster and scissors To fix the dressing in place. A large bowl with disinfectant solution To discard the used instruments. Kidney tray and paper bag To collect the wastes. Mackintosh and towel To protect the bed linens.
  23. TOPICALAGENTS FOR CLEANSING WOUND Mercurochrome 1 to 2.5% Skin antiseptic Tr. Iodine 1 – 2% Savlon 5% Cetavlon 1% Normal saline/ Eusol solution 0.5 to 1% Non irritating antiseptics used for cleaning of wounds Hydrogen peroxide 1.5 to 3% It is an oxidizing agent useful for softening and removing crusted exudate and debris. Acetone, ether, turpentine Used for removing adhesive marks from the skin
  24. PRELIMINARY ASSESSMENT  Check the diagnosis and the general condition of the patient.  Check the purpose for which the dressing is to be done.  Check the condition of the wound- the type of the wound, the types of suturing applied, the type of dressing to be applied etc.  Check the physician’s order for the type of dressing to be applied and the specific instructions, if any, regarding the cleaning solutions, removal of sutures, drains and the application of the medications etc.  Check the patient’s name, bed number and other identification.  Check the nurse’s records to find out the general condition of the wound.  Check the abilities and limitations of the patient.  Check the consciousness of the patient and the ability to follow instructions.  Check the articles available in the unit.
  25. PREPARATION OF THE PATIENT AND ENVIRONMENT  Identify the patient and explain the procedure to win his confidence and co-operation.  Provide privacy with curtains and drapes.  Apply restraints in case of children.  As far as possible avoid meal timings. The dressings may be done either one hour before of the meals or after meals.  Offer bedpan or urinal prior to the dressing.  Give some analgesics if the patient is in pain.  See the cleaning of the room is done at least one hour before the expected time of the dressing.
  26. CON…  Shave the areas if necessary. Removal of adhesive is more painful if hair is present.  Placed the patient in a comfortable position and relaxed position depending on the area to be dressed.  Give proper support to the body parts to the body parts if the patient has to raise and hold it in position for considerable time.  See that patient’s room is in order with no unnecessary articles. Clear the bedside table, so that there is sufficient space to set up a sterile field and to arrange needed supplies and equipment.  Close the doors and windows to prevent drafts. Put off fan.
  27. CON..  Adjust the height of the bed for the comfortable working of the doctors and nurses so that they have neither to stop nor over reach to do the dressing. Bring the patient to the edge to the bed. Call for assistance if necessary.  Protect the bed with a mackintosh and towel.  Fold back the upper bedding towards the foot end of the bed leaving a bath blanket or sheet over the patient. Expose the part as necessary.  Untie the bandage or adhesive and remove them. Make sure that the dressing is not removed from it place until the nurse is ready to do dressing.  Turn the head of the patient to one side, so that the patient may not see the wound and get worried about it.
  28. STEPS OF THE PROCEDURE Steps of the procedure Reason Tie the mask To prevent wound contamination with droplets Wash hands thoroughly To prevent cross infection Put on gown (if necessary), gloves To ensure asepsis Open the sterile tray. Spread the sterile towel around the wound To create a sterile field around the wound Pick up a dissecting forceps and remove the dressings and put into kidney. Discard the dissecting forceps in the bowl of lotion. To prevent contamination of the hands with soiled dressings. If the dressing is adherent to the wound, pour physiologic saline and wet it before removal. Note the type and amount of drainage present. Ask the assistant to pour small amount of cleansing solution into the bowl. To prevent contaminating the hands of the nurse by the outside of the bottle.
  29. CON.. Clean the wound from center to periphery discarding each swab after each stroke. Cleaning the wound should be done from the cleanest area to the less clean area. Wound line is considered cleaner than the surrounding area even if the wound is infected. After thoroughly cleaning of the wound, dry the wound with dry swabs using the same precautions. Discard the forceps in the bowl of lotion. To keep the wound as dry as possible. Apply medications if ordered. To apply the ointment directly to the wound may be difficult. Apply a small portion on the dressing that goes directly over the wound.
  30. CON.. Apply the sterile dressings. Apply the gauze pieces first and then the cotton pads. Reinforce the dressing on the dependent parts where the drainage may collect. Cotton placed directly onto the wound may stick on the wound, when the discharge dries. Reinforcing the dressing will prevent oozing of the drainage onto the bed of the patient. Remove the gloves and discard it into the bowl with lotion. Gloves worn during the dressing will be highly contaminated. Secure the dressings with bandage or adhesive tapes.
  31. AFTER CARE OF THE PATIENT AND ARTICLES  Help the patient to dress up and to take comfortable position in the bed. Change the garments if soiled with drainage.  Replace the bed linen.  Remove the mackintosh and towel.  Take all articles to the utility room. Discard the soiled dressing into a covered container and send for incineration. Remove the instruments and other articles from the disinfectant solution and clean them thoroughly. Dry them. Re-set the tray and send them for autoclaving. Replace all other articles to their proper places. Send the soiled linen to the laundry bag for the washing (remove blood stains before sending them).
  32. CON..  Wash hands.  Record the procedure on nurse’s record with date and time. Record the condition of the wound, type and amount of drainage, condition of the sutures etc. on the nurse’s record. Report to the surgeon if any abnormality found.  Return to the bedside to assess the comfort of the patient. Special instruction in the care of the wound are to be communicated to the patient.  Tidy up the bed and unit of the patient.