WOUND CARE

TYPES 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

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DEGREE OF WOUND CONTAMINATION a. Clean wounds

Uninfected, no inflammation; respiratory, genital and urinary tracts are not entered Surgical wounds and respiratory, genital and urinary tracts has been entered Open, fresh, major break in sterile technique, signs of inflammation old, accidental wounds with dead tissue, with infection, purulent drainage

b. Clean contaminated wounds

c. Contaminated wounds

d. Dirty or infected

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CLASSIFICATION OF WOUND BY DEPTH: a. Partial thickness

Confined to skin Epidermis and dermis

b. Full thickness

Dermis, epidermis, subcutaneous, muscle and bone

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1.

2.

3.

WOUND HEALING quality of living tissue; regeneration THREE PHASES: (IPM) Inflammatory phase - initiated immediately and lasts 3-4 days - marked with HEMOSTASIS and PHAGOCYTOSIS Proliferative phase - until day 21 post injury - Collagen formation whitish protein substance that adds to tensile strength of wound; eschar formation Maturation phase - begins at day 21 until 1 - 2 years; scar formation

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1.

TYPES OF HEALING 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 ULCER Note: repair time is longer scarring is greater susceptibility to infection is greater

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TYPES 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

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KINDS OF WOUND DRAINAGE 1. Serous: = serum; from clear portion of the blood, clear to brownish 2. Sanguineous: = bloody, BRIGHT red 3. Serosanguineous = combination of blood and serum, pinkish 4. Purulent: = pus, YELLOW OR yellow-green

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COMPLICATIONS OF WOUND HEALING

H I D E

= HEMORRHAGE = INFECTION = DEHISCENCE = opening = EVISCERATION = coming out C = CALL for help and assistance C = COVER wound with saline soaked sterile OS K = KEEP MOIST D = DONT REINSERT protruding organs D = DORSAL RECUMBENT position D = DO VSQ5M and prepare for surgery

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-

RYB 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 : b. YELLOW : c. BLACK :

Protect (cover) Cleanse Debride

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RYB 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

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RYB 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

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RYB COLOR CODE OF WOUNDS c. BLACK

DEBRIDEMENT

full thickness or third degree burns, gangrene Covered with occlusive dressing to provide moist environment Eschar removal

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a. b. c. d.

e.
f. g. h.

NURSING INTERVENTIONS Wound dressing RYB color code Surgical dressing Wound drains Wound irrigation Sutures Heat and cold application Supporting and immobilizing wounds a. bandages and binders