Skin structure and function

General FunctionsGeneral Functions

Each skin layer has its own unique function

1048698 Epidermis = protection

1048698 Dermis = nourishment of epidermis

1048698 Hypodermis = Composed mostly of adipose tissue insulation

Skin structure and functionSkin structure and functionProtects deeper tissues from

Mechanical damage ( bumps amp cuts)

Chemical damage (acids amp bases)

Bacterial damage

Thermal damage (heat amp cold)

Ultraviolet radiation (sunlight)

Classifying wounds

A wound can be defined as

ldquoA cut or break in the continuity of any tissue caused by injury or operationrdquo

(Bailliegraverersquos 23rd Ed)

Wound Types and Characteristics

CLOSED

Contusion ( Bruise) ndash Tissue injury without

breaking of skin

CD Purpule contusion 5x7 cm on left face

Hematoma ndash Tissue injury that disrupts a

blood vessels pooling of blood under the

unbroken skin

CD 2 in diameter hematoma on left face

Sprain ndash Wrenching or twisting of a

joint with partial rupture of its ligaments

causes swelling

CD Swelling of right foot and round

malleolus No bruising noted

OPEN

Incision- Surgically made separation of

tissues with clean smooth edges

CD Approx 3-in incision on R lower

quadrant of abdomen well approximated

clean and dry with sutures intact

Laceration ndash Traumatic separation of

tissues with clean smooth edges

CD 2 in jagged (pointy uneven)

laceration app 4 cm deep on L sole

foot

Abrasion- Traumatic scraping away of

surface layers of skin

CD Raw appearing abraded area 2 12

in diameter on lateral aspect of lower

leg

Puncture ndash Wound made by sharp

pointed object through sin or mucous

membranes and underlying tissue

CD Small circular entry wound on R

palm from sharp pointing nail

Penetrating- Variable ndash size open wound

through sin and underlying tissues

made by a bullet or metal or wood

fragment may extend deeply into body

CD Jagged Deep wound 10 in posterior

on L leg

Avulsion ndash Tearing away of a

structure or a part such as a

fingertip accidentally or surgically

CD Avulsion of L leg from VA Attach

only by skin

Ulceration ndash Excavation of sin andor

underlying tissue from injury or

necrosis

CD Ulceration on L sole foot 4 cm x

5 x 2 cm deep Yellow drainage

present Wound edges reddened

bull

Wounds can be classified according to their natureWounds can be classified according to their nature

Superficial Involves only the epidermis Injury is usually the result of fiction shearing (cut) or

burn

Partial Thickness Involves the epidermis and the dermisWounds heal more quickly

Full ThicknessInvolves the epidermis dermis fat fascia and exposes

boneIn order to heal all dead tissue must be removed so

that granulation tissue can gradually fill in the defect

2 According to depth

TYPES OF WOUND DRAINAGETYPES OF WOUND DRAINAGE

Serous -clean watery Purulent - thick yellow green tan

or brown Sanguineous - bright red

indicative of active bleeding Serosanguineous -pale red

watery mixture of serous and sanguineous

Wound healingAll wounds heal following a a specific sequence of phases which may overlap

The process of wound healing depends on the type of tissue which has been damaged and the nature of tissue disruption

The phases areInflammatory phaseProliferative phaseRemodeling or maturation phase

PHASES OF WOUND HEALINGPHASES OF WOUND HEALING

1 INFLAMMATORY PHASE1 INFLAMMATORY PHASE

-starts immediately after injury and lasts 3-6 days or 4-6 days

2 major processes occur during this phase hellip

HEMOSTATIC AND PHAGOCYTOSISHaemostatic Haemostatic - Tissue and capillaries are destroyed

plasma and blood leaks Area blood vessels constrict platelets aggregates and bleeding stops scabs ( rough protective crust) forms preventing entry of infectious organisms

InflammationCharacterized by edema erythema pain temperature

- increase blood flow to wound resulting localized redness and edema attracts WBC and wound growth factors

WBC arrive-clear debris from wound

injury

Exposure of plasma to injured site Release of Histamine

Activation of Hageman Factor Capillary Permeability

Vasodilation

Edema

Calor( Heat)

Rubor (Redness)

Tumor( Swelling)

Inc bld Flow

Kinin Prostaglandin

Clotting

Dolor( Pain)

2 PROLIFERATIVE PHASE2 PROLIFERATIVE PHASE

-extends from day 3 to about day 21 post injury

Macrophages continue to clear the wound debris Stimulates Fibroblast to synthesize collagen 9 main ingr For tissue scaring)

New capillary networks are formed

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Skin structure and functionSkin structure and functionProtects deeper tissues from

Mechanical damage ( bumps amp cuts)

Chemical damage (acids amp bases)

Bacterial damage

Thermal damage (heat amp cold)

Ultraviolet radiation (sunlight)

Classifying wounds

A wound can be defined as

ldquoA cut or break in the continuity of any tissue caused by injury or operationrdquo

(Bailliegraverersquos 23rd Ed)

Wound Types and Characteristics

CLOSED

Contusion ( Bruise) ndash Tissue injury without

breaking of skin

CD Purpule contusion 5x7 cm on left face

Hematoma ndash Tissue injury that disrupts a

blood vessels pooling of blood under the

unbroken skin

CD 2 in diameter hematoma on left face

Sprain ndash Wrenching or twisting of a

joint with partial rupture of its ligaments

causes swelling

CD Swelling of right foot and round

malleolus No bruising noted

OPEN

Incision- Surgically made separation of

tissues with clean smooth edges

CD Approx 3-in incision on R lower

quadrant of abdomen well approximated

clean and dry with sutures intact

Laceration ndash Traumatic separation of

tissues with clean smooth edges

CD 2 in jagged (pointy uneven)

laceration app 4 cm deep on L sole

foot

Abrasion- Traumatic scraping away of

surface layers of skin

CD Raw appearing abraded area 2 12

in diameter on lateral aspect of lower

leg

Puncture ndash Wound made by sharp

pointed object through sin or mucous

membranes and underlying tissue

CD Small circular entry wound on R

palm from sharp pointing nail

Penetrating- Variable ndash size open wound

through sin and underlying tissues

made by a bullet or metal or wood

fragment may extend deeply into body

CD Jagged Deep wound 10 in posterior

on L leg

Avulsion ndash Tearing away of a

structure or a part such as a

fingertip accidentally or surgically

CD Avulsion of L leg from VA Attach

only by skin

Ulceration ndash Excavation of sin andor

underlying tissue from injury or

necrosis

CD Ulceration on L sole foot 4 cm x

5 x 2 cm deep Yellow drainage

present Wound edges reddened

bull

Wounds can be classified according to their natureWounds can be classified according to their nature

Superficial Involves only the epidermis Injury is usually the result of fiction shearing (cut) or

burn

Partial Thickness Involves the epidermis and the dermisWounds heal more quickly

Full ThicknessInvolves the epidermis dermis fat fascia and exposes

boneIn order to heal all dead tissue must be removed so

that granulation tissue can gradually fill in the defect

2 According to depth

TYPES OF WOUND DRAINAGETYPES OF WOUND DRAINAGE

Serous -clean watery Purulent - thick yellow green tan

or brown Sanguineous - bright red

indicative of active bleeding Serosanguineous -pale red

watery mixture of serous and sanguineous

Wound healingAll wounds heal following a a specific sequence of phases which may overlap

The process of wound healing depends on the type of tissue which has been damaged and the nature of tissue disruption

The phases areInflammatory phaseProliferative phaseRemodeling or maturation phase

PHASES OF WOUND HEALINGPHASES OF WOUND HEALING

1 INFLAMMATORY PHASE1 INFLAMMATORY PHASE

-starts immediately after injury and lasts 3-6 days or 4-6 days

2 major processes occur during this phase hellip

HEMOSTATIC AND PHAGOCYTOSISHaemostatic Haemostatic - Tissue and capillaries are destroyed

plasma and blood leaks Area blood vessels constrict platelets aggregates and bleeding stops scabs ( rough protective crust) forms preventing entry of infectious organisms

InflammationCharacterized by edema erythema pain temperature

- increase blood flow to wound resulting localized redness and edema attracts WBC and wound growth factors

WBC arrive-clear debris from wound

injury

Exposure of plasma to injured site Release of Histamine

Activation of Hageman Factor Capillary Permeability

Vasodilation

Edema

Calor( Heat)

Rubor (Redness)

Tumor( Swelling)

Inc bld Flow

Kinin Prostaglandin

Clotting

Dolor( Pain)

2 PROLIFERATIVE PHASE2 PROLIFERATIVE PHASE

-extends from day 3 to about day 21 post injury

Macrophages continue to clear the wound debris Stimulates Fibroblast to synthesize collagen 9 main ingr For tissue scaring)

New capillary networks are formed

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Classifying wounds

A wound can be defined as

ldquoA cut or break in the continuity of any tissue caused by injury or operationrdquo

(Bailliegraverersquos 23rd Ed)

Wound Types and Characteristics

CLOSED

Contusion ( Bruise) ndash Tissue injury without

breaking of skin

CD Purpule contusion 5x7 cm on left face

Hematoma ndash Tissue injury that disrupts a

blood vessels pooling of blood under the

unbroken skin

CD 2 in diameter hematoma on left face

Sprain ndash Wrenching or twisting of a

joint with partial rupture of its ligaments

causes swelling

CD Swelling of right foot and round

malleolus No bruising noted

OPEN

Incision- Surgically made separation of

tissues with clean smooth edges

CD Approx 3-in incision on R lower

quadrant of abdomen well approximated

clean and dry with sutures intact

Laceration ndash Traumatic separation of

tissues with clean smooth edges

CD 2 in jagged (pointy uneven)

laceration app 4 cm deep on L sole

foot

Abrasion- Traumatic scraping away of

surface layers of skin

CD Raw appearing abraded area 2 12

in diameter on lateral aspect of lower

leg

Puncture ndash Wound made by sharp

pointed object through sin or mucous

membranes and underlying tissue

CD Small circular entry wound on R

palm from sharp pointing nail

Penetrating- Variable ndash size open wound

through sin and underlying tissues

made by a bullet or metal or wood

fragment may extend deeply into body

CD Jagged Deep wound 10 in posterior

on L leg

Avulsion ndash Tearing away of a

structure or a part such as a

fingertip accidentally or surgically

CD Avulsion of L leg from VA Attach

only by skin

Ulceration ndash Excavation of sin andor

underlying tissue from injury or

necrosis

CD Ulceration on L sole foot 4 cm x

5 x 2 cm deep Yellow drainage

present Wound edges reddened

bull

Wounds can be classified according to their natureWounds can be classified according to their nature

Superficial Involves only the epidermis Injury is usually the result of fiction shearing (cut) or

burn

Partial Thickness Involves the epidermis and the dermisWounds heal more quickly

Full ThicknessInvolves the epidermis dermis fat fascia and exposes

boneIn order to heal all dead tissue must be removed so

that granulation tissue can gradually fill in the defect

2 According to depth

TYPES OF WOUND DRAINAGETYPES OF WOUND DRAINAGE

Serous -clean watery Purulent - thick yellow green tan

or brown Sanguineous - bright red

indicative of active bleeding Serosanguineous -pale red

watery mixture of serous and sanguineous

Wound healingAll wounds heal following a a specific sequence of phases which may overlap

The process of wound healing depends on the type of tissue which has been damaged and the nature of tissue disruption

The phases areInflammatory phaseProliferative phaseRemodeling or maturation phase

PHASES OF WOUND HEALINGPHASES OF WOUND HEALING

1 INFLAMMATORY PHASE1 INFLAMMATORY PHASE

-starts immediately after injury and lasts 3-6 days or 4-6 days

2 major processes occur during this phase hellip

HEMOSTATIC AND PHAGOCYTOSISHaemostatic Haemostatic - Tissue and capillaries are destroyed

plasma and blood leaks Area blood vessels constrict platelets aggregates and bleeding stops scabs ( rough protective crust) forms preventing entry of infectious organisms

InflammationCharacterized by edema erythema pain temperature

- increase blood flow to wound resulting localized redness and edema attracts WBC and wound growth factors

WBC arrive-clear debris from wound

injury

Exposure of plasma to injured site Release of Histamine

Activation of Hageman Factor Capillary Permeability

Vasodilation

Edema

Calor( Heat)

Rubor (Redness)

Tumor( Swelling)

Inc bld Flow

Kinin Prostaglandin

Clotting

Dolor( Pain)

2 PROLIFERATIVE PHASE2 PROLIFERATIVE PHASE

-extends from day 3 to about day 21 post injury

Macrophages continue to clear the wound debris Stimulates Fibroblast to synthesize collagen 9 main ingr For tissue scaring)

New capillary networks are formed

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Wound Types and Characteristics

CLOSED

Contusion ( Bruise) ndash Tissue injury without

breaking of skin

CD Purpule contusion 5x7 cm on left face

Hematoma ndash Tissue injury that disrupts a

blood vessels pooling of blood under the

unbroken skin

CD 2 in diameter hematoma on left face

Sprain ndash Wrenching or twisting of a

joint with partial rupture of its ligaments

causes swelling

CD Swelling of right foot and round

malleolus No bruising noted

OPEN

Incision- Surgically made separation of

tissues with clean smooth edges

CD Approx 3-in incision on R lower

quadrant of abdomen well approximated

clean and dry with sutures intact

Laceration ndash Traumatic separation of

tissues with clean smooth edges

CD 2 in jagged (pointy uneven)

laceration app 4 cm deep on L sole

foot

Abrasion- Traumatic scraping away of

surface layers of skin

CD Raw appearing abraded area 2 12

in diameter on lateral aspect of lower

leg

Puncture ndash Wound made by sharp

pointed object through sin or mucous

membranes and underlying tissue

CD Small circular entry wound on R

palm from sharp pointing nail

Penetrating- Variable ndash size open wound

through sin and underlying tissues

made by a bullet or metal or wood

fragment may extend deeply into body

CD Jagged Deep wound 10 in posterior

on L leg

Avulsion ndash Tearing away of a

structure or a part such as a

fingertip accidentally or surgically

CD Avulsion of L leg from VA Attach

only by skin

Ulceration ndash Excavation of sin andor

underlying tissue from injury or

necrosis

CD Ulceration on L sole foot 4 cm x

5 x 2 cm deep Yellow drainage

present Wound edges reddened

bull

Wounds can be classified according to their natureWounds can be classified according to their nature

Superficial Involves only the epidermis Injury is usually the result of fiction shearing (cut) or

burn

Partial Thickness Involves the epidermis and the dermisWounds heal more quickly

Full ThicknessInvolves the epidermis dermis fat fascia and exposes

boneIn order to heal all dead tissue must be removed so

that granulation tissue can gradually fill in the defect

2 According to depth

TYPES OF WOUND DRAINAGETYPES OF WOUND DRAINAGE

Serous -clean watery Purulent - thick yellow green tan

or brown Sanguineous - bright red

indicative of active bleeding Serosanguineous -pale red

watery mixture of serous and sanguineous

Wound healingAll wounds heal following a a specific sequence of phases which may overlap

The process of wound healing depends on the type of tissue which has been damaged and the nature of tissue disruption

The phases areInflammatory phaseProliferative phaseRemodeling or maturation phase

PHASES OF WOUND HEALINGPHASES OF WOUND HEALING

1 INFLAMMATORY PHASE1 INFLAMMATORY PHASE

-starts immediately after injury and lasts 3-6 days or 4-6 days

2 major processes occur during this phase hellip

HEMOSTATIC AND PHAGOCYTOSISHaemostatic Haemostatic - Tissue and capillaries are destroyed

plasma and blood leaks Area blood vessels constrict platelets aggregates and bleeding stops scabs ( rough protective crust) forms preventing entry of infectious organisms

InflammationCharacterized by edema erythema pain temperature

- increase blood flow to wound resulting localized redness and edema attracts WBC and wound growth factors

WBC arrive-clear debris from wound

injury

Exposure of plasma to injured site Release of Histamine

Activation of Hageman Factor Capillary Permeability

Vasodilation

Edema

Calor( Heat)

Rubor (Redness)

Tumor( Swelling)

Inc bld Flow

Kinin Prostaglandin

Clotting

Dolor( Pain)

2 PROLIFERATIVE PHASE2 PROLIFERATIVE PHASE

-extends from day 3 to about day 21 post injury

Macrophages continue to clear the wound debris Stimulates Fibroblast to synthesize collagen 9 main ingr For tissue scaring)

New capillary networks are formed

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Sprain ndash Wrenching or twisting of a

joint with partial rupture of its ligaments

causes swelling

CD Swelling of right foot and round

malleolus No bruising noted

OPEN

Incision- Surgically made separation of

tissues with clean smooth edges

CD Approx 3-in incision on R lower

quadrant of abdomen well approximated

clean and dry with sutures intact

Laceration ndash Traumatic separation of

tissues with clean smooth edges

CD 2 in jagged (pointy uneven)

laceration app 4 cm deep on L sole

foot

Abrasion- Traumatic scraping away of

surface layers of skin

CD Raw appearing abraded area 2 12

in diameter on lateral aspect of lower

leg

Puncture ndash Wound made by sharp

pointed object through sin or mucous

membranes and underlying tissue

CD Small circular entry wound on R

palm from sharp pointing nail

Penetrating- Variable ndash size open wound

through sin and underlying tissues

made by a bullet or metal or wood

fragment may extend deeply into body

CD Jagged Deep wound 10 in posterior

on L leg

Avulsion ndash Tearing away of a

structure or a part such as a

fingertip accidentally or surgically

CD Avulsion of L leg from VA Attach

only by skin

Ulceration ndash Excavation of sin andor

underlying tissue from injury or

necrosis

CD Ulceration on L sole foot 4 cm x

5 x 2 cm deep Yellow drainage

present Wound edges reddened

bull

Wounds can be classified according to their natureWounds can be classified according to their nature

Superficial Involves only the epidermis Injury is usually the result of fiction shearing (cut) or

burn

Partial Thickness Involves the epidermis and the dermisWounds heal more quickly

Full ThicknessInvolves the epidermis dermis fat fascia and exposes

boneIn order to heal all dead tissue must be removed so

that granulation tissue can gradually fill in the defect

2 According to depth

TYPES OF WOUND DRAINAGETYPES OF WOUND DRAINAGE

Serous -clean watery Purulent - thick yellow green tan

or brown Sanguineous - bright red

indicative of active bleeding Serosanguineous -pale red

watery mixture of serous and sanguineous

Wound healingAll wounds heal following a a specific sequence of phases which may overlap

The process of wound healing depends on the type of tissue which has been damaged and the nature of tissue disruption

The phases areInflammatory phaseProliferative phaseRemodeling or maturation phase

PHASES OF WOUND HEALINGPHASES OF WOUND HEALING

1 INFLAMMATORY PHASE1 INFLAMMATORY PHASE

-starts immediately after injury and lasts 3-6 days or 4-6 days

2 major processes occur during this phase hellip

HEMOSTATIC AND PHAGOCYTOSISHaemostatic Haemostatic - Tissue and capillaries are destroyed

plasma and blood leaks Area blood vessels constrict platelets aggregates and bleeding stops scabs ( rough protective crust) forms preventing entry of infectious organisms

InflammationCharacterized by edema erythema pain temperature

- increase blood flow to wound resulting localized redness and edema attracts WBC and wound growth factors

WBC arrive-clear debris from wound

injury

Exposure of plasma to injured site Release of Histamine

Activation of Hageman Factor Capillary Permeability

Vasodilation

Edema

Calor( Heat)

Rubor (Redness)

Tumor( Swelling)

Inc bld Flow

Kinin Prostaglandin

Clotting

Dolor( Pain)

2 PROLIFERATIVE PHASE2 PROLIFERATIVE PHASE

-extends from day 3 to about day 21 post injury

Macrophages continue to clear the wound debris Stimulates Fibroblast to synthesize collagen 9 main ingr For tissue scaring)

New capillary networks are formed

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Laceration ndash Traumatic separation of

tissues with clean smooth edges

CD 2 in jagged (pointy uneven)

laceration app 4 cm deep on L sole

foot

Abrasion- Traumatic scraping away of

surface layers of skin

CD Raw appearing abraded area 2 12

in diameter on lateral aspect of lower

leg

Puncture ndash Wound made by sharp

pointed object through sin or mucous

membranes and underlying tissue

CD Small circular entry wound on R

palm from sharp pointing nail

Penetrating- Variable ndash size open wound

through sin and underlying tissues

made by a bullet or metal or wood

fragment may extend deeply into body

CD Jagged Deep wound 10 in posterior

on L leg

Avulsion ndash Tearing away of a

structure or a part such as a

fingertip accidentally or surgically

CD Avulsion of L leg from VA Attach

only by skin

Ulceration ndash Excavation of sin andor

underlying tissue from injury or

necrosis

CD Ulceration on L sole foot 4 cm x

5 x 2 cm deep Yellow drainage

present Wound edges reddened

bull

Wounds can be classified according to their natureWounds can be classified according to their nature

Superficial Involves only the epidermis Injury is usually the result of fiction shearing (cut) or

burn

Partial Thickness Involves the epidermis and the dermisWounds heal more quickly

Full ThicknessInvolves the epidermis dermis fat fascia and exposes

boneIn order to heal all dead tissue must be removed so

that granulation tissue can gradually fill in the defect

2 According to depth

TYPES OF WOUND DRAINAGETYPES OF WOUND DRAINAGE

Serous -clean watery Purulent - thick yellow green tan

or brown Sanguineous - bright red

indicative of active bleeding Serosanguineous -pale red

watery mixture of serous and sanguineous

Wound healingAll wounds heal following a a specific sequence of phases which may overlap

The process of wound healing depends on the type of tissue which has been damaged and the nature of tissue disruption

The phases areInflammatory phaseProliferative phaseRemodeling or maturation phase

PHASES OF WOUND HEALINGPHASES OF WOUND HEALING

1 INFLAMMATORY PHASE1 INFLAMMATORY PHASE

-starts immediately after injury and lasts 3-6 days or 4-6 days

2 major processes occur during this phase hellip

HEMOSTATIC AND PHAGOCYTOSISHaemostatic Haemostatic - Tissue and capillaries are destroyed

plasma and blood leaks Area blood vessels constrict platelets aggregates and bleeding stops scabs ( rough protective crust) forms preventing entry of infectious organisms

InflammationCharacterized by edema erythema pain temperature

- increase blood flow to wound resulting localized redness and edema attracts WBC and wound growth factors

WBC arrive-clear debris from wound

injury

Exposure of plasma to injured site Release of Histamine

Activation of Hageman Factor Capillary Permeability

Vasodilation

Edema

Calor( Heat)

Rubor (Redness)

Tumor( Swelling)

Inc bld Flow

Kinin Prostaglandin

Clotting

Dolor( Pain)

2 PROLIFERATIVE PHASE2 PROLIFERATIVE PHASE

-extends from day 3 to about day 21 post injury

Macrophages continue to clear the wound debris Stimulates Fibroblast to synthesize collagen 9 main ingr For tissue scaring)

New capillary networks are formed

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Puncture ndash Wound made by sharp

pointed object through sin or mucous

membranes and underlying tissue

CD Small circular entry wound on R

palm from sharp pointing nail

Penetrating- Variable ndash size open wound

through sin and underlying tissues

made by a bullet or metal or wood

fragment may extend deeply into body

CD Jagged Deep wound 10 in posterior

on L leg

Avulsion ndash Tearing away of a

structure or a part such as a

fingertip accidentally or surgically

CD Avulsion of L leg from VA Attach

only by skin

Ulceration ndash Excavation of sin andor

underlying tissue from injury or

necrosis

CD Ulceration on L sole foot 4 cm x

5 x 2 cm deep Yellow drainage

present Wound edges reddened

bull

Wounds can be classified according to their natureWounds can be classified according to their nature

Superficial Involves only the epidermis Injury is usually the result of fiction shearing (cut) or

burn

Partial Thickness Involves the epidermis and the dermisWounds heal more quickly

Full ThicknessInvolves the epidermis dermis fat fascia and exposes

boneIn order to heal all dead tissue must be removed so

that granulation tissue can gradually fill in the defect

2 According to depth

TYPES OF WOUND DRAINAGETYPES OF WOUND DRAINAGE

Serous -clean watery Purulent - thick yellow green tan

or brown Sanguineous - bright red

indicative of active bleeding Serosanguineous -pale red

watery mixture of serous and sanguineous

Wound healingAll wounds heal following a a specific sequence of phases which may overlap

The process of wound healing depends on the type of tissue which has been damaged and the nature of tissue disruption

The phases areInflammatory phaseProliferative phaseRemodeling or maturation phase

PHASES OF WOUND HEALINGPHASES OF WOUND HEALING

1 INFLAMMATORY PHASE1 INFLAMMATORY PHASE

-starts immediately after injury and lasts 3-6 days or 4-6 days

2 major processes occur during this phase hellip

HEMOSTATIC AND PHAGOCYTOSISHaemostatic Haemostatic - Tissue and capillaries are destroyed

plasma and blood leaks Area blood vessels constrict platelets aggregates and bleeding stops scabs ( rough protective crust) forms preventing entry of infectious organisms

InflammationCharacterized by edema erythema pain temperature

- increase blood flow to wound resulting localized redness and edema attracts WBC and wound growth factors

WBC arrive-clear debris from wound

injury

Exposure of plasma to injured site Release of Histamine

Activation of Hageman Factor Capillary Permeability

Vasodilation

Edema

Calor( Heat)

Rubor (Redness)

Tumor( Swelling)

Inc bld Flow

Kinin Prostaglandin

Clotting

Dolor( Pain)

2 PROLIFERATIVE PHASE2 PROLIFERATIVE PHASE

-extends from day 3 to about day 21 post injury

Macrophages continue to clear the wound debris Stimulates Fibroblast to synthesize collagen 9 main ingr For tissue scaring)

New capillary networks are formed

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Avulsion ndash Tearing away of a

structure or a part such as a

fingertip accidentally or surgically

CD Avulsion of L leg from VA Attach

only by skin

Ulceration ndash Excavation of sin andor

underlying tissue from injury or

necrosis

CD Ulceration on L sole foot 4 cm x

5 x 2 cm deep Yellow drainage

present Wound edges reddened

bull

Wounds can be classified according to their natureWounds can be classified according to their nature

Superficial Involves only the epidermis Injury is usually the result of fiction shearing (cut) or

burn

Partial Thickness Involves the epidermis and the dermisWounds heal more quickly

Full ThicknessInvolves the epidermis dermis fat fascia and exposes

boneIn order to heal all dead tissue must be removed so

that granulation tissue can gradually fill in the defect

2 According to depth

TYPES OF WOUND DRAINAGETYPES OF WOUND DRAINAGE

Serous -clean watery Purulent - thick yellow green tan

or brown Sanguineous - bright red

indicative of active bleeding Serosanguineous -pale red

watery mixture of serous and sanguineous

Wound healingAll wounds heal following a a specific sequence of phases which may overlap

The process of wound healing depends on the type of tissue which has been damaged and the nature of tissue disruption

The phases areInflammatory phaseProliferative phaseRemodeling or maturation phase

PHASES OF WOUND HEALINGPHASES OF WOUND HEALING

1 INFLAMMATORY PHASE1 INFLAMMATORY PHASE

-starts immediately after injury and lasts 3-6 days or 4-6 days

2 major processes occur during this phase hellip

HEMOSTATIC AND PHAGOCYTOSISHaemostatic Haemostatic - Tissue and capillaries are destroyed

plasma and blood leaks Area blood vessels constrict platelets aggregates and bleeding stops scabs ( rough protective crust) forms preventing entry of infectious organisms

InflammationCharacterized by edema erythema pain temperature

- increase blood flow to wound resulting localized redness and edema attracts WBC and wound growth factors

WBC arrive-clear debris from wound

injury

Exposure of plasma to injured site Release of Histamine

Activation of Hageman Factor Capillary Permeability

Vasodilation

Edema

Calor( Heat)

Rubor (Redness)

Tumor( Swelling)

Inc bld Flow

Kinin Prostaglandin

Clotting

Dolor( Pain)

2 PROLIFERATIVE PHASE2 PROLIFERATIVE PHASE

-extends from day 3 to about day 21 post injury

Macrophages continue to clear the wound debris Stimulates Fibroblast to synthesize collagen 9 main ingr For tissue scaring)

New capillary networks are formed

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

bull

Wounds can be classified according to their natureWounds can be classified according to their nature

Superficial Involves only the epidermis Injury is usually the result of fiction shearing (cut) or

burn

Partial Thickness Involves the epidermis and the dermisWounds heal more quickly

Full ThicknessInvolves the epidermis dermis fat fascia and exposes

boneIn order to heal all dead tissue must be removed so

that granulation tissue can gradually fill in the defect

2 According to depth

TYPES OF WOUND DRAINAGETYPES OF WOUND DRAINAGE

Serous -clean watery Purulent - thick yellow green tan

or brown Sanguineous - bright red

indicative of active bleeding Serosanguineous -pale red

watery mixture of serous and sanguineous

Wound healingAll wounds heal following a a specific sequence of phases which may overlap

The process of wound healing depends on the type of tissue which has been damaged and the nature of tissue disruption

The phases areInflammatory phaseProliferative phaseRemodeling or maturation phase

PHASES OF WOUND HEALINGPHASES OF WOUND HEALING

1 INFLAMMATORY PHASE1 INFLAMMATORY PHASE

-starts immediately after injury and lasts 3-6 days or 4-6 days

2 major processes occur during this phase hellip

HEMOSTATIC AND PHAGOCYTOSISHaemostatic Haemostatic - Tissue and capillaries are destroyed

plasma and blood leaks Area blood vessels constrict platelets aggregates and bleeding stops scabs ( rough protective crust) forms preventing entry of infectious organisms

InflammationCharacterized by edema erythema pain temperature

- increase blood flow to wound resulting localized redness and edema attracts WBC and wound growth factors

WBC arrive-clear debris from wound

injury

Exposure of plasma to injured site Release of Histamine

Activation of Hageman Factor Capillary Permeability

Vasodilation

Edema

Calor( Heat)

Rubor (Redness)

Tumor( Swelling)

Inc bld Flow

Kinin Prostaglandin

Clotting

Dolor( Pain)

2 PROLIFERATIVE PHASE2 PROLIFERATIVE PHASE

-extends from day 3 to about day 21 post injury

Macrophages continue to clear the wound debris Stimulates Fibroblast to synthesize collagen 9 main ingr For tissue scaring)

New capillary networks are formed

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Superficial Involves only the epidermis Injury is usually the result of fiction shearing (cut) or

burn

Partial Thickness Involves the epidermis and the dermisWounds heal more quickly

Full ThicknessInvolves the epidermis dermis fat fascia and exposes

boneIn order to heal all dead tissue must be removed so

that granulation tissue can gradually fill in the defect

2 According to depth

TYPES OF WOUND DRAINAGETYPES OF WOUND DRAINAGE

Serous -clean watery Purulent - thick yellow green tan

or brown Sanguineous - bright red

indicative of active bleeding Serosanguineous -pale red

watery mixture of serous and sanguineous

Wound healingAll wounds heal following a a specific sequence of phases which may overlap

The process of wound healing depends on the type of tissue which has been damaged and the nature of tissue disruption

The phases areInflammatory phaseProliferative phaseRemodeling or maturation phase

PHASES OF WOUND HEALINGPHASES OF WOUND HEALING

1 INFLAMMATORY PHASE1 INFLAMMATORY PHASE

-starts immediately after injury and lasts 3-6 days or 4-6 days

2 major processes occur during this phase hellip

HEMOSTATIC AND PHAGOCYTOSISHaemostatic Haemostatic - Tissue and capillaries are destroyed

plasma and blood leaks Area blood vessels constrict platelets aggregates and bleeding stops scabs ( rough protective crust) forms preventing entry of infectious organisms

InflammationCharacterized by edema erythema pain temperature

- increase blood flow to wound resulting localized redness and edema attracts WBC and wound growth factors

WBC arrive-clear debris from wound

injury

Exposure of plasma to injured site Release of Histamine

Activation of Hageman Factor Capillary Permeability

Vasodilation

Edema

Calor( Heat)

Rubor (Redness)

Tumor( Swelling)

Inc bld Flow

Kinin Prostaglandin

Clotting

Dolor( Pain)

2 PROLIFERATIVE PHASE2 PROLIFERATIVE PHASE

-extends from day 3 to about day 21 post injury

Macrophages continue to clear the wound debris Stimulates Fibroblast to synthesize collagen 9 main ingr For tissue scaring)

New capillary networks are formed

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

TYPES OF WOUND DRAINAGETYPES OF WOUND DRAINAGE

Serous -clean watery Purulent - thick yellow green tan

or brown Sanguineous - bright red

indicative of active bleeding Serosanguineous -pale red

watery mixture of serous and sanguineous

Wound healingAll wounds heal following a a specific sequence of phases which may overlap

The process of wound healing depends on the type of tissue which has been damaged and the nature of tissue disruption

The phases areInflammatory phaseProliferative phaseRemodeling or maturation phase

PHASES OF WOUND HEALINGPHASES OF WOUND HEALING

1 INFLAMMATORY PHASE1 INFLAMMATORY PHASE

-starts immediately after injury and lasts 3-6 days or 4-6 days

2 major processes occur during this phase hellip

HEMOSTATIC AND PHAGOCYTOSISHaemostatic Haemostatic - Tissue and capillaries are destroyed

plasma and blood leaks Area blood vessels constrict platelets aggregates and bleeding stops scabs ( rough protective crust) forms preventing entry of infectious organisms

InflammationCharacterized by edema erythema pain temperature

- increase blood flow to wound resulting localized redness and edema attracts WBC and wound growth factors

WBC arrive-clear debris from wound

injury

Exposure of plasma to injured site Release of Histamine

Activation of Hageman Factor Capillary Permeability

Vasodilation

Edema

Calor( Heat)

Rubor (Redness)

Tumor( Swelling)

Inc bld Flow

Kinin Prostaglandin

Clotting

Dolor( Pain)

2 PROLIFERATIVE PHASE2 PROLIFERATIVE PHASE

-extends from day 3 to about day 21 post injury

Macrophages continue to clear the wound debris Stimulates Fibroblast to synthesize collagen 9 main ingr For tissue scaring)

New capillary networks are formed

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Wound healingAll wounds heal following a a specific sequence of phases which may overlap

The process of wound healing depends on the type of tissue which has been damaged and the nature of tissue disruption

The phases areInflammatory phaseProliferative phaseRemodeling or maturation phase

PHASES OF WOUND HEALINGPHASES OF WOUND HEALING

1 INFLAMMATORY PHASE1 INFLAMMATORY PHASE

-starts immediately after injury and lasts 3-6 days or 4-6 days

2 major processes occur during this phase hellip

HEMOSTATIC AND PHAGOCYTOSISHaemostatic Haemostatic - Tissue and capillaries are destroyed

plasma and blood leaks Area blood vessels constrict platelets aggregates and bleeding stops scabs ( rough protective crust) forms preventing entry of infectious organisms

InflammationCharacterized by edema erythema pain temperature

- increase blood flow to wound resulting localized redness and edema attracts WBC and wound growth factors

WBC arrive-clear debris from wound

injury

Exposure of plasma to injured site Release of Histamine

Activation of Hageman Factor Capillary Permeability

Vasodilation

Edema

Calor( Heat)

Rubor (Redness)

Tumor( Swelling)

Inc bld Flow

Kinin Prostaglandin

Clotting

Dolor( Pain)

2 PROLIFERATIVE PHASE2 PROLIFERATIVE PHASE

-extends from day 3 to about day 21 post injury

Macrophages continue to clear the wound debris Stimulates Fibroblast to synthesize collagen 9 main ingr For tissue scaring)

New capillary networks are formed

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

PHASES OF WOUND HEALINGPHASES OF WOUND HEALING

1 INFLAMMATORY PHASE1 INFLAMMATORY PHASE

-starts immediately after injury and lasts 3-6 days or 4-6 days

2 major processes occur during this phase hellip

HEMOSTATIC AND PHAGOCYTOSISHaemostatic Haemostatic - Tissue and capillaries are destroyed

plasma and blood leaks Area blood vessels constrict platelets aggregates and bleeding stops scabs ( rough protective crust) forms preventing entry of infectious organisms

InflammationCharacterized by edema erythema pain temperature

- increase blood flow to wound resulting localized redness and edema attracts WBC and wound growth factors

WBC arrive-clear debris from wound

injury

Exposure of plasma to injured site Release of Histamine

Activation of Hageman Factor Capillary Permeability

Vasodilation

Edema

Calor( Heat)

Rubor (Redness)

Tumor( Swelling)

Inc bld Flow

Kinin Prostaglandin

Clotting

Dolor( Pain)

2 PROLIFERATIVE PHASE2 PROLIFERATIVE PHASE

-extends from day 3 to about day 21 post injury

Macrophages continue to clear the wound debris Stimulates Fibroblast to synthesize collagen 9 main ingr For tissue scaring)

New capillary networks are formed

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

InflammationCharacterized by edema erythema pain temperature

- increase blood flow to wound resulting localized redness and edema attracts WBC and wound growth factors

WBC arrive-clear debris from wound

injury

Exposure of plasma to injured site Release of Histamine

Activation of Hageman Factor Capillary Permeability

Vasodilation

Edema

Calor( Heat)

Rubor (Redness)

Tumor( Swelling)

Inc bld Flow

Kinin Prostaglandin

Clotting

Dolor( Pain)

2 PROLIFERATIVE PHASE2 PROLIFERATIVE PHASE

-extends from day 3 to about day 21 post injury

Macrophages continue to clear the wound debris Stimulates Fibroblast to synthesize collagen 9 main ingr For tissue scaring)

New capillary networks are formed

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

injury

Exposure of plasma to injured site Release of Histamine

Activation of Hageman Factor Capillary Permeability

Vasodilation

Edema

Calor( Heat)

Rubor (Redness)

Tumor( Swelling)

Inc bld Flow

Kinin Prostaglandin

Clotting

Dolor( Pain)

2 PROLIFERATIVE PHASE2 PROLIFERATIVE PHASE

-extends from day 3 to about day 21 post injury

Macrophages continue to clear the wound debris Stimulates Fibroblast to synthesize collagen 9 main ingr For tissue scaring)

New capillary networks are formed

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

2 PROLIFERATIVE PHASE2 PROLIFERATIVE PHASE

-extends from day 3 to about day 21 post injury

Macrophages continue to clear the wound debris Stimulates Fibroblast to synthesize collagen 9 main ingr For tissue scaring)

New capillary networks are formed

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

3 REMODELLING OR MATURATION PHASE3 REMODELLING OR MATURATION PHASE

-final healing stage may continue for I year or more

Remodeling of scar tissue to provide wound strength

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING FIRST INTENTION HEALING-partial

thickness wounds- a clean incision is made with

primary closure minimal scarring-expected when the edges of clean

surgical incisions are sutured together tissue loss is minimal or absent if the wound is not contaminated with microorganism

-eg-abrasion or skin tear

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

SECOND INTENTION HEALING-granulation

-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count

-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect

-eg-contaminated surgical wound pressure ulcer

Delayed primary healing If there is high infection risk ndash patient is given antibiotics

and closure is delayed for a few days eg bites

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Factors affecting healingImmune statusBlood glucose levels (impaired white cell function)

bull Hydration (slows metabolism)

AgeLifestyle- enhances bld circulationNutrition

bull Blood albumin levels (lsquobuilding blocksrsquo for repair colloid osmotic pressure - oedema)

Oxygen and vascular supplyMedication- Corticosteroids (depress immune function)

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Wound can result fromPlanned events ndash Such as surgery

Accidents ndash such as a fall from a bike

Exposure to environment ndash such as the damage to UV rays in sunlight

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Clinical appearance

Describes the type of material present

In the base of the woundSlough (yellow)Necrotic tissue (black)Infected tissue (green)Granulating tissue (red)Epithelializing (pink)

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Sloughy wound

bull Aim to liquefy slough and aid its removal

bull Dead cells accumulated in exudate

bull Prepare wound bed for granulation

bull Assess wound depth and exudate levels

bull Hydrogels hydrocolloids alginates and hydrofibre dressings

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Necrotic woundbull Aims to debride

and remove eschar

Provide the right

environment for autolysis

bull Assess wound depth and

exudate levelsbull Hydrogels

hydrocolloid

dressings

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Infected woundbull Aims reduce

exudateodour and promotehealingClinical signs of infectionSwab wound ndash systemic antibioticsTreat symptomatically exudate and odour controlChange dressings daily

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Granulating wound

bull Aims support granulation protect new tissue keep moistAssess depth and exudate levelsMoist wound surface ndash non-adherent dressingTreat over-granulationHydrocolloids foams alginates

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Epithelialising woundbull Aims to provide suitable

conditions for re-surfacing films hydrocolloidsDisturb as little as possible

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

COMPLICATIONS OF WOUND HEALING 1 HEMORRRHAGE-risk of hemorrhage is greatest

during the ist 48 hours after surgery

-emergency -N- should apply pressure dressing to the wound and monitor vital signs

2 INFECTION-surgical infection is apparently 2-11

days post operatively

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

N- watched for presence of changed in wound color pain or drainage-culturing of the wound

3 DEHISCENCE WITH POSSIBLE EVISCERATION

-may occur 4-5 days postoperatively

-involves an abdominal wound in which the layers below the skin separates

N- an increase in flow of serosanguinous drainage into the dressing can indicate

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

impending dehiscence- If occurs N should be quickly

supported by sterile dressing soaked in sterile normal saline-position Client in bed with knees benthellipwhy To decrease pull on the incision and Notify physicianhelliphellip

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Infected wound dehiscence

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Wound assessment

WOUND ASSESSMENT

Lab tests

Size depth amp location

Wound bed

bull necrosis

bull granulationSurrounding skin colour moisture

Wound edge

Odour or exudate

Signs of infection

Etiology

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

WOUND MANAGEMENTWOUND MANAGEMENT 1 DRESSINGS - material applied to

wound with or without medication to give protection and assist in healing

-what are the purposesTo protect the wound from

mechanical injurySplint or immobilized the woundAbsorbs dressingPrevent contamination from bloody

discharges

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Promote homeostasis (pressure dressing)

Debride the wound to kill or inhibit microorganism provide a physiologic

environment conducive to healing provide mental and physical

comfort for the patient

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Pressure dressing

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

What are the types of dressingsa DRY TO DRY DRESSINGS-used primarily for wounds closing

by primary intention-offers good protection absorption

amp provide pressure-they adhere to the wound surface

when drainage dries- when remove can cause pain and disruption of granulation tissue

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

b WET TO DRY DRESSINGS-used for untidy or infected wounds

that must be debrided and closed by secondary intention

gthow can it be done-gauze saturated with sterile saline or

antimicrobial solrsquon is packed into the wound the wet dressing are then covered by dry dressings

gtwhen to changed-when it becomes dry

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

c WET TO WET DRESSINGS-used on clean open wounds or on

granulating surfaces-provide a more physiologic

environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort

-surrounding tissues can become ulcerated high risk for infection

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

2 DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface

-what are the purposesa)placed in the wounds only when

abdominal fluid collections are present

b)placed near the incision sitegt wound drainage-drains placed

within the wounds are attached to a portable suction with a collection container

eg hemovac jackson-pratt penrose drain

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

3 BINDERS AND BANDAGES -what are the purposes

Creates pressure over the body parts

Immobilize body partsReduce or prevent edemaSecure a splintsSecure dressing

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Dressing choiceWhat is available

How do we choose

Does the patient have a say

Do we consider cost

Are choices restricted by a protocol

How do we evaluate

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Dressing

∆ To aid debridement∆ To remove excess

exudate∆ To control bleeding∆ To protect a wound∆ To support healing

The ideal dressingbull A dressing that

creates the optimum

environmentbull Wound debridementbull Wound cleansingbull Alternative therapies

A process of cleansing the wound using aseptic solution

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

TYPES OF DRESSINGS Hydrogel Dressings

Hydrogels are indicated for

management of pressure ulcers skin

tears surgical wounds and burns

including radiation therapy burns

Because they contain up to 95

water hydrogels cannot absorb much

exudate and should be reserved for

dry wounds or wounds with minimal

to moderate drainage

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Hydrocolloid Dressings

Because they are occlusive hydrocolloid dressings

do not allow water oxygen or bacteria into the

wound This may help facilitate angiogenesis and

granulation Hydrocolloids also cause the pH of the

wound surface to drop the acidic environment can

inhibit bacteria growth

Like hydrogels hydrocolloids can help a clean wound

to granulate or epithelialize and encourage autolytic

( distruction of cells by own enzymes) debridement in

wounds with necrotic tissue However because of

their occlusive nature hydrocolloids cannot be used if

the wound or surrounding skin is infected

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Alginate Dressings

Previous columns have addressed products that are

appropriate for dry wound beds or wounds with minimal

exudate or drainage-namely hydrogels and

hydrocolloids In contrast alginate dressings absorb

moderate to high amounts of wound drainage

In wounds with moderate to heavy drainage the alginate

forms a gel when it comes in contact with wound fluid

Capable of absorbing up to 20 times its weight in fluid an

alginate can be used in infected and noninfected wounds

Because an alginate is highly absorbent it should not be

used with dry wounds or wounds with minimal drainage

it could dehydrate the wound delaying healing

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Composite dressings

Made of three layers The layers of the composite dressings combine to form an

antimicrobial barrier for moderate to heavy exuding wounds Some composite

dressings also gradually release silver over time to promote healing Our selection

of silver dressings include the popular Acticoat Aquacel and Aquacel AG

Composite dressings have multiple layers and can be used as primary or

secondary dressings They are appropriate for wounds with minimal to heavy

exudate healthy granulation tissue necrotic tissue (slough or moist eschar) or a

mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin

Keep in mind that some insurers will not reimburse a facility or provider if a

composite dressing is used as a secondary dressing with a hydrogel or

impregnated gauze

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Transparent Films

Film dressings are flexible sheets of

transparent polyurethane coated with an

acrylic adhesive They can be used as a

primary or secondary dressing

These dressings are semipermeable vary in

size and thickness and have an adhesive that

holds the dressing on the skin They conform

easily to the patients body but do not hold

well in high-friction areas such as the sacrum

or buttocks

Because films are transparent the wound can

be easily monitored

Because films are semiocclusive and trap

moisture they allow autolytic debridement of

necrotic wounds and create a moist healing

environment for granulating wounds

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

PrinciplesExplain the procedure to the patientHandwashing before and after the procedureClean from least contaminated to the most contaminated areaUse separate cotton for each strokeStart from the center going outward

bull Observe aseptic technique

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

EquipmentSterile glovesPicking forcepDressing forcepBandage scissorAdhesive tapesDry cotton ballsWaste receptacleSterile gauze

Cotton balls with cleanserCotton balls with antisepticNormal Saline Solution (NSS)

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Procedures1 Check physicians order for specific

wound care and medication instructions

Helps to plan for proper type and amount of supplies needed

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

2 Secure equipment and wash hands thoroughlyTo save time and effort Reduces

transmission of pathogen

Procedures

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Procedure

3 Assess the existing dressingIndicates types of dressing or applications

to use

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Procedure4 Explain the procedure to the patient

and instruct client not to touch wound area or sterile suppliesDecreases anxiety and to gain cooperation

Sudden unexpected movement on clients part could result in contamination of wound and supplies

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Procedure5 Loosen and remove the dressing with the use of the

dressing forcep If the dressing adheres to the wound loosen it by moistening with sterile NSSMicroorganism can be transferred by direct contact from

dressing to hands An intact scab is a body defense and can be damage if not handled gently

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Procedure

6 Observe the dressing for the amount type color and odor of the drainage

Provides estimate of drainage amount and assessment of wounds condition

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Procedure

7 Discard the soiled dressing in the waste receptacleReduces the transmission of

microorganism

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Procedure8 Clean the wound aseptically using the

dressing forcep from the center going outward in circular motion with

ABetadine cleanserBDry gauzeCBetadine antiseptic solution(use each gauze for only one stroke)

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

ProcedurePrevents contamination of previously cleanedPrevents introduction of organism into woundReduces excess moisture which could eventually harbor microorganismHelps reduce growth of microorganism

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Procedure9 Apply a new dressing by gently placing

the gauze sponges at the wound center and moving progressively outward to the edges of the wound site

Promotes proper absorption of drainage and protects wound from entrance of microorganism

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Procedure10 Secure the edges of the dressing to

the patientrsquos skin with strips of adhesive tapesEnsures that dressing remains intact and

covers wound

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Procedure

11 Make the patient feel comfortable and tidy the unit

Promotes clients sense of well-being Enhances comfort

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Procedure

12 Do the aftercare of the equipment Soak the dressing forceps in 5 lysol solution for 30 minutes then wash them with soap and water Rinse them then dry Send them to the CSR for sterilization

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Procedure

13 Wash hands

Prevent spread of microorganism

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Procedure

14 Chart site of wound character of wound discharges treatment given if any(eg ointment used) and reaction of patient

For proper documentation and legal purposes

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

ReferenceFundamentals of Nursing fifth edition page 1598-1605 by Potter and PerryhttpimagesgooglecomphimgresimgFundamentals of Nursing seventh edition page636-645 by WolffFundamentals of Nursing by Kozier

Questions

Wound evisceration from stab wound

Wound dehiscence

Wound evisceration from stab wound

Wound dehiscence

Wound dehiscence