Wound Care

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A wound is a break in the skin (the outer layer of skin is called the epidermis). Wounds are usually caused by cuts or scrapes. Different kinds of wounds may be treated differently from one another, depending upon how they happened and how serious they are. Healing is a response to the injury that sets into motion a sequence of events. With the exception of bone, all tissues heal with some scarring. The object of proper care is to minimize the possibility of infection and scarring.

Phases of Wound HealingI. Inflammatory Phase

A) Immediate to 2-5 days 2B) Hemostasis Vasoconstriction Platelet aggregation Thromboplastin forms clot C) Inflammation Vasodilation Phagocytosis

II. Proliferative Phase

A) 2 days to 3 weeks B) Granulation Fibroblasts lay bed of collagen Fills defect and produces new capillaries C) Contraction Wound edges pull together to reduce defect D) Epithelialization Crosses moist surface Cell travel about 3 cm from point of origin in all directions

III. Remodeling Phase

A) 3 weeks to 2 years B) New collagen forms which increases tensile strength to wounds C) Scar tissue is only 80 percent as strong as original tissue

New Trends

Major trend is to use moisture retentive dressing rather than drying the wound. ( this allows the tissue to granulate) Moisture enhances cellular activity in all phases of wound repair, facilitates autolytic wound debridement of necrotic tissues, enables epithelial cells to migrate into the wound bed, insulates and protects nerve endings

Clinical notes

Document how long client has had wound Determine previous treatment if any and treatment results Check for allergies



Pliable disposable measuring device CottonCotton-tip applicator stick Plastic disposable bag Clean gloves Sterile gloves

Wound AssessmentAssessment1.



Assess wound for moisture, debridement, infection and cleanliness Rationale: To assess wound appropiately Make sure drainage from wound site is contained and adjacent skin is protected Rationale: To prevent microorganisms from entering wounds Make sure skin sealant is used appropriately Rationale: To maintain sterility during dressing changes

Wound Assessment4.


Check that dressing is dry on air-exposed airsite Rationale: To prevent bacterial proliferationtion Make sure drainage system is operating Rationale:To Rationale:To maintain drainage if a drainage system is used



Wear sterile gloves Examine wound. Note appearance of wound bed Check for exudate, exudate, drainage, necrotic tissue or sign of infection

3.Assess surrounding area for problems in skin nutrition

Atrophy, loss of hair, thickening of nails Edema of skin or scaly skin Skin hydration Skin integrity or maceration Skin color (red [inflammation], white [arterial insufficiency],black [necrosis], brown[venous insufficiency]) Skin temperature (cool, cold,warm,normal) cold,warm,normal)

4.Assess extent of wound

Measure length and width of wound using disposable measuring device Measure depth of wound by using cotton-tipped cottonapplicator stick Check for tunneling or sinus tract by placing cottoncotton-tipped applicator stick into suspected area advancing until resistance is met

5. Observe color of wound : A. black (necrotic tissue), B. yellow (pus,fibrin,debris), pus,fibrin,debris), C. red (wound ready to heal)

6. Assess for wound

drainage: drainage:A. Type (dry or moist), B. Amount ( minimum, moderate, maximum), C. Color of drainage -clear[serous], clear[serous], -brown, brown-yellow brown[slough], slough], -yellow,yellow-green[pus yellow,yellow-green[pus from strep or staph], staph], blueblue-green [pseudomonas]) pseudomonas])

7. Assess for level of moisture in wound. A moist environment allows wound to heal without forming a scab

8. Assess odor of wound: A. foul (infected[necrotic tissue has an odor even if not infected]) B. sweet (pseudomonas infection)

LABORATORY ASSESSMENTLaboratory values need to be assessed routinely while the wound is healing: 1. Increased WBC count indicates infection 2. Low hemoglobin and hematocrit indicate anemia, which can decrease oxygen transport to the wound 3. Altered serum glucose level


Wound CleaningEquipment1. 2. 3. 4. 5. 6. 7. 8. 9.

Sterile normal saline or any non-cytotoxic wound noncleanser Sterile dressing Tape Sterile round bowl Sterile emesis basin Sterile gloves Absorbent pads Disposable bags Googles

Clinical note

If a wound is clean and has granulation tissue present, cleaning is contraindicated Rationale: Wound healing can be delayed by destroying newly produced tissue. It can also remove exudate that may have bactericidal properties.

WOUND CLEANING PROCEDURE1. Check physician s order for wound cleaning solution. Sterile saline or noncytotoxic solution should be used. Rationale:other products such as hydrogen peroxide should be avoided as they are toxic to cells

2. Pour cleaning solution over gauze pads. Do not use products that shed cotton fibers.(this can lead to foreign body reaction, thus delaying the healing process prolonging the inflammatory phase If antimicrobial solutions are used, be sure to dilute it Warm solution to body temperature( this prevents lowering of wound temperature delaying the healing process)

3. Wear sterile gloves Pick up several gauze pads, pulling edges together to form a ball ( prevents glove from touching the wound) Sterile cleansing solutions can be poured directly over wound before gauze pads are use for cleaning. Place emesis basin on side of patient to catch excess cleansing solution. Clean wound from cleanest to dirtiest Clean from top to bottom using new gauze with each stroke


Wound IrrigationEquipment:1. 2. 3. 4.

Same as in wound cleaning Warm irrigation solution Syringe: 30 to 60 ml syringe Clean and sterile gloves (2 pairs)




Check orders for type and amount of irrigating solution to be used. Don sterile gloves and remove dressing. discard dressing and gloves in disposable bag Open sterile supplies, pour warmed irrigating solution into sterile basin

4. Don sterile gloves. Draw up solution into syringe 5. Instill solution into wound 6. Place sterile emesis basin next to wound to catch irrigation solution as it drains from wound 7. Repeat irrigation process until returns are clear and free from debris

8. Cleanse around wound with moist gauze pads; dry thoroughly with dry gauze pads 9. Remove gloves and place in disposable bag 10. Don sterile gloves and apply dressing 11. Remove gloves and place in disposable bag


A. Wet to Damp DressingEquipment1. 2. 3. 4. 5. 6. 7.

4x4 gauze ABD pads Sterile solutions Sterile gloves Clean gloves Tape Disposable bag

Wet to Damp Dressing Procedure:1. Identify type and number of dressings and type of solution needed.

2.Clean over-bed table; overopen sterile packages and place on overoverbed table. Arrange packages making sure you do not cross sterile field. Cut tape strips and place on over-bed overtable.

3.Ensure that two packages of 4 x 4 gauze pads are open for use in outer dressing. Fanfold top linen to foot of bed. Provide patient s privacy Place bag for soiled dressing near the table

4. Pour sterile solution into 4 x 4 gauze dressing container

5. Wear clean gloves and remove dressing. Place in disposable bag

6.Obtain wound specimen for culture if ordered. Remove clean gloves and dispose in appropriate container

Collecting Wound Specimen

Rinse wound with sterile NSS Use non-cotton tipped swab nonRotate swab while obtaining specimen Swab wound edges starting from top; crisscross wound to bottom Do not take specimen from exudate Remove gloves and place in disposable bag Wash your hands

7. Don sterile gloves and have materials needed for dressing change available

8. Wring out several gauze pads until slightly moist.( if dressing is too moist risk of infection and maceration of surrounding skin is increased. Fluff moistened dressing and lightly packed them in all crevices and depressions in wound.Necrotic tissues are usually in deep crevices(tightly packed wound dressing inhibit wound edges from contracting and may compress capillaries) Irrigate wound if grossly contaminated.

9.Apply dry sterile gauze over moist dressing Rationale: This will absorb excess exudates

10.Place sterile ABD pads over wound site. Rationale: Pads protects wound from trauma and external contamination

11.Tape wound securely. Tape wound dressing lengthwise , top and bottom of dressing

B. Dry Dressing for Open Wound DrainageEquipments:1. 2. 3. 4. 5. 6. 7. 8. 9.

Dressings (4 x 4 gauze, ABD pads) Precut sterile 4 x 4 gauze pads (2) Forceps and cotton balls Sterile cleansing solution and sterile container Sterile safety pin Sterile scissors Sterile gloves Clean gloves Disposable bag

Dry Dressing Procedure:1. Wear clean gloves 2. Remove soiled dressing and place in disposable bag Remove clean gloves Open sterile packages;place on overoverbed table Pour sterile cleansing solution into container Observe wound closely for sign of infection or healing.

3.Don sterile gloves and closely observe pin in Penrose drain. If pin is crusted replace with new sterile pin. Be careful not to dislodge pin

Penrose Cleaning 1.



To advance Penrose drain, complete the following steps: Using s