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TYPES OF WOUNDS
Incision = sharp instrument (knife) Contusion = blow from blunt instrument Abrasion = surface scrape Laceration = tissues torn apart Penetrating = deeper penetration: from bullet Puncture = shallow penetration
WOUND CARE
DEGREE OF WOUND CONTAMINATION a. Clean wounds
Uninfected, no inflammation; respiratory, genital and urinary tracts are not entered Surgical wounds and respiratory, genital and urinary tracts has been entered Open, fresh, major break in sterile technique, signs of inflammation old, accidental wounds with dead tissue, with infection, purulent drainage
c. Contaminated wounds
d. Dirty or infected
WOUND CARE
CLASSIFICATION OF WOUND BY DEPTH: a. Partial thickness
b. Full thickness
WOUND CARE
1.
2.
3.
WOUND HEALING quality of living tissue; regeneration THREE PHASES: (IPM) Inflammatory phase - initiated immediately and lasts 3-4 days - marked with HEMOSTASIS and PHAGOCYTOSIS Proliferative phase - until day 21 post injury - Collagen formation whitish protein substance that adds to tensile strength of wound; eschar formation Maturation phase - begins at day 21 until 1 - 2 years; scar formation
WOUND CARE
1.
TYPES OF HEALING Primary Intention; FIRST INTENTION - tissue surfaces have been closed and minimal tissue loss; - SURGICAL INCISION
2.
Secondary Intention - extensive and with tissue loss, edges cannot be approximated; - PRESSURE ULCER Note: repair time is longer scarring is greater susceptibility to infection is greater
WOUND CARE
TYPES OF HEALING:
3. Tertiary intention healing;
- DELAYED or secondary closure - indicated when there is reason to delay a suturing wound - ABDOMINAL WOUND THAT IS LEFT OPEN FOR DRAINAGE AND IS LATER CLOSED
WOUND CARE
KINDS OF WOUND DRAINAGE 1. Serous: = serum; from clear portion of the blood, clear to brownish 2. Sanguineous: = bloody, BRIGHT red 3. Serosanguineous = combination of blood and serum, pinkish 4. Purulent: = pus, YELLOW OR yellow-green
WOUND CARE
COMPLICATIONS OF WOUND HEALING
H I D E
= HEMORRHAGE = INFECTION = DEHISCENCE = opening = EVISCERATION = coming out C = CALL for help and assistance C = COVER wound with saline soaked sterile OS K = KEEP MOIST D = DONT REINSERT protruding organs D = DORSAL RECUMBENT position D = DO VSQ5M and prepare for surgery
WOUND CARE
-
RYB COLOR CODE OF WOUNDS Based on the color of an open wound rather than depth and size of wound Can be applied to wound allowed to heal by SECONDARY INTENTION
WOUND CARE
RYB COLOR CODE OF WOUNDS a.
-
RED
-
PROTECT
Gentle cleansing Avoiding use of dry-gauze or wet to dry saline dressings Application of topical antimicrobial agent Transparent film or hydrocolloid dressing Change dressing infrequently
WOUND CARE
RYB COLOR CODE OF WOUNDS b. YELLOW :
CLEANSE
To absorb drainage and remove nonviable tissue Apply wet-wet dressing Irrigating the wound Use of absorbent dressing material Consult MD as to use of antimicrobial agent
WOUND CARE
RYB COLOR CODE OF WOUNDS c. BLACK
DEBRIDEMENT
full thickness or third degree burns, gangrene Covered with occlusive dressing to provide moist environment Eschar removal
WOUND CARE
a. b. c. d.
e.
f. g. h.
NURSING INTERVENTIONS Wound dressing RYB color code Surgical dressing Wound drains Wound irrigation Sutures Heat and cold application Supporting and immobilizing wounds a. bandages and binders