Types of wound according to contamination
1. Clean Wound
-Uninfected wound
-Minimal inflammation
-The respiratory,alimentary, genital,
urinary tractsare not entered
Clean wounds primarily closed wounds
2. clean-Contaminated Wound
-Surgical woundsinwhich respiratory,
alimentary, genital or urinary tractshasbeen entered.
-No evidence of
3. Contaminated Wound
-Open, fresh, accidental wounds and surgical wounds.
-Major break in sterile technique or large amount of spillages from
gastrointestinal tract.
-Evidence of inflammationinfection
4. Dirty or Infected
-Wounds containing dead tissue
-Wound withevidence of clinical
infection
-Purulent discharge•
Types of wound according to tissue
layer involved
1. Incision
-Caused by sharpinstrument
-Open wound
-Deep or shallow
2. Contusion
-Blow from blunt instrument
-Closed wound skin appearsechymotic
(bruised)
-Because of damagedblood vessles
3. Abrasion
-Surface scrape,unintentionally or intentionally
-Open wound
4. Puncture
-Penetrating of the skin and underlyingt issues
-Sharp instrument
-unintentionally or intentionally
5. Laceration
-Tissue torn
-From accident
-Open wound
-Edgesare uneven
6. Penetrating Wound
-Penetration of skin and underlying tissue
-Unintentionally
-Open wound
Wound Healing
1-Primary intention
-Skin edgesapproximate
-Risk of infection islow
-No tissue loss
-Minimal granulation tissue and scarring
-Ex. Closed surgical incision healing
2-Secondary intention
-Lossof tissue
-open wound
-filled with scar tissue
-Longer healing
-Granulation tissue
-wound contraction occur
-Ex. Pressure ulcer wound healing
Phases of wound healing
1-Inflammatory phase
-Immediately after wound -3-6 days
-Hemostasis
-Vascular and cellular response
-Increase blood supply
-WBCmove to site
-Macrophage
-Microcirculatory network
2-Proliferative phase
-3-4 to 21 days after injury
-Fibroblast
-Collagen provide strength to the wound
-Capillariesgrow
-Fibrin
-Granulation tis
3-Maturation phase
- 21 days post injury -1-2 years
-Begin when scar isformed
- Collagen replaced with new tissue
-Wound remodeled and contracted
-Strong scar
Wound drainage
Exudates
Material such as fluid and cellsescaped fromblood vessels during inflammatory process and depositsin tissue
Types of exudate
-Serous(clear, watery exudates)
-Purulent (green,brown, dark yellow,
pus foul smelling)
-Sanguineous(bloody)
Complicationsof Wound Healing
-Hemorrhage–internal or external
-Infection
-Dehiscence–separation of healingwound
-Evisceration –organsprotrude through wound
-Fistula–unnatural opening between organs
-Delayed Wound Closure
Dressing wounds
Purposes
-Protect woundsfrom
-Mechanical injury
-Microbial contamination
-Maintain humidity
-Absorb drainage
-Prevent hemorrhage
-Splint and immobilize site
Typesof dressing
-Transparent
-Hydrocolloid dressing
-Securingdressing
-Hydrogel
-Foam
-Exudate absorber
Typesof Bandages
-Gauze
Retain dressingson wounds-
Bandage handsand feet
-Elasticized Provide pressure to an area
-Improve venouscirculation in legs
-Binders
Support large areasof body Triangular arm sling; straight abdominal binder
Pressure ulcer
(Docubitus Ulcer, Bed Ulcer, Bed Sore, Pressure Sores)
Definition
-Any lesion caused by unrelieved pressure that resultsin damage to underlyingtissue
-Tissue become compressed between bony prominence and bed, that lead to ischemia
Etiology
-Pressure
-Shearing force
-Friction
Risk factors
-Immobility
-Inadequate nutrition
-Fecal and urinary incontinent
-Decrease mental status
-Diminished sensation
-Excessive body heat
-Advanced age
-Chronichealth problems
-Poor lifting technique
-Hard support surfaces
Stages of pressure ulcer
1. Non-blanched Erythema
-Signaling Potential ulceration
-persistent rednessof skin
2. Partial Thickness
-Abrasion
-Blister involving epidermis or dermis
3. Partial ThicknessII
-Necrosisof subcutaneous
4. Full Thickness
-Tissue necrosis
-Lossof skin
-Damage to muscle, bone, tendon, joint capsule ulceration
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