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 ASEPSIS AND INFECTION CONTROL 2

WOUND DRESSING

Wound, any break in the external or internal

surfaces of the body involving a separation

of tissue, and caused by external injury or

force. Wounds are classied as incised, orcut, if they are produced by a sharp

instrument or object; puncture, if the

instrument is pointed and narrow; lacerated,

if accompanied by a tearing of the tissue;

contused, if a substantial amount of tissue is

bruised; penetrating, if the wound passes

completely through a part of the body; and

subcutaneous, if it involves deep destruction

of tissue with a relatively small opening, or

none at all, in the surface. Septic, or

infected, wounds are those in which the area

is contaminated by bacteria, which can

cause suppuration or shedding of tissue.

W!"#

CLASSIFICATION OF WOUNDS

1.Mechanism o in!u"#

a$ Incision% open wound;

painful;deep;shallow

b$ Contusion%closed wound, skin appears

ecchymotic &bruised$.c$  Abrasion%open wound involving the

skin; painful

d$ Puncture%open wound which

penetrates the skin and underlying

tissues.

e$ laceration%made by object that tears

tissues

f$ 'enetrating wounds%open wound that

penetrates the skin and the underlying

tissues.$. Acco"din% &o de'&h

a$ 'artial thickness% conned to the skin

b$ (ull%thickness% involving the dermis,

epidermis, subcutaneous tissues and

possibly muscle and bone.

#ecubitus ulcer

)unshot wound

Stab wound

*acerating wound

(. De%"ee o con&amina&ion

a$ +lean%an aseptically made wound, that

does

not enter the alimentary, respiratory or

genito%urinary tracts.

b$ +lean contaminated%are surgical wounds

in which the alimentary, respiratory and

genitals or urinary tract has been entered.

c$ +ontaminated% wounds exposed to

excessive amounts of bacteria

d$ #irty or infected%wounds containing

dead tissues and with evidence of clinical

infection &purulent discharged$.

T)*ES OF WOUND DRAINAGE

-. Serous%clean, watery

. 'urulent% thick, yellow, green, tan or

brown.

/. Serosanguineous%pale, red, waterymixture of serous and sanguineous.

0. Sanguineous% bright red, indicative of

active bleeding.

*+ASES OF WOUND +EALING

1. INFLAMMATOR) *+ASEstarts

immediately after injury and lasts /%1 days or

0%1 days.

major processes occur during this phase 2

HEMOSTATIS  AND PHAGOCYTOSIS3emostatis% blood vessels constrict, platelets

aggregates and bleeding stops, scabs forms,

preventing entry of infectious organisms.

4n5ammation%increase blood 5ow, to wound

resulting locali6ed redness and edema,

attracts W7+ and wound growth factors.

W7+ arrive%clear debris from wound.

$. *ROLIFERATI-E *+ASEextends from

day / to about day - post injury.

collagen synthesis establishment of new

capillaries creation of granulation tissue 

wound contraction epithelia6ation.

(. REMODELLING OR MATURATION

*+ASE

%nal healing stage may continue for 4 year

or more.

8emodeling of scar tissue to provide wound

strength.

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%used primarily for wounds closing by

primary intention.

Eadv%oFers good protection, absorption G

provide pressure

Edadv%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.

Ehow can it be doneB

%gau6e saturated with sterile saline or

antimicrobial soln. is packed into the wound,

the wet dressing are then covered by dry

dressings

Ewhen to changedB

%when it becomes dry0. WET TO WET DRESSINGS

%used on clean open wounds or on

granulating surfaces.

Eadv%provide a more physiologic

environment &warmth moisture$ which can

enhance the local healing processes and

assure greater patient comfort.

Edadv%surrounding tissues can become

ulcerated. high risk for infection.

. DRAINS device or a tube used todraw 5uids from an internal body

cavity to the surface.

%what are the purposesB

a$ placed in the wounds only when

abdominal 5uid collections are

present.

b$ placed near the incision site

E ound d"aina%edrains placed within the

wounds are attached to a portable suction

with a collection container.

e.g. hemovac, jackson%pratt, penrose drain.

 

(. INDERS AND ANDAGES

  %what are the purposesB

a$ +reates pressure over the body parts

b$ 4mmobili6e body parts

c$ 8educe or prevent edema

d$ Secure a splints

e$ Secure dressing

UNE2*ECTED OUTCOMES 3 RELATED

INTER-ENTIONS

1. Infamed and tender ounds !ic!

e"idence o# draina$e and #ou% odor.

"? a. =onitor clients for signs of infection

&fever, increase in W7+ count$.

b. notify physician

  c. obtain wound culture as ordered.

&. Increase ound draina$e

"? a. changed dressing freAuently

b. notify physician

/. Wound bleeds during dressing change

*A*ER AND *ENCIL TEST

*ART 1

-. 7ased on your readings, dressings

may be used for what 1 reasonsB

. #uring dressings changes, woundsand surrounding tissues must be

inspected forB

/. What will be the assessment data you

must collect prior to any dressingB

0. #escribe on how to set%up, prepare

materials needed for dressing thus,

maintaining sterility. #raw a picture to

help explain your answer.

*ART $xplain what should be done in each of the

following situations to avoid contamination

during wound dressing.

-. :ou are in the middle of a sterile

dressing change with the wound

exposed and reali6e that you need

more dressings from the +S8.

. :ou begin to snee6e prior to beginning

a sterile procedure.

/. < patient with abdominal wound is

walking in the hall when his dressing

falls onto the 5oor.

0. When removing the cap from any

sterile solution bottle, be sure the cap

is placed with the inner side up. Why

is this critically importantB

T+AN4 )OU5