surgical wound care
TRANSCRIPT
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Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 1
CHAPTER 13
Surgical Wound Care
CHAPTER 13
Surgical Wound Care
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 2
Phases of Wound HealingPhases of Wound Healing
1. Hemostasis
Termination of bleeding
Begins as soon as the injury occurs
2. Inflammatory Phase
An initial increase in blood elements and water flow outof the blood vessel into the vascular space
Causes cardinal signs and symptoms of inflammation:erythema, heat, edema, pain, and tissue dysfunction
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Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 4
Wound HealingWound Healing
3. Reconstruction Phase
Collagen formation occursa glue-like proteinsubstance that adds tensile strength to the wound andtissue.
Appearance changes to an irregular, raised, purplish,immature scar.
Wound dehiscence most frequently occurs during thisphase.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 5
Wound HealingWound Healing
4. Maturation Phase
Fibroblasts begin to exit the wound.
The wound continues to gain strength, al though healedwounds rarely return to the strength the tissue hadbefore surgery.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 6
Reviewing the Phases of HealingReviewing the Phases of Healing
1. Hemostasis
2. Inflammatory Phase
3. Reconstruction Phase
4. Maturation Phase 5. Primary Intention
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Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 7
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 8
Process of wound healingProcess of wound healing
Primary Intention Wound is made surgically with little tissue loss.
Skin edges are close together.
Minimal scarring results.
It begins during the inflammatory phase of healing.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 9
Figure 13-1Figure 13-1
Types of wound healing. A, Primary intention.B, Secondary intention. C, Tertiary intention.
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment andmanagement of clinical problems. [6th ed.]. St. Louis: Mosby.)
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Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 10
Process of Wound HealingProcess of Wound Healing
Secondary Intention Healing occurs when skin edges are not close together
If wound has purulent exudates, the surgeon provides ameans for its release via drainage system or by packingthe wound.
The necrotized tissue decomposes and escapes.
The cavity begins to fill with granulation tissue.
The amount of granulation tissue required depends onthe size of the wound.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 11
Tertiary Intention
Occurs when a contaminated wound isleft open and sutured closed after theinfection is controlled
or a primary wound becomes infected,is opened, allowed to granulate, andthen sutured.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 12
Factors that Effect HealingFactors that Effect Healing
Nutritional Needs If the patient cannot tolerate food or fluids, total
parenteral nutrition or nasogastric feedings can be
provided.
Fluids Offer hourly; encourage 2000 to 2400 ml in 24 hours.
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Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 13
Factors that Affect Wound HealingFactors that Affect Wound Healing
Rest and Activity
Rest is vital to facilitate healing
Activity is also encouraged to decreasevenous stasis.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 14
Surgical WoundSurgical Wound
The surgeons goal is to enter the cavity involved,repair the injured or diseased area, and minimizetrauma as quickly as possible.
Many options are available to the surgeon for closingthe surgical incision.
Sutures, staples, Steri-Strips, butterfly strips, andtransparent sprays and films
Binder or bandage used to support the incision ofsecure dressings without the use of adhesivematerials
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 15
Figure 13-4Figure 13-4
Sutures. A, Interrupted, or separate. B, Continuous. C, Blanket. D,Retention.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.Louis: Mosby.)
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Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 16
Figure 13-5Figure 13-5
Wound closure with staples.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.Louis: Mosby.)
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 17
Figure 13-6Figure 13-6
Steri-Strips placed over incision for closure.
(From Potter, P.A., Perry, A.G. [2003].Basic nursing: Essentials for practice. [5th ed.]. St. Louis:Mosby.)
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 18
Surgical WoundSurgical Wound
The PT should inspect dressings every 2 to 4 hoursfor the first 24 hours, PRN, or as ordered.
On the day of surgery, most wounds will have
sanguineous or serosanguineous exudates.
As the exudate subsides, it becomes serous.
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Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 19
Figure 13-2Figure 13-2
Types of dressings.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.Louis: Mosby.)
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 20
Surgical WoundSurgical Wound
The inflammatory response depends on the level ofinjury inflicted, size of the area involved, andphysical condition of the patient.
Phagocytosis occurs when exudate from the injuredcell is surrounded, engulfed, and digested byleukocytes.
An infectious process would be evidenced by anelevated _ _ _ count.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 21
Care of the IncisionCare of the Incision
Surgical wounds, because they are asepticallycreated, generally heal well and quickly.
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Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 22
Care of the IncisionCare of the Incision
Removing Dressings An analgesic may need to be given at least 30
minutes before exposing a wound.
Sterile technique is followed whenever the wound ordressing is handled.
A gown, mask, and protective goggles are worn ifsoiling or splashing of wound exudate is expected.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 23
Skill 13-1: Steps 9 & 11Skill 13-1: Steps 9 & 11
Changing a sterile dry dressing.
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 24
Care of the IncisionCare of the Incision
Dry Dressings May be chosen for management of a wound with little
exudate/drainage
Protects the wound from injury, prevents introductionof bacteria, reduces discomfort, and speeds healing
Most commonly used for abrasions and nondrainingpostoperative incisions
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Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 25
Care of the IncisionCare of the Incision
Wet-to-Dry Dressing
Primary purpose is to debride awound.
The moistened contact layer of the dressingincreases the absorptive ability of the dressing tocollect exudate and wound debris.
As the dressing dries, it adheres to the wound anddebrides it when the dressing is removed.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 26
Care of the IncisionCare of the Incision
Transparent Dressings Advantages
Adheres to undamaged skin to contain exudates andminimize wound contamination
Serves as a barrier to external fluids and bacteria yetstill allows the wound to breathe
Promotes a moist environment that speeds epithelialcell growth
Permits visualization of the wound
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 27
Skill 13-3: Steps 11a & 11bSkill 13-3: Steps 11a & 11b
Applying a transparent dressing.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.Louis: Mosby.)
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Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 28
Care of the IncisionCare of the Incision
Irrigations
A cleansing solution is introduced directly into thewound with a syringe, syringe and catheter, shower,or whirlpool.
Promote wound healing through removing debris froma wound surface, decreasing bacterial counts
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 29
Care of the IncisionCare of the Incision
Irrigations
Principles of Basic Wound Irrigation
Cleanse in a direction from the leastcontaminated area to the mostcontaminated area.
When irrigating, all of the solution flowsfrom the least contaminated area to themost contaminated area.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 30
Skill 13-4: Steps 10 & 13Skill 13-4: Steps 10 & 13
Performing sterile irrigation.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.Louis: Mosby.)
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Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 31
Complications of Wound HealingComplications of Wound Healing
De-his-cence Wound layers separate.
It may result after periods of sneezing, coughing, orvomiting.
It may be preceded by serosanguineous drainage.
Patient should remain in bed and given reassurance .
Place a warm, moist sterile dressing over the areauntil the physician evaluates the site.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 32
Complications of Wound HealingComplications of Wound Healing
Evisceration Abdominal organs protrude through an opened
incision.
The wound and contents should be covered withwarm, sterile saline dressings.
The surgeon is notified immediately.
This is a medial emergency, and the wound requiressurgical repair.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 33
Complications of Wound HealingComplications of Wound Healing
Wound Infection CDC labels a wound infected when it contains
purulent (pus) drainage.
A patient with an infected wound displays a fever,tenderness, and pain at the wound; edema; and anelevated _ _ _ count.
Purulent drainage has an odor and is brown, yellow,or green, depending on the pathogen.
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Staple and Suture RemovalStaple and Suture Removal
Sutures and staples are generally removed within 7to 10 days after surgery, or sooner if healing is
adequate.
The physician determines and orders removal ofsutures or staples
Replaced with a Steri-Strip as the first phase, withthe remainder removed in the second phase.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 35
Staple and Suture RemovalStaple and Suture Removal
Sutures Sutures are threads of wire or other materials used to
sew together body tissues.
Sutures are placed within tissue layers in deepwounds and superficially as the final means of woundclosure.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 36
Skill 13-5: Step 17Skill 13-5: Step 17
Removing sutures.
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
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Staple and Suture RemovalStaple and Suture Removal
Staples Staples are made of stainless steel wire are quick to
use, and provide ample strength. They are popular for skin closure of abdominal
incisions and orthopedic surgery when theappearance of the incision is not critical.
Removal of staples requires a sterile staple extractorand maintenance of aseptic technique.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 38
Skill 13-5: Step 9Skill 13-5: Step 9
Removing staples.
(From Perry, A.G., Potter, P.A. (1998). Clinical nursing skills and interventions.(4th ed.). St. Louis:Mosby.)
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 39
Exudate/DrainageExudate/Drainage
Serous Clear, watery fluid that has been separated from its
solid elements
Sanguineous Fluid that contains blood
Serosanguineous Thin and red; composed both of serum and blood
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Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 40
Figure 13-7Figure 13-7
Jackson-Pratt drains have a wide, flat area brought through the stabwound with great force.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.Louis: Mosby.)
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 41
Exudate/DrainageExudate/Drainage
Drainage Systems Closed Drainage
System of tubing and other apparatus attached to thebody to remove fluid in airtight circuit that preventsenvironmental contaminants from entering the wound orcavity
Open Drainage
Drainage that passes through an open-ended tube intoa receptacle or out onto the dressing
Suction Drainage
Use of a pump or other mechanical device to helpextract a fluid
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 42
Figure 13-8Figure 13-8
Jackson-Pratt drainage device. A, Drainage tubes and reservoir. B,
Emptying drainage reservoir.
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
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Exudate/DrainageExudate/Drainage
Drainage Systems
Requires close monitoring
Note the color, consistency, andamount of drainage.
Note patency of tube; it should not bekinked or occluded.
If blood clots or exudate have sloweddrainage, record and report.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 44
Skill 13-6: Step 6Skill 13-6: Step 6
Maintaining Hemovac/Davol suction and T-tube drainage.
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 45
Figure 13-10Figure 13-10
Wound VAC system using negative pressure to remove fluid fromarea surrounding the wound.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
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Skill 13-7: Step 2Skill 13-7: Step 2
Wound Vacuum-Assisted Closure.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 47
Skill 13-7: Step 12Skill 13-7: Step 12
Wound Vacuum-Assisted Closure.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
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Skill 13-7: Step 14Skill 13-7: Step 14
Wound Vacuum-Assisted Closure.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
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Skill 13-7: Step 15Skill 13-7: Step 15
Wound Vacuum-Assisted Closure.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 50
Skill 13-7: Step 16Skill 13-7: Step 16
Wound Vacuum-Assisted Closure.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 51
Bandages and BindersBandages and Binders
Bandage A strip or roll of cloth or other material that may be
wrapped around a part of the body in a variety of waysfor multiple purposes.
Bandages are available in rolls of various widths andmaterials, including gauze, elasticized knit, elastic
webbing, flannel, and muslin.
Binders A binder is a bandage that is made of large pieces of
material to fit a specific body part, such as anabdominal binder or a breast binder.
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Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 52
Skill 13-9: Step 5cSkill 13-9: Step 5c
Applying a binder, arm sling, and T-binder.
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
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Bandages and BindersBandages and Binders
After a bandage is applied, the PT should Assess, document, and immediately report changes in
circulation, skin integrity, comfort level.
Assess to be sure it is properly applied and isproviding therapeutic benefit; soiled bandages shouldbe replaced.
Mosbyitemsand derived items 2006,2003, 1999,1995,1991 by Mosby,Inc.Slide 54
The EndThe End
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