Wound Healing, Wound Types, Wound Dressings, & Drainage Devices

1. Wound Healing, Wound Types, Wound Dressings, & Drainage Devices ST230 Concorde Career College

2. Wound Types & Wound Healing Objectives: • List and define the four types of wound classifications and provide examples of wound types for each category. • List and describe the types of wounds and provide examples of each. • List and describe the types of wound healing and explain the mechanism for each type.

3. Wound Types & Wound Healing Objectives: • Identify the factors that influence wound healing and understand how to implement techniques that promote optimal wound healing. • Describe Halsted’s principles of tissue handling and explain the relationship of those principles to today’s methods of suturing. • List and describe the techniques used for suturing and provide examples of when each may be utilized.

4. Wound Types & Wound Healing Objectives: • Outline the dressing application process and identify the optimal time for dressing placement. • Identify basic abdominal incisions and identify the tissue layers of the abdominal wall.

5. Wound Types & Wound Healing

6. Wound Types & Wound Healing Wound Classifications

7. Wound Types & Wound Healing Surgical Wound Classifications Type I Clean Wound Type II Clean-contaminated Wound Type III Contaminated Type IV Dirty/Infected

8. Wound Types & Wound Healing Type I - Clean Wound (Potential infection rate 1%-5%) • No inflammation • No break in sterile technique • Wound primarily closed/Not drained • Aerodigestive and genitourinary tract not entered

9. Wound Types & Wound Healing Type II - Clean-contaminated Wound (Potential infection rate 8% - 11%) • No inflammation/Infection present • Minor break in technique • Wound primarily closed/Not drained • Aerodigestive or genitourinary tract entered under controlled circumstances

10. Wound Types & Wound Healing Type III - Contaminated Wound (Potential infection rate 15% - 20%) • Traumatic wound (less than 4 hours old) • Acute inflammation present • Major break in technique • Gross spillage/contamination from respiratory, gastrointestinal, biliary, or genitourinary tracts

11. Wound Types & Wound Healing Type IV - Dirty/Infected Wound (Potential infection rate 27% - 40%) • Traumatic wound (more than 4 hours old) • Organisms present at surgical site prior to procedure/Existing infection • Perforation (Gastrointestinal, biliary, respiratory, genitourinary tract)

12. Wound Types & Wound Healing Types of Wounds

13. Wound Types & Wound Healing Types of Wounds • Intentional (Surgical) • Accidental (Traumatic) • Chronic

14. Wound Types & Wound Healing Intentional (Surgical) • Incision • Purposeful cut through intact tissue for the purpose of exposure or excision Wounds • Excisional • Removal of tissue

15. Wound Types & Wound Healing Six Types of Accidental • Closed • Simple • Clean (Traumatic) Wounds • Open • Complicated • Contaminated

16. Wound Types & Wound Healing Closed Traumatic Wound Skin Intact / Underlying tissue damaged Examples: • Blister • Simple Fracture

17. Wound Types & Wound Healing Open Traumatic Wound Skin Disrupted Examples: • Laceration • Compound Fracture

18. Wound Types & Wound Healing Simple Traumatic Wound Skin Disrupted/No loss or destruction of tissue/No foreign body implanted Examples: • Minor penetration • Cut with sharp object

19. Wound Types & Wound Healing Complicated Traumatic Wound Skin disrupted/Underlying tissue lost or destroyed/Foreign body implanted Examples: • Severe burn • Stab or bullet wound

20. Wound Types & Wound Healing Clean Traumatic Wound Simple wound caused by a sharp edged object Expected to be sutured and heal by first intention without infection Example: • Laceration

21. Wound Types & Wound Healing Contaminated Traumatic Wound Complicated wound caused by a dirty object May need debridement and has a high potential for becoming infected Examples: • Crush Type Injury • Foreign Body Implantation

22. Wound Types & Wound Healing A SINGLE WOUND MAY BE CLASSIFIED IN MORE THAN ONE CATEGORY

23. Wound Types & Wound Healing Chronic Wound - Wound that fails to heal over an extended period of time Examples: • Decubitus ulcer (Pressure sore) • Wound caused by inadequate circulation or in which healing is delayed as a result of vascular compromise • Infected wounds

24. Wound Types & Wound Healing Wound Healing

25. Wound Types & Wound Healing Types of Wound Healing • First Intention (Primary Union) • Second Intention (Granulation) • Third Intention (Delayed Primary Closure)

26. Wound Types & Wound Healing First Intention (Primary Closure) • Wound is sutured closed • Healing occurs from side-to-side • Healing occurs rapidly with little inflammation and minimal scarring • Wound heals in three phases

27. Wound Types & Wound Healing Phases of Wound Healing by First Intention • Phase I - Lag Phase or Inflammatory Response Phase • Phase II - Proliferation Phase • Phase III - Maturation or Differentiation Phase

28. Wound Types & Wound Healing Phase I - Lag Phase or Inflammatory Response Phase • Begins within minutes of the injury and lasts 3-5 days • Inflammation is present (manifested by heat, redness, swelling, pain, loss of function) • Inflammation is a result of increased blood flow to the area caused by arterial dilation

29. Wound Types & Wound Healing Phase I (continued) • Bleeding controlled by platelet aggregation • Oxygenated blood delivered to the site • Epithelial cells for repair formed • Scab formed • Phagocytosis occurs

30. Wound Types & Wound Healing Phase I (continued) • Basal cells seal wound surface • Fibroblasts begin reconstruction of nonepithelial tissue

31. Wound Types & Wound Healing Phase II - Proliferation Phase • Begins about the 3rd postoperative day and continues up to 20 days • Fibroblasts multiply (proliferate) and bridge wound edges • Collagen secreted from fibroblasts

32. Wound Types & Wound Healing Phase II (continued) • Collagen fibers begin to restore tensile strength of tissue • Capillary networks established and lymphatic networks reformed

33. Wound Types & Wound Healing Phase II (continued) Definition: Tensile Strength: Ability to resist rupture • During the proliferation phase (phase II) of wound healing by first intention the wound regains 25%-30% of its original tensile strength

34. Wound Types & Wound Healing Phase III - Maturation or Differentiation Phase • Begins on the 14th postoperative day and lasts until the wound is completely healed, (may take up to 12 months) • Tensile strength increased by interweaving of collagen fibers

35. Wound Types & Wound Healing Phase III (continued) • Collagen density increases and formation of new blood vessels decreases • Cicatrix is formed

36. Wound Types & Wound Healing Second Intention (Granulation) • Wound is intentionally left open • Healing occurs from the bottom - up • High risk of infection (if not already present) • Union is weak and scar formation extensive

37. Wound Types & Wound Healing Second Intention (Granulation) (continued) • Granulation tissue containing myofibroblasts forms in the wound • Gaps in tissue fill from bottom upward closing the wound by contraction • Epithelial growth is secondary

38. Wound Types & Wound Healing Third Intention (Delayed Primary Closure) Two granulated surfaces are approximated • Wound is left open to heal by second intention for 4-6 days • Then, wound is closed Equation 2+1=3 (Second Intention plus First Intention equals Third Intention)

39. Wound Types & Wound Healing Factors Affecting Wound Healing Three main factors influence wound healing: • Physical condition of the patient • Intraoperative tissue handling • Application of the principles of asepsis

40. Wound Types & Wound Healing Physical Condition • Age • Nutritional Status • Disease (Chronic or Acute) of the Patient • Smoking • Radiation Exposure • Immunocompromised or Immunosuppressed Patients

41. Wound Types & Wound Healing Intraoperative • Length and direction of the incision • Dissection technique (sharp or blunt) • Length of surgery • Hemostasis Tissue Handling • Minimal and gentle tissue handling • Precise tissue approximation • Elimination of dead space • Secure wound closure

42. Wound Types & Wound Healing Halsted's Methods of Tissue Handling • Strict aseptic technique • Gentle handling of tissue • Use of the finest suture material • Small stitches and low tension on the tissue • Complete closure of wounds whenever possible

43. Wound Types & Wound Healing These basic procedures had a far-reaching effect on the practice of surgery, making it safer and more effective than it had been previously. William S. Halsted

44. Wound Types & Wound Healing Dead Space • Dead space is a separation of wound edges, which have not been closely approximated or air that has become trapped between tissue layers. This space may allow for serum or blood to collect and provide a medium for microbial growth that may result in infection.

45. Wound Types & Wound Healing Dead Space Reduce or eliminate dead space with the use of: • Proper suturing techniques • Wound drains • Pressure dressings

46. Wound Types & Wound Healing Application of the Principles of Asepsis Through the Use of Sterile Technique • A sterile field is created for each surgical procedure • Sterile team members must be appropriately attired prior to entering the sterile field • Movement in and around the sterile field must not compromise the sterile field

47. Wound Types & Wound Healing Complications of • Dehiscence • Evisceration • Hemorrhage • Infection • Adhesions Wound Healing • Herniation • Fistula • Sinus tract • Suture complications • Keloid scar formation

48. Wound Types & Wound Healing

49. Wound Types & Wound Healing Knot Tying Basics • Knot Security • Knot Tying Principles • Square Knot (Two Hand Technique) • Surgeon’s Knot

50. Wound Types & Wound Healing Knot Security Knot security is of utmost importance in preventing wound complications • Use the most simple; secure knot possible