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WOUND CARE. Wound Healing 1. inflammatory phase 2. proliferative or granulation phase 3. maturation, or wound remodeling, phase. Wound Classification. BY CAUSE 1. intentional 2. unintentional CLEANLINESS 1. clean
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WOUND CARE Wound Healing1. inflammatory phase2. proliferative or granulation phase3. maturation, or wound remodeling, phase
Wound Classification • BY CAUSE 1. intentional 2. unintentional • CLEANLINESS 1. clean 2. contaminated 3. infected • DEPTH 1. superficial 2. partial thickness 3. full thickness • COLOR - by using the RYB Classification.
The RYB Classification System • Classifies open wound s that are healing by secondary or delayed primary intention in both chronic or acute wounds. • It can be used to determine the state of healing. • Red wound s- can be in inflammatory, proliferative or maturation stage. • Yellow wound – infected, contain fibrogenous slough. • Black wound – contain necrotic tissue. Not ready to heal.
Types of Wound Healing • Primary Intention – simplest form of wound healing. Skin is cleanly incised. e.g. surgical incision or traumatic laceration. Closed with suture or staples. • Secondary Intention – The wound heals by granulation. Granulation tissue builds, it fills the gap under the skin and cells epithelize from edge of the wound to create the closure. e.g. burns, pressure ulcers and wounds with large piece of skin missing. • Tertiary Intention – leaves open wound to heal. Wound cannot be sutured. Dehiscence occurred or wound is infected.
Major Factors Affecting Wound Healing • Nutrition • General Physical Health • Medications
Goals of Wound Care • Remove necrotic tissue and promote wound healing. • Prevent, eliminate, or control infection. • Absorb drainage (exudate). • Maintain a moist wound environment. • Protect the wound from further injury. • Protect the surrounding skin from infection and trauma.
Associated With Wound Healing Complication • Adhesions • Incisional strangulated internal hernias • Contractures – shortening of the scar tissue. • Wound Infections
Wound Infection prevention • Use of semi-occlusive dressing reduced incidence of infection, promotes moist environment. • Observation of Standard Precaution. Proper Hand Hygiene. • Maintaining Asepsis during wound dressing. • Using sterile supplies and equipment. Clinical S/S of Infection generally begin 3-5 days post-operatively or following the injury.
S/S of Wound Infection • Progressively more tender wound • Painful • Edematous • WBC count of 12, 000/mm3 or greater lasting longer than 72 hours. • Foul smelling and purulent drainage.
Microorganism Causing Wound Infection • Staphylococcus Aureus - major • Escherichia Coli • Streptococcus faecalis • Proteus Vulgaris • Klebsiella • Enterobacter • Pseudomonas Aerogenusa • Wound Specimen for Culture – Dx test.
Measures to Prevent Infection • Completing Surgical hand Hygiene • Donning Sterile Gloves • Pouring from Sterile Container Equipment: Sterile container Non sterile container Sterile Solution Procedure: See accompanying procedure.