WOUND CARE Wound Healing 1. inflammatory phase 2. proliferative or granulation phase 3. maturation, or wound remodeling, phase Inflammatory phase – occur immediately after an injury and last 2- 5 days small blood vessels dilates, fluid leaks into traumatized tissue as a result of histamine and prostaglandin Plasma and electrolytes leaks into interstitial spaces causing edema. Edema leads to a reddened, swollen, and tender wound. Neutrophiles proceed to the site to help with phagocytosis to assist in preventing infection by ingesting and digestingbacteria. 4th day day monocytes enter the wound and differentiates into macrophages digest necrotic tissue, remove debris, and inhibit microbial growth. Microphages play a role in creating collagen – macrophages direct healing through the release of monokines. Profiferative or granulation phase – between 2 days – 3 weeks end 14 – 24 days. Rapid growth of epithelial cells to produce a protective covering for the wound. collagens fibers increase the tensil strength of the wound and provide wound integrity. Large wounds may take months to build enough granulation tissue to close the wound. Reddish –pink color color – healthy granulation. Maturation , or wound remodeling phase – wound contraction begins between 14 and 21 days and can last up to 2 years. Result of formation of myofibroblast which assist in moving the wound edges toward the center of the wound and fascia of the healed wound. Scar tissue has fewer melanocytes and thus a lighter color than normal skin.

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. Primary Intention – wound closed rapidly because there are no gaps in the tissue. Wound surface is sealed therefore preventing bacteria from entering and fluid from escaping. Tensil of wound is weak at this stage of healing. Secondary Intention - No wound edges is available to be approximated and sutured. Wound is at risk for local and systemic infection due to the destruction of the dermis and the increased time necessary for healing to occur. Tertiary Intetion – Clients with peritonitis, a ruptured appendix, or diverticula frequently requires this type of wound healing.

Major Factors Affecting Wound Healing Nutrition General Physical Health Medications Nutrition – low level of albumin slows the diffusion of oxygen and diminish the ability of the neutrophils to kill bacteria. Low oxygen at the capillary level diminishes the proliferation of healthy granulation tissue. Zinc deficiency can slow the rate of epithelialization and decrease wound and collagen strength. Need adequate amount of Vit. A C Iron and copper for collagen formation and protein, carbohydrate and fats. COOH and CHON requirements are doubled for age. Infection is the major obstacle to wound healing. Immunosupressed client have more difficulty healing wounds because imflammatory stage is impaired. Presence of chronic diseases that reduced formation of adequate WBC especially macrophages adversely affects healing. Medications such as steroid and nonsteroidal medications used for arthritis or respiratory conditions also impairs wound healing. Steroids decrease the tensil strenght of a close wound and ause inadequate deposits of collagen. Anti-inflammatories decrease epithelialization and wound contraction and may also affect fibroblast proliferation and collagen sysnthesis.

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.