care of Wounds for nursing student.ppt.pptx

Nursing College

1. Wounds Working by :- Presentation About of :- Republic of Yemen. Sana'a University. Faculty of medicine.

2. The contents of wounds Definition Classification Types of wounds Signs and Symptoms Wound assessment Wound dressing Suturing The wound healing process Factors that affecting wound healing Complication Nursing care contents

3. D amaged skin or soft tissue result from trauma (Injury ), Wounds are any break in the integrity of the skin or tissues which may be associated with disruption of structure or function . They include cuts, scrapes, scratches, and punctured skin. They often happen because l accident, but surgery, sutures, and stitches also cause wounds. Definition:

4. Depending on the healing time of a wound - It can be classified as acute or chronic. Those classified as - Acute wounds (with no complications). - Chronic wounds take a longer time to heal and might have soma complications. Classification of wounds:

5. Classification of wounds: Depending on the healing time of a wound - Another way to classify wounds Is to determine If the wound Is clean or contaminated. Clean wounds have no foreign materials or debris inside, whereas contaminated wounds or infected wounds might have dirt, fragments of the causative agent, bacteria or other foreign materials. - Wound origin can be either Internal or external . Internal wounds result from Impaired Immune and nervous system functions and/or decreased supply of blood, oxygen or nutrients to that area; such as in cases of chronic medical illness (diabetes , atherosclerosis, deep vein thrombosis). External wounds are usually caused by penetrating objects or non- penetrating trauma .

6. Types of Wounds: Wounds may be either closed or open Closed wounds : There Is no opening In skin or mucous membrane Closed wound occur more often from blunt trauma or pressure . The type of close wound are Contusions . [ bruise ] Injury to soft tissue underlying the skin from the force of contact with a hard object . The Injured area becomes painful and swollen . Haematoma . If the amount of bleeding is excessive , a haematoma forms, localized collection of blood due to rupture of a sizeable vessels.

7. Open wounds: Open wounds can be classified according to the object that caused the wound. The types of open wound are: Abrasions . An abrasion is scraping away of the superficial layers of the skin due to friction with a hard rough surface. The wound is very painful due to exposure of the sensitive nerve ending Incised wounds . These are produced by sharp cutting objects as a razor, a piece of glass or a knife The wound is longer than deep ,it is edges are clean cut and there is no much destruction Penetrating wounds . These are caused by penetration of a pointed object as a knife , The wounds are more deep than long, so there is risk of Injury to deep Important structures .

8. Laceration wounds . A separation of skin and tissue in which the edges are torn and irregular, these are caused by severe violence with blunt object like, road traffic accidents [RTA] or falling from a height, crushed : more extensive type of lacerated wound . Ulceration wounds . A shallow crater In which thin or mucous membrane is missing. like , bed sore . Puncture wounds . an opening Of skin , underlying tissue , or mucous membrane caused by a narrow, sharp, pointed object, nail, animal teeth. Avulsions , injuries In which a body structure is forcibly detached from its normal point of Insertion.

9. The signs and symptoms depend on the wound site, depth and causative agent. In general, wounds present with: Pain Redness Swelling bleeding and loss or impairment of function to the wounded area. Symptoms may include fever malodorous pus drainage and heat particularly in cases of infection. Signs and symptoms :

10. Patient name Hospital number Date of assessment {weekly} Max length (cm) Max width(cm) Max depth(cm) Wound bed-approximate % cover (enter %) Necrotic (Black) Slough (Yellow) Granulating (red) Epithelializing (Pink) Wound dimensions

11. Intact Healthy Fragile Dry Scaly Erythema Maceration Oedema Eczema Skin nodules Skin stripping Dressing allergy Tape allergy Other (please state ) Skin around wound

12. Odour (see over for rating ) Bleeding None Slight Moderate Strong None Low Moderate High Amount increasing Amount decreasing Exudate level None Slight Moderate Heavy Al dressing change

13. Level (0-10) Continu0us At specific times ( specify ) Wound Infection suspected Swab taken (Y\N) Swab result Treatment Assessment review date Initials of Assessor Pain form wound (see over for rating scale )

14. Dressings : A dressing [cover over a wound ] . Indication: Keeping the wound clean. To prevent infection. Absorbing drainage. Controlling bleeding. Holding medication in place . Protect new tissue and removing dead tissue , Removing a moist environment . To promote physical and emotional . Wound dressing

15. Removing the Old Dressing. Caring for the Wound. Putting on the New Dressing. Surgical wound care –open:

16. Caring for the wound Dressings do several things, including: Protect the wound from germs. Reduce the risk of infection. Cover the wound so that stitches or staples don't catch on clothing Protect the area as it heals. Soak up any fluids that leak from the wound . Surgical wound care – closed:

17. Types of Antiseptic :- Bactericidal : N/S : to clean the wound + bed sore . Spirt : to clean closed wound . Savilon : to wash the structure or wound in head . Iodine : to protect injury from any infection and to protect around the injury clean ,and to dry the wound and to help healing Bacteriostatic : H2O2 : using for deep injury also pus , death tissue .  

18. Suturing : Define as : surgical means of closing wound by sewing ,wiring or stapling , sutures are knotted ties that hold an incision together.

19. Absorbable

20. Non –absorbable suture :

21. The healing process of a skin wound follows predictable Patten . A wound may fail to heal if one or more of the healing stages are interrupted , The normal wound stages include:- In f lammation stage :- Blood vessels at the site constrict [ tighten ] to prevent blood loss and platelets [ special clotting cells ] gather to build a clot. This is way a healing wound at first feels warm and looks red. WBC flood the area to destroy microbes and other foreign bodies . Skin cells multiply and grow across the wound. The healing process of wound

22. Fibroblastic stage :- Collagen the protein fiber that gives skin its strength , starts to grow within the wound . the growth of collagen encourages the edges of the wound to shrink together and close small blood vessels [capillaries ] form at the site to service the new skin with blood

23. Maturation stage :- The body constantly adds more collagen and refines the wounded area . this may take months or even years , this Is why scars tend to fade with time and why we must take care of wounds for some time after they have healed.

24. General { Systemic } factors: Age Malnutrition Chronic diseases like , uremia , jaundice , anemia. Cytotoxic drugs . Diabetes . Irradiation Local factors : Vascularity { blood supply } Immobilization Tension Infection Foreign bodies and necrotic tissue such as pus , pieces of clothes . Adhesion . Impaired venous drainage , Denervation . Factors that affecting healing wound

25. The most common wound complications are: Infections Inflammation : Inflamed wounds are hot, red, painful, swollen and hard to move Scarring : Regenerated cells have different characteristics and fibrous tissue that can heal the wound, but may leave a scar behind. Loss of function : Many wounds can be disabling and life threatening if a major organ, blood vessel or nerve was damaged. Either way while the wound is still fresh or healing, the affected limb or area will lose its functionally until all lost or damaged tissue is repaired. Complication :

26. This procedure consider nursing care Change old dressing as needed, Checking for vital signs to monitor any advanced of temperature ,or if there is signs of infection, Administration of antibiotics as needed, Give analgesic for pain Frequency check for wound sites. Monitor if there is pus or bleeding. Frequency cleaning of wound. Nursing care :