Dressing

DR SUNIL VISHWAKARMA

1. DRESSING An artificial wound cover Dr. SUNIL VISHWAKARMA K.B.B. HOSPITAL , BANDRA WEST MUMBAI

2. Introduction Antisepsis: is a process of destruction of disease causing microorganism to prevent infection on patient body surface. it could be bacteriostatic(limiting growth of bacteria) or bacteriocidal procedure (kills bacteria) . Disinfection: process of killing pathogenic organism from innominate objects like instruments . Asepsis: practice to reduce or eliminate infection causing agents from entering in environment of patient.

3. Dressing Material applied to wound with or without medication to give protection and assist in wound healing. Ideal dressing : They should They should 1. absorbent , remove excess exudate 2. maintain moist environment 3.aid tissues to remove necrotic material 4. promote healing

4. 5. prevent trauma to underlying healing grnulation tissue. 6. leak-proof, prevent passage of organism to wound 7.maintain temperature & gaseous exchange 8. allow easy pain free dressing change 9. odourless 10. cosmetically acceptable & comfortable 11. inexpensive

5. What is ideal topical agent ? Ideal topical agent should meet following: Wide antibacterial action Non toxic Non irritant Good penetration economical

6. Classification of dressing Primary / seconday Passive/active / interactive

7. Primary dressing 1. also called contact layer 2.comes in direct contact of wound Ex. Band aid Secondary dressing Is placed over primary dressing to provide increased protection . Ex. Self –adhesive elastic bandage

8. Passive/active/interactive 1.Passive- for protection ,as protective dressing 2.Active – promotes healing through the creation of moist wound environment. 3.Interactive dressing- not only creates a moist wound environment but interact with the wound bed component to further enhance wound healing.

9. Interative dressing Reduces bacterial colonization count In wound bed Reduces the level of exudate Improves wound bed moisture retention. Improves wound collagen matrix. Removes cellular debris Provide protection to the epithelial bed

10. Moist wound heals faster ??? Moist wound heals faster than dry wounds. Prevent scab or crust formation over the wound bed , it eliminates the energy and time for the body to break this down. Reduce travel time for keratinocytes as they easily migrate across the moist wound bed. Traps enzyme at the wound bed facilitating autolytic debridement. Preserve growth factors and promotes collagen synthesis.

11. Aim of wound dressing To keep the wound clean To reduce the spread of micro organisms To enhance tissue healing To absorb or localize drainage of wound To support injured part

12. Indication of wound dressing Open wounds Infected wounds Removal of stitches, staples or clips while removing drains

13. Purpose of wound Dressings To protect the wound from m echanical injury To protect the wound from m icrobial contamination To provide or maintain high m oisture of the wound To provide thermal insulation To absorb exudate To prevent heamorhage and speed up process of clotting. Reduce patient pain either by analgesic added in them or by compression or preventing further trauma to wound Reduce Psychological stress of patient by obscuring the wound.

14. Layers of dressing There are three layers in dressing which are fron deep to superficial are as follows: First layer : covers the wound and collects blood , discharge, fibrin, debris. Second layer : collects excess drainage Third layer : protects the wound from external contamination.

15. TYPES OF WOUNDS DRAINAGE Exudate : material, such as fluid and cells, that has escaped from blood vessel during the inflammatory process and is deposited in tissue or on tissue surfaces. 1. Serous exudate - consist chiefly of serum or the clear portion of the blood derived from the blood and serous membranes. 2. Purulent Exudate - It is thicker than serous exudate due to presence of pus cell . 3. Sanguineous exudate - Consist of large amounts of red blood cells , indicating damage to capillaries that is severe enough to allow the escape of red blood cells.

16. General rules of dressing care: No tight dressings– compromise blood supply. Tight dressing only to control bleeding temporary . Pressure should be equally distributed . Newer allow tight banding around limbs or fingers. While changing shouldn’t damage tissues of healing wound.

17. Instruction for wound dressing Take utmost care to prevent cross infection. All instruments used in dressing should be sterlised . Wash hands thoroughly before and after dressing Use instruments for one dressing only. After dusting , sweeping dressing should not be done for 15 MINUTES. Avoid coughing , talking and sneezing while dressing. Clean the wound from centre to periphery . If dressing is sticking then apply sline or savlon to remove it. Wound and drain area should be dressed separately Amount of discharge should be examined for colour,odour,consistency . Give analgesis before painful dressing. Isolate the wound by spreading sterile towel.

18. BASIC DRESSSING MATERIAL : (A) Gauze (B) Gamgee (c) Bandage (D)Elastic adhesive (E) surgical wool

19. Surgical wool Clean , long fibred Bleached white – discharge can be seen clearly Defattened by passing in 10% KOH Ideal surgical cotton should sink in water in 10 seconds Available in (a) sterile rolls (b) unsterile rolls Uses: for painting the parts for dressing for swabbing deep cavity for benzoin seal to make orthopedic padding before applying plaster of paris keep the bottom of a bottle intact

20. Gauze piece Piece of woven surgical cotton Types : (a)closed: 16x16 fibers/ sq inch used in making bandage (b)open : 8x8 fibers/ sq inch in making peanuts- blunt dissection Uses: dressing heamostatic purpose painting the parts tissue dissection drainage and package of absess cavity.

21. Surgical pad Made by wrapping cotton within gauze piece Usually have size of 4x6 sq inch Uses: in dressing of drained abscess in dressing of burns and ulcers padding to avoid direct pressure and trauma to wound

22. Gamgee A layer of cotton is sandwiched between gauze piece and rolled Uses: 1. in dressing of wound with discharge 2.in dressing of burns patients

23. Bandage Soft ,light, porus turns: (a) circular :horizontally across the part mainly used in begening to secure the bandage it interfere with circulation so should be avoided in limb . (b ) spiral :spiral fashion across the limb each turn should cover half to 2/3 of preceding turn used in parts with uniform thickness e.g. arm , fingers (c) reverse spiral : reverse turn useful when thickness is not uniform e.g. forearm (d) figure of eight : over joints (e ) spica : type of figure of eight bandage but one loop is much larger than other e.g. hip spica (f) recurrent : series of alternating turns are taken e.g. amputation stump dressing

24. Dressing trolly What important equipments are kept in it: Upper tray should have: 1. betadine lotion 2.hydrogen peroxide 3.spirit 4.eusol 5.cheatel forecep 6.kidney tray 7.gauze cotton pad 8.scissors 9.blade, scarpel , syringes, artey foreceps etc Lower shelf : Gloves , cotton,adhesive tape,torch,dustbin Note : all cheatel and holders should be autoclaved daily idealy or boil for 20 min stored in savlon which should be changed daily.

25. Hydogen peroxide(H2O2 ) COMPOSITION: 20-volume of hydrogen peroxide One volume of 20 – volume H2O2 will release 20 volume of nascent O2 It’s a cleansing agent not an antiseptic Uses: 1-produces froth so helps in bringing deep debris out of wound 2-destroys anerobic organism – used in cleaning contaminated wounds 3-produces heat when in contact with tissue– so reduces capillary bleeding hence used in achieving heamostasis . 4-used to remove blood stain 5-very diluted forms are used in throat spray and mouth wash and ear syringing to remove wax.

26. Weak Iodine solution Composition : tincture iodine---- 5% alcohol-------- 48-65%(v/v) Use : preoperative painting of skin Special points: It should be wiped out with sprit after 2 min Alcohol increses permeability of iodine Savlon due to its detergent action reduces effect of iodine. It kills 90% of bacteria on skin in 90 sec . Iodine and sprit is best for skin preparation .

27. sprit Composition: alcohol (optimum concertration is 70% alcohol) uses: disinfection skin before intramuscular and intravenous injection. removal of iodine in skin preparation. cleaning of stiched wound. cleaning of surrounding skin of uler and open wound. it desolves gresy material so used in ear drops (50% spirit—gutta spirit). used with other disinfectant .

28. EUSOL Edinburgh university solution Composition:1.25gm boric acid, 1.25 gm bleaching powder , sterile water up to 100 ml Mechanism: it releases nascent chlorine and becomes useless after 24 hours Uses: 1- to remove sloughs from wound , ulcer, bed sore ,burn wound 2- acidic in ph so very useful for wound infected with pseudomonas bacteria.

29. cidex 2% aqueous solution of glutaraldehyde it kills all pathogen.(bactericidal, tuberculocidal,pseudomonacidal , viricidal,fungicidal .) Complete disinfection in 10 min but spore are killed in 4 hours . Uses: 1-Used in sterilization of instruments , scope , endoscope , lenses . 2-Sterilisation of small and sharp instruments , catheter , thermometers . 3-Sterilisation of instruments of anashthesia . Remarks: Best disinfectant with rapid action. Effective even in presence of protein material. Time recommended is 10 hours to take care of deep cervices in instruments .

30. Glycerine magnesium sulphate Mixture of mgso4 crystals and glycerine (sterile) Solution is warmed and then cooled Uses: As it is hygroscopic it is used to reduce edema in cases of cellulitis paraphimosis piles Mgso4 enema in order to reduce intracranial pressure .

31. Ether evaporable and highly inflammable , makes skin surface cool. Uses: surface and inhalational anashthesia . Cleaning dirty wound as it dissolve greasy material. Acriflavin available in crystals 0.5-2% solution made with water. Yellow in colour Uses .1:mild antiseptic and astringent on ulcers with purulent discharge. 2:effective in wound with gram negative bacteria .

32. Silver nitrate Solution with dilution ranging from 1:100 to 1:10000 Kept in dark as on exposure to light it gets destroyed . Uses: 1.chemical cauterization of warts and hyperpigmented tissue. 2. in dressing of burns patients. 3. in bladder irrigation in heamaturia due to cauterizing effect.

33. Providone -iodine (betadine) Available as : Solution-5-10% ; scrub 7.5% w/v; ointment , mouth wash . Iodine is good germicide , effective against viruses, bacteria , protozoa ,yeast , fungi But its frequent use is contraindicated due to : insolubility, staining, irritability, instability- -- overcome by mixing it with polyvinyl pyrrolidone (combination called providone iodine ) Providone iodine retains bactericidal activity of iodine and lacks toxicity. water soluble and eliminates toxic effects of iodine. NOTE: Loss of colour OF SOLUTION is accompanied by loss of bactericidal activity .

34. Advantage: broad spectrum antiseptic immediate action – nonselective Film formimg safe Uses: ( application Is painful due to its irritant action) Used in wound with granulation tissue after eschar sepration . mouth rinse and gargles . in irrigation of bladder and peritoneum , pyothorax . Shuld not be used on superficial burns which are highly painful.

35. WOUND A wound is a type of physical trauma whereby the integrity of skin or of any tissue gets compromised . Also called break in continuity of mucus membrane, skin , bone or any body tissue caused by physical chemical and biological insult. Etiology of wound : 1.Blunt trauma: : RTA fall assault sport injuries and animal bite 2.Penetrating trauma: stab and gun shot injuries 3.Surgical insult: wound caused by surgical procedure 4.Burn injuries: chemical , thermal , electrical , radiation and cold burn

36. Wound classification According to the etiology Surgical wounds :These are wounds caused by surgical procedure Penetrating wounds : Wounds caused by penetrating trauma Blunt wounds : Wounds caused by blunt trauma Burn wounds : Wounds caused by burn injuries

37. According to Rank-Wakefield classification system Tidy wounds These are wounds inflicted by sharp instruments and contain no devitalized tissue Such wounds can be closed primarily with the expectation of quite primary healing They are usually single with clean cut Associated fractures are uncommon Examples: surgical incisions, cuts from glass and knife wounds Untidy wounds These are wounds resulting from crushing, avulsion,burns , and contain devitalized tissue They are usually multiple and irregular Commonly associated with fractures Such wounds can not be closed primarily and therefore should be allowed to heal by second intention

38. According to the duration of the wound healing 1:Acute wounds Acute wounds are wounds that usually heal in the anticipated time frame Duration of the wound: days to few weeks Examples are wounds acquired as a result of trauma or an operative procedure 2:Chronic wounds Wounds that fail to heal in the anticipated time frame and often reoccur Duration of the wound ⇒ > 4 weeks to 3 months Wounds occur as a result of an underlying condition such as extended pressure on the tissues, poor circulation, or even poor nutrition Pressure ulcers, venous leg ulcers, and diabetic foot ulcers are examples

39. According to the integrity of the skin Open wounds 1. Type of wounds in which the skin has been compromised and underlying tissues are exposed Examples include incised wounds, laceration, punctured wounds etc Closed wounds Wounds in which the skin has not been compromised, trauma to underlying structures has occurred 3. Closed wounds have fewer categories, but are just as dangerous as open wounds Examples of closed wounds are: 4. Contusions - (more commonly known as a bruise) - caused by blunt force trauma that damages tissue under the skin 5. Hematoma - (also called a blood tumor ) - caused by damage to a blood vessel that in turn causes blood to collect under the skin

40. According to wound depth Superficial wounds 1. Only the epidermis is affected 2. A truly superficial wound usually does not bleed and heals within a few days Examples include most abrasions and blisters Partial-thickness wounds The epidermis and part of the dermis is affected A partial-thickness wound does bleed 3. If left uncovered, a blood clot will cover the wound and a scar will form 4. The missing tissue will then be replaced, followed by regeneration of the epidermis 4. A partial-thickness wound can take from several days to several weeks to heal

41. Full-thickness wounds 1. A full-thickness wound involves the epidermis and the dermis 2. The underlying fatty tissue, bones, muscles, or tendons may also be damaged 3. If full-thickness wounds cannot be sutured, the healing process will create new tissue to fill the wound, followed by regeneration of the epidermis 4.The full-thickness wound takes longer time to heal than does a partial-thickness wound, sometimes as long as several months

42. According to morphological characteristics 1.Bruises / contusion These are closed wounds Caused by blunt trauma that damage the tissue under the skin without breaking the skin Characterized by skin discoloration due to bleeding into the tissues Ex. Blows to the chest, abdomen, or head with a blunt instrument can cause contusions 2.Hematoma These are also closed wounds caused by damage to a blood vessel that in turn causes blood to collect under the skin Initially this is fluid, but it will clot within minutes or hours ⇒later after few days the hematoma will again liquefy → increased risk of secondary infection → pus formation

43. 3.Abrasions An abrasion is a shearing injury of the skin In which the surface is rubbed off Most are superficial and will heal by epitheliazation 4. Lacerated wound Caused by tearing of tissues Wounds have irregular borders Loss of tissue is limited to skin and s/c tissue 5.Crush wounds Crush wounds are caused by a great or extreme amount of force applied over a long period of time . occur when a heavy object falls onto a person, splitting the skin and shattering or tearing underlying structures

44. 6.Penetrated wound Caused by sharp pointed object. Have relatively small opening. May be very deep. Infection/ foreign particles might have been carried deep in to wound. 7.Perforating wound 1.Have two opening one of entrance one of exit ex. Gun shot

45. According to degree of contamination 1.Clean wounds No break in aseptic technique Incision is made under sterile condions No inflammation is encountered The respiratory tract, alimentary, genital or uninfected urinary tracts are not entered Primary closure can be done. ex. Herniorrhaphy 2.Clean Contaminated wounds Operative wounds in which the respiratory, alimentary, genital or urinary tract is entered under controlled conditions and without unusual contamination .

46. 3.Contaminated wounds Open, fresh or accidental wounds; operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract 4.Dirty or Infected wounds Old traumatic wounds with retained devitalized tissue and existing clinical infection.

47. THE R Y B COLOR CODE This concept is based on the color of an open wound - Red, Yellow, Black. 1.Red wound: are usually in the late regeneration phase of tissue repair and are clean and uniformly pink in appearance . this type of wound needs to be protected. Protect the Red wound: a. gentle cleansing b. avoiding the use of dry gauze. c. applying a topical antimicrobial agent. d. changing the dressing as infrequent as possible.

48. 2.YELLOW WOUNDS: Characterized by primarily by liquid to semiliquid “slough” that is often accompanied by purulent discharges. CLEANSE THE YELLOW WOUNDS Yellow wounds should be Cleanse to absorb drainage and remove nonviable tissue. 1.Apply wet dressing. 2.Hydrogel dressings 3.Exudate absorbent dressings 3.BLACK WOUNDS This type of wound is covered with necrotic tissue. BLACK WOUNDS requires debridement ( removal of infected and necrotic material

49. GUIDELINES IN WOUND CLEANING 1.Use Isotonic saline or lactated ringers solution to clean or irrigate the wound. 2.Warm the solution to body temperature before use. 3.If wound is grossly contaminated by foreign material, bacteria, or necrotic tissue, clean the wound at every dressing change . 4. If wound is clean, has little exudate , and reveals healthy tissue avoid repeated cleaning. 5. Use gauze squares. 6.Avoid using cotton balls and other products that shed fibers onto the wound surface. The fibers become embedded in the granulation tissue and act as a foci for infection 7.Consider cleaning superficial noninfected wounds by irrigating them rather than by mechanical means.

50. procedure Patient preparation Explain the procedure to the patient to gain cooperation and consent Screen bed and close nearby windows for privacy Assist the patient to lie in the most appropriate and comfortable position considering the site of the wound and condition of the patient. Expose only the area to be dressed for privacy and dignity.

51. CHOICE OF AGENTS LOTION: when wound is increasing and have profuse discharge .ex glycerine mgso4 when you want to reduce edema by hygroscopic action. Ointment: when discharge from wound has stopped and there is appearance of granulation tissue, ex betadine ,zinc ointment. Powder: when wound is having scanty discharge and has good granulation tissue, Neosporin powder Dry dressing: in wound without granulation tissue . Wet dressing: when wound is with granulation tissue ex. Eusol, saline,betadine

52. Vac dressing This therapy involves application of controlled sub-atmospheric pressure to local wound environment , using a sealed wound dressing connected to a vaccume pump. Promotes wound healing – continued fluid is drawn from wound and and increases blood flow in that area. May be applied continuously or intermittent . Typically dressing is changed 2-3 times / week . Presssure commoly used between negative (75- 125mmHg).

53. HAND HYGIENE 5 moments of hand washing : Before patient contact Before aseptic procedure After coming in contact with body fluid After patient contact After contact with patient surrounding

54. HOW TO HAND WASH Lather with enough soap Scrub your hand vigorously /thoroughly: done for atlesat 20-30seconds It is done in 6 stages: Make your hand wet with running water 1. palm to palm 2.Back of hand 3.Between the fingers 4.Finger tips 5.Thumbs and its base 6.Nail in the palm of opposite hand 7.Wrist Rinse with running tap water dry with clean and dry towel Turn off tap with towel or elbow Throw the towel

55. Important events in hand washing Scrubbing with soap : causes 2-4 log germs reduction Rinsing with running water further help in removings germs Drying hand 1 long germs reduction Use of fresh towel – reduction of cross contamination Hand washing removes trasient flora of hand :human hand have two flora resident : present under cells of stratum corneum and difficult to remove. Trasient : colonizes the superficial layers of skin more amenebale to removal by hand wash.

56. Hand sanitizer Useful in clean hands not in grossly contaminated and dirty hands Alcohol based – need atleast 60% alcohol Useful in health care setting while handling patients in between. Not useful in killing all microbes Must remain in contact for 20 seconds or rub your hands till they get dry . Generally used in non availability of soap and water

57. THANK YOU Reference : 1.ward procedure by y.upaydhyay 2.practical orthopedic by Jayant sharma 3.Orthobullet.com