Exam 12 - Surgical Wound Care

Wound Classification

• Wound classifications are determined based on various factors, including cause, severity, contamination, and size.
• Understanding the cause is crucial for determining the correct treatment plan.
• Planned surgical wounds are typically created by incision or puncture, often closed with sutures or drains.
• Traumatic wounds, caused by external forces, are managed differently, often requiring the practitioner to close the wound edges.
• Surgical wounds are classified based on contamination levels, ranging from Class I (clean) to Class IV (dirty, infected).
• The risk of infection increases with higher contamination levels.
• Contamination can be caused by exposure to gastrointestinal matter (e.g., feces) or environmental factors.
• Contaminated wounds, such as those with gangrene, have a significantly higher risk of infection.

Wound Healing

• Wound healing involves four phases: hemostasis, inflammatory, reconstruction, and maturation.
• Hemostasis begins immediately after injury, involving platelet aggregation and fibrin clot formation to stop bleeding.
• The inflammatory phase involves increased blood flow and fluid leakage, leading to the classic signs of inflammation: redness, heat, swelling, pain, and dysfunction.
• Leukocytes (white blood cells) play a role in engulfing bacteria and other foreign particles, decreasing in number if no infection is present.
• The reconstruction phase starts on day 3-4, where fibroblasts produce collagen, a protein that strengthens the wound.
• Wound dehiscence (separation of wound edges) is more common during the reconstruction phase.
• The maturation phase begins around 3 weeks, as fibroblasts exit the wound and collagen continues to strengthen.
• Keloids, thickened scar tissue, can occur during the maturation phase, more common in individuals with darker skin tones.

Wound Healing Processes

• Primary intention healing occurs when wound edges are close, minimal tissue is lost, and scarring is minimal.
• Secondary intention healing involves granulation tissue formation when wound edges are not close together or infection is present.
• Tertiary intention healing involves delayed closure of contaminated wounds, allowing for infection control and creating a larger scar.
• Wound healing stages are not strictly sequential and can occur simultaneously.

Factors Affecting Wound Healing

• Adequate nutrition is essential for promoting wound healing.
• Patients requiring nutritional support might benefit from parenteral nutrition, nasogastric feeding, or frequent small meals.
• Foods rich in protein, vitamins A and C, and zinc promote wound repair.
• Maintaining adequate hydration is crucial for wound healing.
• Balancing rest and activity helps prevent venous stasis and promote healing.
• Avoiding strain on suture lines is essential for wound healing.
• Preexisting conditions like malnutrition and chronic diseases can negatively impact wound healing.
• Age, obesity, impaired oxygenation, smoking, and certain medications can interfere with wound healing.
• Diabetes mellitus and radiation can impair tissue perfusion and wound healing.

Surgical Wound

• The location of the surgical wound is chosen based on tissue, organ, injury, inflammation, and the strength of the site.
• Closure options include sutures, staples, adhesive strips, and transparent sprays.
• Dressings help support the incision, secure dressings, and protect the wound.
• Post-operative wound inspection should be performed routinely to monitor for bleeding and infection signs.

Standard Steps in Wound Care

• Before a wound care intervention, it is essential to review the patient's medical record, care plan, and any specific interventions.
• Introduce yourself to the patient and verify their identity accurately.
• Explain the procedure in clear and understandable terms, addressing any potential discomfort and providing time for questions.
• Assess the patient before the procedure and provide any necessary patient teaching.
• Perform hand hygiene and wear clean gloves to ensure safety and prevent infection.
• Ensure patient privacy and comfort by closing the door or curtain, raising the bed, and positioning them appropriately.
• Encourage patient involvement throughout the intervention.
• Monitor patient tolerance during the procedure, being alert for any signs of discomfort or fatigue.
• After completing the procedure, assist the patient to a comfortable position, ensure they have a means to call for assistance, and raise the side rails.
• Remove gloves and protective barriers, dispose of contaminated supplies and equipment properly, and perform hand hygiene.
• Document the patient's response, expected and unexpected outcomes, and patient teaching.
• Report any unexpected outcomes to the appropriate healthcare provider.

Care of the Incision

• Surgical wounds are often covered with dressings to protect them until epithelialization and minimize contamination.
• Dressings can be gauze, semiocclusive, or occlusive, depending on the wound's needs.
• The choice of dressing depends on wound size, location, drainage, and frequency of changes.
• Dry dressings are suitable for wounds with little exudate, like abrasions or nondraining incisions.
• Moistening a dry dressing helps prevent trauma during dressing removal.
• Provide patient education and analgesia if necessary before a dressing change to minimize discomfort.

Wound Care

• Dressing Removal: If underlying drains are present, avoid removing or displacing them during dressing removal.
• Sterile Technique: Follow sterile technique when handling wounds or dressings.
  • Asepsis (absence of germs) protects the nurse and decreases the introduction of pathogenic organisms into the wound.
  • Good hand hygiene and sterile aseptic procedures are essential for surgical wound care.
  • Wear a gown, mask, and protective goggles if soiling or splashing is anticipated.
• Wound Infection: Wound infections are a continual threat, especially after surgery.
  • Factors that influence wound infections: virulence of bacterial contamination and patient resistance.
  • Incubation period for wound infections is typically 4 to 6 days.
  • Exudate and drainage are normal signs of healing.
• Wet-to-Dry Dressings:
  • Frequently used in the past, but now being reconsidered due to potential damage to granulation tissue during removal.
  • Wetting agents: normal saline solution, lactated Ringer’s solution, acetic acid, sodium hypochlorite solution (Dakin's), povidone-iodine.
  • Discard wetting solutions 24 hours after opening.
• Hydrocolloid Dressings: Used for extra dry wound sites.
• Hydrogel Dressings: Promote hydration and prevent infection.
• Collagen Dressings: Improve the movement of keratinocytes and fibroblasts.
• Transparent Dressings: Thin, self-adhesive, act as a temporary second skin.
  • Advantages: contain exudate, minimize contamination, allow wound to breathe, promote moist environment, allow wound assessment without removal.
  • Suitable for skin tears and IV sites.
  • Can stay in place for up to 7 days if complete occlusion is maintained.
  • Not absorbent, so not recommended for draining wounds.
• Wound Irrigation: Gentle washing with a stream of solution delivered through an irrigating syringe.
• Benefits: cleansing and medication administration.
• Common irrigant: normal saline solution.
• Cleanse from least contaminated to most contaminated area.
• Promotes healing by removing debris, decreasing bacterial counts, and loosening eschar.
• Nonsurgical indications include management of pressure injuries.
• Methods: syringes, pressure canisters, whirlpool agitators, and hose sprayers.
• Pressure guidelines: 4 to 15 psi.
• Sterile or clean technique should be used.
• Position patients on their side to encourage irrigant flow away from the wound.
• Shower tables and whirlpools can also be used for cleansing.

Complications of Wound Healing

• Impaired Wound Healing: Requires accurate observation and ongoing interventions.
• Bleeding: May indicate a slipped suture, dislodged clot, coagulation problem, or trauma.
  • Monitor vital signs, intake and output (I&O), skin condition, wound site, and patient response.
  • Internal bleeding may cause abdominal rigidity and distention.
• Dehiscence: Separation of wound layers.
  • May be preceded by serosanguineous drainage.
  • Keep patient in bed, NPO, and restrict coughing.
  • Steri-Strips or butterfly strips may be used for closure.
• Evisceration: Internal organs protrude through an opened incision.
  • Medical emergency.
  • Keep patient in bed in low Fowler’s position, knees flexed, NPO.
  • Cover wound with warm, sterile saline dressings.
  • Notify the surgeon immediately.
  • Monitor vital signs and pulse oximetry.
  • Provide emotional support.
• Wound Infection: Wound becomes contaminated.
  • CDC defines wound infection as containing purulent (pus) drainage.
  • Signs: fever, tenderness and pain, edema, elevated WBC count.
  • Culture of exudate confirms the presence of the pathogenic organism.

Staple and Suture Removal

• Sutures: Threads of wire or other material used to sew body tissues together.
  • Types: interrupted, continuous, blanket, retention.
• Staples: Made of stainless-steel wire, quick to use, provide ample strength.
• Removal:
  • Institution policy determines who can remove staples and sutures.
  • Obtain a healthcare provider's written order before removal.
  • Timing for removal depends on the stage of incisional healing and extent of surgery.
  • Sutures and staples generally are removed in 7 to 10 days after surgery.
  • Equipment: sterile staple extractor and maintenance of aseptic technique.
  • Inspect the area to ensure all sutures or staples have been removed.

Exudate And Drainage

• Exudate: Fluid, cells, or other substances that leaked from cells or blood vessels.
• Drainage: Removal of fluids from a body cavity, wound, or other source.
• Types: serous, sanguineous, serosanguineous, purulent.
• Characteristics: Color (clear, red, pink, brown-green), amount, consistency, odor.
• Abnormal amounts: Treat exudate or drainage greater than 300 mL in the first 24 hours as abnormal.
• Drainage Systems: Facilitate removal of exudate from a cavity.
  • Closed drainage: Airtight circuit that prevents contamination.
  • Open drainage: Open-ended tube into a receptacle or out onto the dressing.
  • Suction drainage: Uses a pump to extract fluid.

Drainage Systems

• A drainage system should be chosen to fit the drainage area, type of exudate, and the drainage amount.
• Penrose Drain
  • A rubber or plastic drain, sometimes used to remove exudate from a wound.
  • It can be positioned through an incision or stab wound.
  • A sterile safety pin prevents the drain from slipping into the wound.
• Closed Drainage System
  • Hemovac: a portable vacuum container with tubes connected to the drainage site.
    • Gentle suction collects exudate in the drainage receptacle.
  • Jackson-Pratt evacuator: a closed drainage system with a bulb that provides a vacuum.
• T-Tube Drainage System
  • Used after gallbladder removal to maintain bile flow.
  • The T-tube is inserted into the bile duct and exits through the abdominal or surgical wound.
  • Drainage occurs by gravity into a closed system.
  • Nursing interventions for T-tube drainage include maintaining patency, keeping the collection receptacle below the wound level, protecting surrounding skin, and monitoring bile drainage.
• Suction Drainage System
  • Wound Vacuum-Assisted Closure (VAC)
    • Applies negative pressure to wounds.
    • Facilitates healing by increasing blood flow, improving drainage, and encouraging wound edge approximation.
    • Promotes granulation tissue formation.
    • Reduces local edema, improves circulation, and decreases bacterial counts.
    • Used for various acute and chronic wounds.
    • Dressing changes vary depending on wound status.
    • During dressing changes, all sponges and remnants must be removed, as retaining them can delay healing.
    • Wound assessment is crucial to monitor healing progress, identify complications, and ensure adequate supplies and assistance.
    • Assess the patient's comfort level, knowledge, and expected outcomes.

Bandages and Binders

• A bandage is a strip or roll of material wound around a body part for specific purposes.
  • Types of bandages include gauze, elasticized knit, elastic webbing, flannel, and muslin.
  • Gauze bandages are lightweight and affordable, allowing air circulation and preventing skin maceration.
  • Elastic bandages conform to body parts and can apply pressure.
  • Flannel and muslin bandages support and provide warmth.
• A binder is a larger bandage made to fit a specific body part (e.g., abdominal or breast binder).
• Correct application of bandages and binders minimizes discomfort and prevents injury.
• Guidelines for applying bandages and binders:
  • Position the body part comfortably in its normal anatomical alignment.
  • Prevent skin friction with gauze or cotton padding.
  • Apply bandages securely to prevent slippage.
  • When bandaging extremities, start at the distal end and move towards the trunk (heart).
  • Apply bandages firmly with equal tension.
  • Position pins, knots, and ties away from wounds or sensitive areas.
  • Remove and reapply elastic bandages every 8 hours.
  • Remove bandages when necessary to readjust or address patient discomfort.
  • Apply bandages to the lower extremities while the patient is lying down.
  • Use wider bandages for larger areas.
  • Secure bandages on children with tape instead of loose clips or pins.
  • Monitor the patency of tubes and drains in patients with binders.
• Nursing responsibilities before applying a bandage or binder include:
  • Inspecting the skin for abrasions, edema, discoloration, or exposed wound edges.
  • Covering wounds or open abrasions with sterile dressings.
  • Assessing underlying dressings and changing them if soiled.
  • Assessing the skin for signs of circulatory impairment (coolness, pallor, diminished pulses, numbness, tingling).
• After applying a bandage, assess, document, and report changes in circulation, skin integrity, comfort, and body function promptly.
• Loosen or readjust bandages as needed, but obtain a healthcare provider's order before removing them.
• Explain the firmness of the bandage to the patient.
• Assess the bandage to ensure proper application and therapeutic benefit.
• Replace soiled bandages.

Nursing Process

• Assessment
  • Observe wound edges, exudate, wound bed, surrounding characteristics, pain, and signs of infection.
  • Note any complications, such as wound dehiscence or evisceration.
  • Monitor dressing saturation and reinforce it with sterile gauze if needed without changing it.
  • Record the amount of exudate and dressings applied.
• Patient Problems
  • Compromised Skin Integrity:
    • Identify and address problems related to wound healing.
  • Risk for Poor Wound Healing:
    • Recognize factors that may impair healing (e.g., malnutrition, tissue loss, physical immobilization, exposure to secretions).
• Expected Outcomes and Planning
  • Create a plan of care based on patient needs.
  • Develop nursing diagnostic statements and interventions to promote healing.
  • Include discharge planning instructions for patients.
  • Provide patient and family teaching to empower them in wound care.
  • Consider the unique needs of older adults when providing wound care, especially regarding skin assessment and dressing selection.

Wound Care: Binders and Dressings

• Patients needing wound care may require two binders for washing and drying.
• Older adults may require reassurance during suture removal.
• Assess patients for comprehension of the procedure, especially older adults.
• Older individuals have a higher risk of wound dehiscence.
• Ensure adequate fluid intake to prevent dehydration.
• Take measures to prevent confused patients from removing drains.
• Compensate for disabilities (auditory, visual, cognitive) during wound care procedures.
• A decrease in sensory receptors leads to decreased pain sensation.
• Wound care goals include healing without complications and minimizing pain.
• Expected outcomes encompass infection-free wounds and minimal patient discomfort.

Implementation of Wound Care

• Monitor wound care for signs of infection.
• Maintain sterile technique for wound care procedures and materials.
• Document the appearance of the wound, drain presence and drainage, medications used, dressings, and patient response.
• Report any deviation from normal wound healing to healthcare providers.
• Incorporate dressing change techniques into the nursing care plan for continuity of care.

Evaluation of Wound Care

• Evaluate healing after each dressing, heat/cold therapy, wound irrigation, and stress to the wound.
• Assess if expected outcomes are achieved.
• Conduct regular assessments of wound condition, patient discomfort during procedures, and dressing conditions.
• Use a pain scale of 0 to 10 to assess pain levels.
• Compare medication dosage and frequency during recovery to evaluate pain management.

Key Points about Bandages, Binders and Wound Care

• Bandages and binders are essential for wound management and support.
• The nursing process is crucial for effective wound care, encompassing assessment, planning, implementation, and evaluation.
• Understanding and addressing patient problems is critical for successful wound healing.
• Developing realistic expected outcomes guides the care plan.
• Implementing care involves performing necessary interventions, including dressing changes and sterile techniques.
• Ongoing evaluation throughout the healing process ensures optimal outcomes.

Test your knowledge on wound classification and the healing process with this comprehensive quiz. Explore key concepts such as the differences between surgical and traumatic wounds, phases of healing, and the importance of infection control. Perfect for nursing and healthcare students!