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Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 1
CHAPTER 13
Surgi cal Wound Care
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 2
Phases of Wound Healing
1. Hemostasis
Termination of bleeding
Clotting soon after the injury occurs
2. Inflammatory Phase
An initial increase in blood elements and water flow out
of the blood vessel into the vascular space
Causes cardinal signs and symptoms of inflammation:
erythema, heat, edema, pain, and tissue dysfunction
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 3
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Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 4
Wound Healing
3. Reconstruction Phase
Collagen formation occursa glue-like protein
substance that adds tensile strength to the wound and
tissue.
Appearance changes to an irregular, raised, purplish,
immature scar.
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 5
Wound Healing
4. Maturation Phase
Fibroblasts begin to exit the wound.
The wound continues to gain strength, although healed
wounds rarely return to the strength the tissue had
before surgery.
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 6
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Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 7
Process of wound healing
Primary Intention
Wound is made surgically with little tissue loss.
Skin edges are close together.
Minimal scarring results.
It begins during the inflammatory phase of healing.
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 8
Review the Phases of Healing
1. Hemostasis
2. Inflammatory Phase
3. Reconstruction Phase
4. Maturation Phase
5. Primary Intention
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 9
3 TYPES OF WOUND HEALING
First type is called Primary Intention
(FromLewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and
management of clinical problems. [6
th
ed.]. St. Louis: Mosby.)
4
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 10
Example of Pri mary Intention Wound
Wound closure with staples.
(FromElkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3
rd
ed.]. St.
Louis: Mosby.)
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 11
2. Secondary Intention
Skin edges are not close together
The necrotized (dead) tissue decomposes and
escapes.
The cavity begins to fill with granulation tissue.
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 12
Another Example of Secondary intention
Cavity Type Wound, Significant drainage, Left
Open to heal
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Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 13
3. Tertiary Intention
Occurs when a surgically contaminated wound is left
open and sutured closed after the infection is
controlled
Or a primary wound becomes infected, is opened,
allowed to drain and granulate, then sutured.
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 14
Factors that Effect Healing
Nutritional Needs
If the patient cannot tolerate food or fluids, total
parenteral nutrition or nasogastric feedings can be
provided.
Fluids
Offer hourly; encourage 2000 to 2400 ml in 24 hours.
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 15
Factors that Affect Wound Healing
Rest and Activity
Rest is vital to facilitate healing
Activity is also encouraged to decrease
venous stasis.
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Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 16
Surgical Wound Care Principles
The PT should inspect dressings PRN or as ordered.
Exudate: term to describe broadly any fluid drainage
Exudate can be described of as small, medium to large
amounts.

Sanguineous exudate: Bright red, indicates active bleeding

Serosanguineous exudate: pale, light red, pinkish, watery
Serous: clear and watery
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 17
Figure 13-2
Types of dressings.
(FromElkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3
rd
ed.]. St.
Louis: Mosby.)
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 18
Cleaning
(FromPotter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6
th
ed.]. St. Louis: Mosby.)
7
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 19
Care of the Incision
Dry Dressings (primary wound)
May be chosen for management of a wound with little
exudate/drainage
Protects the wound from injury, prevents introduction
of bacteria, reduces discomfort, and speeds healing
Most commonly used for abrasions and nondraining
postoperative incisions
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 20
Care of the Incision
Wet-to-Dry Dressing (secondary &
tertiary wounds)
Primary purpose is to debride a
wound. (debridement)
The moistened contact layer of the dressing
increases the absorptive abi lity of the dressing to
col lect exudate and wound debris.
As the dressing dries, it adheres to the wound and
debrides it when the dressing is removed.
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 21
Care of the Incision
Transparent Dressings
Advantages
Adheres to undamaged skin to contain exudates and
minimize wound contamination
Serves as a barrier to external fluids and bacteria yet
still allows the wound to breathe
Permits visualization of the wound
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Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 22
Skill 13-3: Steps 11a & 11b
Applying a transparent dressing.
(FromElkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3
rd
ed.]. St.
Louis: Mosby.)
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 23
Care of the Incision
Irrigations
A cleansing solution is introduced directly into the
wound with a syringe, syringe and catheter, shower,
or whirlpool.
Promote wound healing by removing debris from a
wound surface, decreasing bacterial counts
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 24
Care of the Incision
Principles of Basic Wound Irrigation
Cleanse from the least contaminated area
to the most contaminated area.
When irrigating, all of the solution flows
from the least contaminated area to the
most contaminated area.
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Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 25
Skill 13-4: Steps 10 & 13
Performing sterile irrigation.
(FromElkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3
rd
ed.]. St.
Louis: Mosby.)
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 26
Complications of Wound Healing
Dehiscence
Wound layers separate.
It may result after periods of sneezing, coughing, or
vomiting.
Patient should remain in bed and given reassurance .
Place a warm, moist sterile dressing over the area
until the physician evaluates the site.
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 27
Complications of Wound Healing
Evisceration
Abdominal organs protrude through an opened
incision.
The wound and contents should be covered with
warm, sterile saline dressings.
The surgeon is notified immediately.
This is a medial emergency, and the wound requires
surgical repair.
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Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 28
Complications of Wound Healing
Wound Infection
CDC labels a wound infectedwhen it contains
purulent (pus) drainage.
A patient with an infected wound displays a fever,
tenderness, and pain at the wound; edema; and an
elevated _ _ _ count.
Purulent drainage has an odor and is brown, yellow,
or green, depending on the pathogen.
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 29
Staple and Suture Removal
Sutures and staples are generally removed within 7
to 10 days after surgery, or sooner if healing is
adequate.
The physician determines and orders removal of
sutures or staples
Replaced with a Steri-Strip as the first phase, with
the remainder removed in the second phase.
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 30
Staple and Suture Removal
Sutures
Sutures are threads of wire or other materials used to
sew together body tissues.
Sutures are placed within tissue layers in deep
wounds and superficially as the final means of wound
closure.
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Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 31
Skill 13-5: Step 17
Removing sutures.
(FromPotter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6
th
ed.]. St. Louis: Mosby.)
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 32
Staple and Suture Removal
Staples
Staples are made of stainless steel wire are quick to
use, and provide ample strength.
They are popular for skin closure of abdominal
incisions and orthopedic surgery when the
appearance of the incision is not critical.
Removal of staples requires a sterile staple extractor
and maintenance of aseptic technique.
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 33
Skill 13-5: Step 9
Removing staples.
(FromPerry, A.G., Potter, P.A. (1998). Clinical nursing skills and interventions. (4
th
ed.). St. Louis:
Mosby.)
12
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 34
Exudate/Drainage: Need to know
Serous
Clear, watery fluid that has been separated from its
solid elements
Sanguineous
Fluid that contains blood
Serosanguineous
Thin and red; composed both of serum and blood
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 35
Figure 13-7
J ackson-Pratt drains have a wide, flat area brought through the stab
wound with great force.
(FromElkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3
rd
ed.]. St.
Louis: Mosby.)
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 36
Figure 13-8
J ackson-Pratt drainage device. A, Drainage tubes and reservoir. B,
Emptying drainage reservoir.
(FromPotter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6
th
ed.]. St. Louis: Mosby.)
13
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 37
Exudate/Drainage
Drainage Systems
Requires close monitoring
Note the color, consistency, and
amount of drainage.
Note patency of tube; it should not be
kinked or occluded.
If blood clots or exudate have slowed
drainage, record and report.
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 38
Skill 13-6: Step 6
Maintaining Hemovac/Davol suction and T-tube drainage.
(FromPotter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6
th
ed.]. St. Louis: Mosby.)
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 39
Figure 13-10
Wound VAC systemusing negative pressure to remove fluid from
area surrounding the wound.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
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Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 40
Skill 13-7: Step 2
Wound Vacuum-Assisted Closure.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 41
Skill 13-7: Step 12
Wound Vacuum-Assisted Closure.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 42
Skill 13-7: Step 16
Wound Vacuum-Assisted Closure.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
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Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 43
Documentation
After a bandage is applied, the PT should
Date, time and initial on the edge of the dressing
Assess comfort level of the client (use pain scale)
Document in the IDNs (clients chart) the following:
Status of the wound
Descripti on of exudate and quantity
Type of dressings applied
Client s response to the procedure
Patient teaching
Immediately report changes in circulation, skin
integrity, comfort level, or accidential removal of a
drain.
Mosby items and deriveditems 2006, 2003, 1999, 1995, 1991by Mosby, Inc.
Slide 44
Thursday morning you begin
wound care principals, good luck,
class is over