Transcript Wound Healing, Wound Types, Wound Dressings, & Drainage

Wound Healing, Wound Types,
Wound Dressings, & Drainage
Devices
ST230
Concorde Career College
Wound Types & Wound Healing
Objectives:
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List and define the four types of wound classifications
and provide examples of wound types for each
category.
List and describe the types of wounds and provide
examples of each.
List and describe the types of wound healing and
explain the mechanism for each type.
Wound Types & Wound Healing
Objectives:
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Identify the factors that influence wound healing and
understand how to implement techniques that
promote optimal wound healing.
Describe Halsted’s principles of tissue handling and
explain the relationship of those principles to today’s
methods of suturing.
List and describe the techniques used for suturing
and provide examples of when each may be utilized.
Wound Types & Wound Healing
Objectives:
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Outline the dressing application process and identify
the optimal time for dressing placement.
Identify basic abdominal incisions and identify the
tissue layers of the abdominal wall.
Wound Types & Wound Healing
Wound Types & Wound Healing
Wound Classifications
Wound Types & Wound Healing
Surgical Wound Classifications
Type I Clean Wound
Type II
Clean-contaminated Wound
Type III
Contaminated
Type IV
Dirty/Infected
Wound Types & Wound Healing
Type I - Clean Wound
(Potential infection rate 1%5%)
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No inflammation
No break in sterile
technique
Wound primarily
closed/Not drained
Aerodigestive and
genitourinary tract not
entered
Wound Types & Wound Healing
Type II - Clean-contaminated
Wound
(Potential infection rate 8% 11%)
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No inflammation/Infection
present
Minor break in technique
Wound primarily closed/Not
drained
Aerodigestive or
genitourinary tract entered
under controlled
circumstances
Wound Types & Wound Healing
Type III - Contaminated Wound
(Potential infection rate 15% 20%)
 Traumatic wound (less than 4
hours old)
 Acute inflammation present
 Major break in technique
 Gross spillage/contamination
from respiratory,
gastrointestinal, biliary, or
genitourinary tracts
Wound Types & Wound Healing
Type IV - Dirty/Infected Wound
(Potential infection rate 27% 40%)
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Traumatic wound (more than
4 hours old)
Organisms present at surgical
site prior to
procedure/Existing infection
Perforation (Gastrointestinal,
biliary, respiratory,
genitourinary tract)
Wound Types & Wound Healing
Types of Wounds
Wound Types & Wound Healing
Types of Wounds

Intentional (Surgical)

Accidental (Traumatic)
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Chronic
Wound Types & Wound Healing
Intentional (Surgical)
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Incision

Purposeful cut through
intact tissue for the
purpose of exposure or
excision
Wounds
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Excisional
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Removal of tissue
Wound Types & Wound Healing
Six Types of Accidental
(Traumatic) Wounds

Closed
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Open
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Simple

Complicated

Clean

Contaminated
Wound Types & Wound Healing
Closed Traumatic Wound
Skin Intact / Underlying tissue damaged
Examples:
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Blister
Simple Fracture
Wound Types & Wound Healing
Open Traumatic Wound
Skin Disrupted
Examples:
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Laceration
Compound Fracture
Wound Types & Wound Healing
Simple Traumatic Wound
Skin Disrupted/No loss or destruction of tissue/No foreign
body implanted
Examples:
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Minor penetration
Cut with sharp object
Wound Types & Wound Healing
Complicated Traumatic
Wound
Skin disrupted/Underlying
tissue lost or
destroyed/Foreign body
implanted
Examples:
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Severe burn
Stab or bullet wound
Wound Types & Wound Healing
Clean Traumatic Wound
Simple wound caused by a sharp edged object
Expected to be sutured and heal by first intention without
infection
Example:
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Laceration
Wound Types & Wound Healing
Contaminated Traumatic
Wound
Complicated wound caused by
a dirty object
May need debridement and
has a high potential for
becoming infected
Examples:
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Crush Type Injury
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Foreign Body
Implantation
Wound Types & Wound Healing
A SINGLE WOUND MAY BE CLASSIFIED IN MORE
THAN ONE CATEGORY
Wound Types & Wound Healing
Chronic Wound - Wound that
fails to heal over an
extended period of time
Examples:
 Decubitus ulcer (Pressure
sore)
 Wound caused by
inadequate circulation or in
which healing is delayed as
a result of vascular
compromise
 Infected wounds
Wound Types & Wound Healing
Wound Healing
Wound Types & Wound Healing
Types of Wound Healing
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First Intention (Primary Union)
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Second Intention (Granulation)
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Third Intention (Delayed Primary Closure)
Wound Types & Wound Healing
First Intention (Primary
Closure)
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Wound is sutured closed
Healing occurs from
side-to-side
Healing occurs rapidly
with little inflammation
and minimal scarring
Wound heals in three
phases
Wound Types & Wound Healing
Phases of Wound Healing by First Intention
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Phase I - Lag Phase or Inflammatory Response Phase
Phase II - Proliferation Phase
Phase III - Maturation or Differentiation Phase
Wound Types & Wound Healing
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Phase I - Lag Phase or Inflammatory Response Phase
Begins within minutes of the injury and lasts 3-5 days
Inflammation is present (manifested by heat, redness,
swelling, pain, loss of function)
Inflammation is a result of increased blood flow to the
area caused by arterial dilation
Wound Types & Wound Healing
Phase I (continued)
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Bleeding controlled by platelet aggregation
Oxygenated blood delivered to the site
Epithelial cells for repair formed
Scab formed
Phagocytosis occurs
Wound Types & Wound Healing
Phase I (continued)
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Basal cells seal wound
surface
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Fibroblasts begin
reconstruction of
nonepithelial tissue
Wound Types & Wound Healing
Phase II - Proliferation Phase
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Begins about the 3rd postoperative day and continues up
to 20 days
Fibroblasts multiply (proliferate) and bridge wound edges
Collagen secreted from fibroblasts
Wound Types & Wound Healing
Phase II (continued)

Collagen fibers begin to
restore tensile strength
of tissue
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Capillary networks
established and
lymphatic networks
reformed
Wound Types & Wound Healing
Phase II (continued)
Definition:
Tensile Strength: Ability to resist rupture
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During the proliferation phase (phase II) of wound healing
by first intention the wound regains 25%-30% of its
original tensile strength
Wound Types & Wound Healing
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Phase III - Maturation or Differentiation Phase
Begins on the 14th postoperative day and lasts until the
wound is completely healed, (may take up to 12 months)
Tensile strength increased by interweaving of collagen
fibers
Wound Types & Wound Healing
Phase III (continued)

Collagen density
increases and
formation of new
blood vessels
decreases
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Cicatrix is formed
Wound Types & Wound Healing
Second Intention
(Granulation)
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Wound is intentionally
left open
Healing occurs from the
bottom - up
High risk of infection (if
not already present)
Union is weak and scar
formation extensive
Wound Types & Wound Healing
Second Intention (Granulation) (continued)
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Granulation tissue containing myofibroblasts forms in the
wound
Gaps in tissue fill from bottom upward closing the wound
by contraction
Epithelial growth is secondary
Wound Types & Wound Healing
Third Intention (Delayed
Primary Closure)
Two granulated surfaces are
approximated
 Wound is left open to heal
by second intention for 4-6
days
 Then, wound is closed
Equation 2+1=3
(Second Intention plus First
Intention equals Third
Intention)
Wound Types & Wound Healing
Factors Affecting Wound Healing
Three main factors influence wound healing:
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Physical condition of the patient
Intraoperative tissue handling
Application of the principles of asepsis
Wound Types & Wound Healing
Physical Condition
of the Patient
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Age
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Smoking
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Nutritional Status
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Radiation Exposure
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Disease (Chronic or
Acute)
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Immunocompromised or
Immunosuppressed
Patients
Wound Types & Wound Healing
Intraoperative
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Length and direction of
the incision
Dissection technique
(sharp or blunt)
Length of surgery
Tissue Handling
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Hemostasis
Minimal and gentle tissue
handling
Precise tissue
approximation
Elimination of dead space
Secure wound closure
Wound Types & Wound Healing
Halsted's Methods of Tissue Handling
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Strict aseptic technique
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Gentle handling of tissue
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Use of the finest suture material
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Small stitches and low tension on the tissue
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Complete closure of wounds whenever possible
Wound Types & Wound Healing
These basic procedures
had a far-reaching
effect on the practice
of surgery, making it
safer and more
effective than it had
been previously.
William S. Halsted
Wound Types & Wound Healing
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Dead Space
Dead space is a separation of wound edges, which have
not been closely approximated or air that has become
trapped between tissue layers. This space may allow for
serum or blood to collect and provide a medium for
microbial growth that may result in infection.
Wound Types & Wound Healing
Dead Space
Reduce or eliminate
dead space with the
use of:
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Proper suturing
techniques
Wound drains
Pressure dressings
Wound Types & Wound Healing
Application of the Principles of Asepsis Through the Use of
Sterile Technique
 A sterile field is created for each surgical procedure
 Sterile team members must be appropriately attired prior
to entering the sterile field
 Movement in and around the sterile field must not
compromise the sterile field
Wound Types & Wound Healing
Complications of
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Dehiscence
Evisceration
Hemorrhage
Infection
Adhesions
Wound Healing
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Herniation
Fistula
Sinus tract
Suture complications
Keloid scar formation
Wound Types & Wound Healing
Wound Types & Wound Healing
Knot Tying Basics
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Knot Security
Knot Tying Principles
Square Knot (Two Hand
Technique)
Surgeon’s Knot
Wound Types & Wound Healing
Knot Security
Knot security is of utmost importance in preventing wound
complications
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Use the most simple; secure knot possible
Wound Types & Wound Healing
Knot Tying Principles
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Knot must be firm
Tie knot as small as possible and trim ends as close as
possible
When tying, avoid “sawing” motion or excessive tension,
which may damage the integrity of the suture
Wound Types & Wound Healing
Two Simple Knots
(Over 1,000 types of knots available)
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Square Knot - Easiest and most reliable
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Surgeon’s Knot - Provides extra security
Wound Types & Wound Healing
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NO GRANNIES!!!!
A Granny knot is a slip
knot and is NOT
acceptable as a surgical
knot!
Wound Types & Wound Healing
Square Knot
(Two Hand Technique)
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Right over left (first
throw)
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Left over right
(second throw)
Wound Types & Wound Healing
Surgeon’s Knot
First step
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Right over left
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Repeat right over left
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Then tighten
Wound Types & Wound Healing
Surgeon’s Knot
Second Step

Left over right
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Tighten
DONE!!
It should look like this...
Wound Types & Wound Healing
Tissue Approximation
Wound Types & Wound Healing
Suturing Techniques
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Primary Suture Line
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Holds wound edges
together
Heals by first intention
May be continuous or
interrupted
Wound Types & Wound Healing
Suturing Techniques
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Secondary Suture Line
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Supports and reinforces
primary suture line
Also called retention
sutures
Usually interrupted
Wound Types & Wound Healing
Primary and Secondary Suture Lines
Wound Types & Wound Healing
Continuous Suture Line
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Also called “running”
stitch
Series of stitches
placed with one
continuous suture
Wound Types & Wound Healing
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Continuous
PROS
Quick placement
Less foreign body in
wound
Tension evenly distributed
Suture Line
CONS
 Over tensioning can cause
suture failure leading to
wound disruption
 Can allow fluid to travel
along suture line - may
spread infection
Wound Types & Wound Healing
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Interrupted Suture
Each suture strand is
placed individually
Individual suture
strands are tied and cut
Key concept in
Halsted’s suturing
principles - still
employed today
Wound Types & Wound Healing
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Interrupted
PROS
Secure closure
Remaining sutures
should hold wound
edges together if one
stitch fails
Microbes less likely to
move along interrupted
suture line
Suture Line
CONS
 Time consuming
 More foreign body in
wound
Wound Types & Wound Healing
Continuous Suturing
Techniques
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Over and Over
Running Stitch
Wound Types & Wound Healing
Continuous Suturing
Techniques
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Interlocking Stitch
Wound Types & Wound Healing
Interrupted Sutures
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Simple Interrupted
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Evenly spaced
Equal depth
Ends uniformly cut
Wound Types & Wound Healing
Interrupted Sutures
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Vertical Mattress
Wound Types & Wound Healing
Interrupted Sutures
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Horizontal Mattress
Wound Types & Wound Healing
Dressing Application
Wound Types & Wound Healing
Dressing Application

Last step of the sterile
procedure
Wound Types & Wound Healing
Basic Abdominal Incisions
Wound Types & Wound Healing
Basic Abdominal
Incisions
Wound Types & Wound Healing
Layers of the Abdominal
Wall
Wound Healing, Wound Types,
Wound Dressings, & Drainage
Devices
ST230
Concorde Career College
Sponges
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Laparotomy
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Ray-Tec
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ray
Cottonoids
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Tapes, packs, laps
Patties
Tonsil
Kittner
Peanut
** must be counted**
Sponges
Peanut
Lap sponge
Ray-Tec
Tonsil
78
Sponges
 Have
a radiopaque strip so they can be
located by X-ray
Discarded
Dirty sponges are
placed in kick bucket
or sponge tree
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Dressing
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Choice determined by several factors:
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Type, size, and location of the wound
Amount of drainage expected
Surgeon preference
Age and size of the patient
Underlying medical conditions
Condition of the surrounding skin
Comfort of the patient
81
Dressing
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One-layer
Three-layer
Pressure
Bulky
Rigid
Specialty
Packing
82
Dressing
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One-layer dressing
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Cover small incisions
Frequently used to cover IV access
Transparent polyurethane film/adhesive backing
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Dressing
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One-layer dressing
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OP-site
Collodion
Aerosol adhesive sprays, foams, gels
Skin closure tapes
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Dressing
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Three-layer dressing
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Inner (contact) layer
Intermediate (absorbent) layer
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Absorbs drainage
4X4, kerlix, fluffs
Outer ( securing) layer

Tape, stockinette
85
3 layer dressing/ Contact Layer
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Nonpermeable
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Semipermeable
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Occlusive
xeroform
Semi-occlusive
Exu-derm, aqua-gel
Permeable
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Nonocclusive
Telfa, adaptic
Wicking action
Dressing
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Pressure dressing
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Immobilization of an area
Support
Absorption of excessive drainage
Even pressure distribution
Elimination of dead space
Reduced edema
Reduced hematoma formation
87
Dressing

Bulky dressing
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Three-layer dressing
Additional material is added to the intermediate layer
Used to immobilize an area
Provide support
Absorb excessive drainage
88
Dressing

Rigid dressing
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Casts
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Encircles
Provide support
Prevent movement
Often incorporates the joint
Splints
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Applied to one side of a structure
Support
Prevent unidirectional movement
89
Specialty Dressing
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Bolster
Wet-to-dry
Wet-to-wet
Drain
Ostomy
Peri-pad
Dressing

Packing
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Assist with hemostasis
Provide pressure
Provide support
Eliminate dead space
Catheters
• Used to remove fluid
or other objects
• Used to monitor body
functions
• Insert fluids
92
Catheters
•
•
•
•
Remove air and fluids
Decompression
Maintain patency
Administration of
oxygen, anesthetic,
medications, fluids
93
Cystostomy catheter
Drains

Passive Drains

air or fluid moves from an area of high pressure to one of lower
pressure.
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Penrose
Cigarette
T-tube
Gastrostomy
Cystostomy
Nephrostomy
Penrose Drain
Drains

Active Drains

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Negative pressure
Connected to a collection device
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Hemovac
Jackson-Pratt
Stryker
Jackson Pratt(JP) drain
Hemovac Drain with trocar
Tubes
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Used to remove air and fluids
Decompression
Maintain patency of a lumen
Administer oxygen, anesthetics, and other gases
Administer medications
Gastrostomy tube
Nephrostomy
tube
Non-suture Needles

Hypodermic
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Arterial
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Used to withdraw fluid from medication or tissue
12g-30g; ½-4 inches long
Used to place plastic indwelling catheter
Intravenous
Biopsy
Non-suture needles
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Insufflation
Heparin
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Irrigate vessels
Spinal
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3-4 inches
Beveled stylet within the cannula
Syringes
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Luer lock
Luer slip ( slip tip)
3-60 cc
Three ring or control syringe
Bulb
Asepto