Zanzibar university

• Faculty of health and allied sciences• Department of nursing and midwifery

• Prepared by:-• Abdullah khamis ngwali• Supervised by • Dr, zhu• General surgeon at abdulla mzee hospital

Pemba• 20th bench medical team of china

Contents

Definition

Classification of wounds

Pathophysiology of a Wound

Infection

Cardinal Signs of

Inflammation

Management of Wounds

Social Toilet

Wound Closures

Surgical debridment

Types of wound healing

Factors affecting wound

healing

Complication of wound

and their managements'

Wounds

RN,BSN. ABDULLA KHAMIS NGWALI

Wound

• Definition :-

• Disruption of the continuity of soft tissues

(skin and mucous membranes) produced by

external mechanical force

Classification of Wounds• Classification by degree of contamination:• Clean wounds are mostly those made in the

operating rooms in hospitals.• They have clear sharp edges, not contaminated

and have minimal tissue damage.• E.g- Neurological procedures, Endocrine

procedures, Eye surgery, Orthopedic procedures

Classification by degree of contamination cont...

• Clean contaminated wounds occur outside the operation rooms, they are potentially contaminated thus liable to develop infection. Tissue damage may be extensive.

• Gastrointestinal, respiratory or genitor-urinary tracts entered without significant spillage

Classification by degree of contamination cont...

• Infected wounds show obvious signs of infection like pus and necrotic tissue.

• Fresh traumatic wound from clean source • Gross spillage from the gastrointestinal tract

• Dirty - infected • Traumatic wound from dirty source • Traumatic wound with delayed treatment • Fecal contamination • Foreign body • Retained devitalized tissue

Classification according to onset

• Acute • Chronic

Classification according to mechanism of injury

• Cut wound• Penetrating wound• Stub / Puncture wound• Gun short wound• Laceration • Abrasion• Crush wounds• Avulsions

Classification according to mechanism of injury cont..

• Lacerations, irregular tear-like wounds caused by some blunt trauma

• Abrasions (grazes), superficial wounds in which the topmost layer of the skin (the epidermis) is scraped off. – Abrasions are often caused by a sliding fall onto a

rough surface.

• Puncture wounds, caused by an object puncturing the skin, such as a nail or needle.

PICTURE OF WOUND

• Abrasion Crush wound

CONTINUE..................

• Laceration stub wound

Classification according to mechanism of injury cont..

• Penetration wounds, caused by an object such as a knife entering the body

• Gunshot wounds, caused by a bullet or similar projectile driving into or through the body. There may be entry and exit wounds, such is generally known as a through-and-through.

• Avulsion injury - Soft tissue injury where a flap of tissue has been removed or is barely attached

Avulsion wound

CONTINUE......

• penetrating head trauma

• Penetrating chest trauma

• Penetrating abdominal trauma

Pathophysiology of a Wound Infection

• Most wounds are contaminated except for surgical wounds made under aseptic conditions.

• Wound infection follows contamination by dirt, damaged tissue, and foreign bodies.

• The bacteria invade tissues and cause more damage while tissues which have not been damaged resist infection by a process called inflammation.

Pathophysiology of a Wound Infection cont...

• When a wound is inflamed, blood vessels dilate to bring more blood to the injured part.

• The capillary walls change so that antibodies and white cells can pass through more easily.

• The result is the part becomes warmer and redder because there is more blood in it, and swollen because there are more white cells and fluid.

• Pain is partially due to increased swelling in the part, and partially due to the effects of the inflammation process.

Signs of Acute Inflammation (Cardinal Signs of Inflammation)

• Heat (Calor ) • Redness (Rubor )• Pain (Dolor )• Swelling (Tumor )• Loss of function (Functio laesa)

Pathophysiology of a Wound Infection cont...

Management of Wounds

• Wound Assessment

• Cleansing the Wound (Social Toilet)

• Surgical Toilet

Wound Assessment

History• How long ago was the wound sustained? • How was the wound sustained? • What is the status of active immunization against

tetanus? • Document any pain – location, causative factors,

intensity, quality, duration, alleviating factors, patterns, variations, interventions

Wound Assessment cont..

• Examination of the wound; look for:• Site • Depth and describe tissues involved • Edges • Active bleeding• Contamination• Document Size. Measure in centimeters –

ALWAYS Document Length x Width X Depth

Wound Assessment cont..

• Describe any drainage (exudate) – type, amount, or odo

• Sanguineous – thin, bright red • - Serosanguineous – thin, watery, pale red to pink • - Serous – thin, watery, clear • - Purulent – thick or thin, opaque tan to yellow • - Foul Purulent – thick opaque yellow to green with

offensive odor

Wound Assessment cont...

• Describe surrounding tissue: Color, edema, firmness, intact, induration, pallor, lesions, texture, scar, rash, staining, moisture

Management of Wounds

• Wound Assessment

• Cleansing the Wound (Social Toilet)

• Surgical Toilet

Cleansing the Wound (Social Toilet)

• Clean the wound and surrounding skin with soap and water.

• Do not use hard brush, sponge should suffice

Surgical Toilet

• All contaminated wounds need to undergo surgical toilet.

• Clean the wound by debridement (remove dead and damaged tissues using a knife and apply antiseptic solution).

Classes and Indications for Wound Closures

• Primary wound closure• Clean post operative wounds• Surgically clean wounds after surgical toilet

• Delayed primary closure• Done for contaminated wounds after surgical toilet• Wound is observed for three to four days observing for

onset of infection• If there is no infection then wound closure is

performed

CONTINUE...........

• Secondary closure• Indicated for obviously infected wounds• Closure is deferred until infection is under

control

CT,.........

• Close clean wounds immediately to allow healing by primary intention

CT..........

• Do not close contaminated and infected wounds, but leave them open to– heal by secondary intention

• In treating clean contaminated wounds and clean wounds that are more

• than six hours old, manage with surgical toilet, leave open and then close 48 hours later. – This is delayed primary closure.

• Contraindications to Secondary Closure• wounds that are associated with exposure of an

important underlying structure or are located in areas where a tight scar will be

• particularly problematic• Fracture sites, • Tendons • Prosthetic devices (e.g. artificial joints)

Types of wound healing

• Primary intention healing• When wound edges are re-approximated by

sutures (stitches), staples, or adhesive tape• Minimizes scarring• Example - Most surgical wounds

Secondary intention healing

• The wound is allowed to granulate• Healing process can be slow due to presence

of drainage from infection• Results in a broader scar

Tertiary intention healing

• Occur in delayed primary closure or secondary suture.

• contaminated wound• If the cleansing" of the wound is incomplete,

chronic inflammation can ensue, resulting in prominent scarring.

Factors that affect wound healing

Patient factors • Age• Weight• The patient’s nutritional status• Dehydration• Adequate blood supply to the wound site • Underlying illnesses or disease: – anemia, diabetes or immunocompromised

• Effect of the injury on healing (e.g. devascularization)

Factors that affect wound healing cont..• Wound factors (Local factors)• - Organ or tissue injured• - Extent of injury• - Nature of injury (for example, a laceration

will be a less• complicated wound than a crush injury)• -Contamination or infection• -Time between injury and treatment (sooner

is better)

• Foreign bodis• Ultravolet light• Faulty technique in wound closure

Systemic factors

• Hormones such as glucocorticoids - inhibit collagen synthesis and have well-documented anti-inflammatory effects

• Inadequate blood supply• Metabolic status can change wound healing.

Diabetes mellitus - consequence of the microangiopathy

• Nutrition – protin, vit C,A,Zn, Ca, Mn

• Chronic diseases. Coronary artery disease, peripheral vascular disease, cancer, and diabetes mellitus, jaundice, uraemia.

Vitamin C• Collagen synthesis and subsequent

crosslinking as well as the formation of new blood vessels (angiogenesis)

• help the immune system• increases the absorption of iron.

Vitamin A

• increases the inflammatory response in wounds, stimulating collagen synthesis.

• can restore wound healing impaired by longterm steroid therapy or by diabetes.

Trace elements

• Zinc plays a key role in protein and collagen synthesis, and in tissue growth and healing

• Iron• provides oxygen to the site of the wound

(haemoglobin)

Complications of Wounds and Their Management

• Cellulitis• Non suppurative invasive infection of

surrounding tissues by organisms such as ß-haemolytic streptococci, staphylococci and Clostridium perfringens.

• Treatment - application of local antiseptic and systemic antibiotics

Septicemia

• Multiplication of bacteria in the blood with the production of severe systemic symptoms such as fever and hypotension.

• It has an extremely high mortality • It demands immediate and appropriate

attention.• It is managed by adequate rehydration,

systemic antibiotics and antipyretics

• Soft tissue injuries are those injuries excluding fractures, affecting the joints and muscles of the limbs

• Ligaments connect bone to bone• Tendons connect muscle to bone• Strains: Injuries to the musculotendonous unit• Sprains: Ligamentous injuries associated with

the overextension of a joint

• The treatment of soft tissue injuries is based on resting the injured part, applying ice packs to limit swelling and reduce pain by prescribing analgesics or local analgesic cream or gel.

• R= Rest I= Ice C= Compression E= Elevation

Complications of Soft Tissue Injuries

• Compartment Syndrome• Increased tissue pressure within a muscle

compartment compromising the blood supply and the function of structures within that space. Causes

• Tight casts or dressings• External limb compression• Burn eschar• Fractures

Clinical presentation

• Pain out of proportion to the injury• Puffy/tense muscle compartments to palpation • Parasthesia (decreased sensation)• Paralysis (weakness of the involved muscle

groups) • Pallor • Pulselessness (decreased capillary refill, late

finding)

Management

• Split the cast and remove dressings, if present• Place limb in neutral position; elevation may be

harmful• Support circulation with IV fluids or blood where

indicated• Observe carefully for improvement i.e. colour, pulse

and pain• If signs and symptoms persist, refer for immediate

surgical decompression (fasciotomy)• Fasciotomy must be performed early, ideally within six

hours of the onset of symptoms

Myositis Ossificans

• Myositis ossificans is an unusual condition that often occurs in athletes who sustain a blunt injury that causes deep tissue bleeding.

• Severe bleeding into the muscle creates a hematoma, which may trigger a healing pathway that leads to formation of ectopic bone in the muscle.

• Treatment of myositis ossificans consists of: • Rest • Immobilization in a stretched position

Complication of wound healing

• Implantaton cyst• Painfull scar• Keloids • Neoplasia squamous cell carcinoma

AHSANTENI