Wound Healing, Wound Types, Wound Dressings, & Drainage Devices ST230 Concorde Career College

Wound Types & Wound Healing Objectives: 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: 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: 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%) 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%) 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%) 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) Chronic

Wound Types & Wound Healing Intentional (Surgical) Incision Purposeful cut through intact tissue for the purpose of exposure or excision Wounds Excisional Removal of tissue

Wound Types & Wound Healing Six Types of Accidental Closed Simple Clean (Traumatic) Wounds Open Complicated Contaminated

Wound Types & Wound Healing Closed Traumatic Wound Skin Intact / Underlying tissue damaged Examples: Blister Simple Fracture

Wound Types & Wound Healing Open Traumatic Wound Skin Disrupted Examples: Laceration Compound Fracture

Wound Types & Wound Healing Simple Traumatic Wound Skin Disrupted/No loss or destruction of tissue/No foreign body implanted Examples: Minor penetration Cut with sharp object

Wound Types & Wound Healing Complicated Traumatic Wound Skin disrupted/Underlying tissue lost or destroyed/Foreign body implanted Examples: 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: 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: Crush Type Injury 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 Types & Wound Healing Types of Wound Healing First Intention (Primary Union) Second Intention (Granulation) Third Intention (Delayed Primary Closure)

Wound Types & Wound Healing First Intention (Primary Closure) 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 Phase I - Lag Phase or Inflammatory Response Phase Phase II - Proliferation Phase Phase III - Maturation or Differentiation Phase

Wound Types & Wound Healing 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) 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) Basal cells seal wound surface Fibroblasts begin reconstruction of nonepithelial tissue

Wound Types & Wound Healing Phase II - Proliferation Phase 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 Capillary networks established and lymphatic networks reformed

Wound Types & Wound Healing Phase II (continued) Definition: Tensile Strength: Ability to resist rupture 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 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 Cicatrix is formed

Wound Types & Wound Healing Second Intention (Granulation) 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 Pg. 282

Wound Types & Wound Healing Second Intention (Granulation) (continued) 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: Physical condition of the patient Intraoperative tissue handling Application of the principles of asepsis

Wound Types & Wound Healing Physical Condition Age Nutritional Status Disease (Chronic or Acute) of the Patient Smoking Radiation Exposure Immunocompromised or Immunosuppressed Patients

Wound Types & Wound Healing Intraoperative Length and direction of the incision Dissection technique (sharp or blunt) Length of surgery Hemostasis Tissue Handling 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 Strict aseptic technique Gentle handling of tissue Use of the finest suture material Small stitches and low tension on the tissue Complete closure of wounds whenever possible Refer to chapter diagrams for suturing types – interrupted sutures

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 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: 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 Dehiscence Evisceration Hemorrhage Infection Adhesions Wound Healing Herniation Fistula Sinus tract Suture complications Keloid scar formation Pg. 283-284 tables 11-2 & 11-3

Wound Types & Wound Healing

Wound Types & Wound Healing Knot Tying Basics Knot Security Knot Tying Principles Square Knot (Two Hand Technique) Surgeon’s Knot See Ethicon wound closure manual

Wound Types & Wound Healing Knot Security Knot security is of utmost importance in preventing wound complications Use the most simple; secure knot possible

Wound Types & Wound Healing Knot Tying Principles 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) Square Knot - Easiest and most reliable Surgeon’s Knot - Provides extra security

Wound Types & Wound Healing 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) Right over left (first throw) Left over right (second throw)

Wound Types & Wound Healing Surgeon’s Knot First step Right over left Repeat right over left Then tighten

Wound Types & Wound Healing Surgeon’s Knot Second Step Left over right Tighten DONE!! It should look like this...

Wound Types & Wound Healing Tissue Approximation Pg. 296-298

Wound Types & Wound Healing Suturing Techniques Primary Suture Line Holds wound edges together Heals by first intention May be continuous or interrupted

Wound Types & Wound Healing Suturing Techniques Secondary Suture Line 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 Also called “running” stitch Series of stitches placed with one continuous suture

Wound Types & Wound Healing 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 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 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 Over and Over Running Stitch

Wound Types & Wound Healing Continuous Suturing Techniques Interlocking Stitch

Wound Types & Wound Healing Interrupted Sutures Simple Interrupted Evenly spaced Equal depth Ends uniformly cut

Wound Types & Wound Healing Interrupted Sutures Vertical Mattress

Wound Types & Wound Healing Interrupted Sutures 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 ST4ST table 14-3 fig. 14-12

Wound Types & Wound Healing Layers of the Abdominal Wall

Wound Healing, Wound Types, Wound Dressings, & Drainage Devices ST230 Concorde Career College

Sponges Laparotomy Ray-Tec Cottonoids Tonsil Kittner Peanut Tapes, packs, laps Ray-Tec ray Cottonoids 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

Dressing Choice determined by several factors: 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 One-layer Three-layer Pressure Bulky Rigid Specialty Packing 82

Dressing One-layer dressing Cover small incisions Frequently used to cover IV access Transparent polyurethane film/adhesive backing 83

Dressing One-layer dressing OP-site Collodion Aerosol adhesive sprays, foams, gels Skin closure tapes 84

Dressing Three-layer dressing Inner (contact) layer Intermediate (absorbent) layer Absorbs drainage 4X4, kerlix, fluffs Outer ( securing) layer Tape, stockinette 85

3 layer dressing/ Contact Layer Nonpermeable Occlusive xeroform Semipermeable Semi-occlusive Exu-derm, aqua-gel Permeable Nonocclusive Telfa, adaptic Wicking action

Dressing Pressure dressing 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 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 Casts Splints Encircles Provide support Prevent movement Often incorporates the joint Splints Applied to one side of a structure Support Prevent unidirectional movement 89

Specialty Dressing Bolster Wet-to-dry Wet-to-wet Drain Ostomy Peri-pad

Dressing Packing 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. Penrose Cigarette T-tube Gastrostomy Cystostomy Nephrostomy

Penrose Drain

Drains Active Drains Negative pressure Connected to a collection device Hemovac Jackson-Pratt Stryker

Jackson Pratt(JP) drain

Hemovac Drain with trocar

Tubes 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 Arterial Intravenous Biopsy Used to withdraw fluid from medication or tissue 12g-30g; ½-4 inches long Arterial Used to place plastic indwelling catheter Intravenous Biopsy

Non-suture needles Insufflation Heparin Spinal Irrigate vessels 3-4 inches Beveled stylet within the cannula

Syringes Luer lock Luer slip ( slip tip) 3-60 cc Three ring or control syringe Bulb Asepto