SILLIMAN UNIVERSITY COLLEGE OF NURSING : Oumaguete City WOUND CARE Wound ~ an injury to the body (as from violence, accident, or surgery) that typically involves laceration or breaking of a membrane (such asthe skin) anc usually, damage to underiving tissues Classification of wounds ‘A. Open wound - it involves a break in the skin that leaves the internal tissue exposed and allows the blood and other fluids to be lost from the body allows entrance of microorganisms. y Incised ~ a clean cut from a sharp edge, such as broken glass or a knife, that causes an incision cau Laceration ~ a crushing or ripping forces results in a rough tears on the tissues. . ‘Abrasion ~ a superficial wound in which the top layers of the skin are scraped.of, leaving a raw tender area Punctured -a wound with a small entry site, but with a deep track of internal damage. Gunshot ~is physical trauma due toa bullet from a firearm. Damage may include bleeding, broken'bones, gtgan damage, infection of the wound, or loss of the ability to move part ofthe body. The entry point may be small Dut the exit point may be large and ragged. Avulsion ~ a forceful tearing away or separation of tissues from the casualty or patient's body. 7. Pressure ulcer - (also known as pressure sores or bedsores) are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. 8. Closed wound - tissue damage and bleeding occur under the surface ofthe skin. Bleeding is purely internal 1. Contusion ~ (bruise) a blunt blow or punch and rupture the blood vessels (capillaries) beneath the skin 2. Blisters - a fluid-filled elevation of the epidermis often caused by burns or constant rubbing ‘Types of Bleeding in Wounds z ‘A. Arterial bleeding — bright red due to high oxygen content. Blood spurts from the wound in time of heart beat. A severed main artery may jet blood several feet high and rapidly reduces the volume of circulating blood., B._ Venous bleeding — the blood is dark red in color due to the deoxygenated blood in the veins. Bleeding isles profuse than arterial bleeding. C. Capillary bleeding - this type of bleeding occurs atthe site ofall wounds. Blood loss is usualy slight. Severe External Bleeding . ‘A. Objectives of Treatment ; 1. Tocontrol the bleeding. : 2. Toprevent and minimize the effects of shock. 3, Tominimize the risk of infection(s). 44, To arrange for the urgent transport of the casualty to the nearest hospital B. First Aid , 1._ Remove or cut clothing to expose the wound. Watch for sharp objects such as glasses that may injure you. 2. Apply direct pressure over the wound, with your fingers or palms, preferably over a sterile dressing or clean pad. Note: Use the cleanest material or cloth available if there is no sterile dressing, if you can not apply direct pressure, for example, an abjectis protruding, just press down firmly on either side. Do not attempt to remove or pull the object. 3, Raise and support an injured limb above the level of the casualty’s heart, : 4. Laythe casualty down. This will reduce blood flow to the sit of injury and minimize shock : 5. Leaving any original pad in place, apply another sterile (if available) dressing ontop and secure with a bandage firmly, but not so tightly as to impede the circulation. If blood still seeps through, add another {dressing on top and secure it with a bandage.cl _A there is a protruding foreign body, build up padding on either side of the object and apply bandage without pressing the object down, Secure and support the injured part with band 7. Do the following a) Dial for an ambulance. ') Treat for shock ©). Check the dressing for seepage. ) Check for circulation beyond the bandage 5 : : Application of indirect Pressure , This may e applied if ts impossible to apply direct pressure, or if direct pressure is insufficient to staunch : bleeding from a limb. . a) Indirect pressure may be applied to a pressure point above the bleeding artery, where the main artery runs, lose ta the bone. )_Firstidentiy the artery by feeling for pulsation and then apply pressure until the blood supply to the limb is" sreatly reduced ©) Hourly release of tourniquet for 10 minutes. 4d) Pressure points: : di. Brachial pressure point —runs along the inner side of the upper arm 4.2. Femoral pressure point - where femoral artery crosses pelvic bone in the center of the groin crease. Dressings A Jefinition Z It isa piece of material placed on wound to help control bleeding and/or cover the wound to protect it from contamination, thereby reducing the risk of infection. General Rules for Applying Dressings 1. The dressing pad should always extend well beyond the wound's edges. 2., Place dressings directly on a wound. Do not slide them from the side. 3. If blood seeps through, do not remove but instead apply another dressing over the top. 4, Ifthere is only one sterile dressing, use this to cover the wound and use another clear! material as top dressings. Types of Dressings 1. Hydrocolloid dressings can be used on burns, wounds that are emitting liquid, necrotic wounds, pressure Ulcers, and venous ulcers. These are non-breathable dressings that are self-adhesive and require no taping, It creates a moist condition and helps in healing 2. Hydrogel can be used for a range of wounds that are leaking little or no fluid, and are painful or necrotic wounds, or are pressure ulcers or donor sites, Hydrogel can also be used for second-degree burns and infected wounds. 3. Alginate dressings are made to offer effective protection for wounds that have high amounts of drainage, and burns, venous ulcers, packing wounds, and higher state pressure ulcers, These dressings absorb excess liquid and create a gel that helps to heal the wound or burn more quickly. . 4, Collagen dressings can be used for chronic wounds or stalled wounds, pressure sores, transplant sites, ‘| surgical wounds, ulcers, burns, or injuries with a large surface area. These dressings act as a scaffolding for ‘new cells to grow and can be highly effective when it comes to healing : 5. For wounds. varying degrees of severity, foam dressings can work incredibly well, as well as for injuries | that exhibit odours. Foam dressings absorb exudates from the wounds surface, creating an envionment that promotes faster healing. : 6, Transparent dressings are useful for when medical professionals or carers want to monitor wound healing, as these dresings cover the wound with a clear film. These make identifying potential complications much easier, such as by making infections easier to spot at an earlier time, .dressings are the most commonly used dressings, often used to protect open wounds or areas of 7 beoken skin, They are suitable for minor injuries such as gazes, cuts or areas of delicate skin. These ‘ A %2ssin@8 core inal shapes and sizes, from small coverings for fingers to larger ones for wounds across . wider areas of the body. Cleaning and Dressing of Wounds: Steps . 1._Assess the wound in terms of the following: site, the size of the wound, type of wound and the type of bleeding, , 2. Plan for appropriate action: : ; ‘Stop the bleeding and prevent shock G Clean the wound and apply dressing + Refer the patient to the nearest heath facility , , 3. Wash hands ‘ : Prepare the equipment and supplies for wound care ‘ * Soap and water for dirty wound Hydrogen peroxide for infected wound ‘© Betadine cleanser and/or antiseptic orother antiseptic recommended by the institution. . ‘+ 0.9% Sodium Chloride (for wound washing/flushing) : + Sterile gauze Plaster : Clean gloves Working forceps : + Picking forcep (sterile) needed in the hospital setting 5. Implementation a) Assemble the equipment at the bedside. b) Putthe gloves on. é c)_ Inthe community setting, may ask the patient to wash the wound with soap and water. 4) Clean the wound from the center to the outer portion, until it becomes clean, using the available wound . cleansing agent. For old dirty wound, may use hydrogen peroxide and betadine cleansing solution for fresh wounds. Repeat as necessary. €)_ Dry and apply betadine antiseptic. ) Apply sterile dressing directly over the wound. 4). Secure the dressing with an adhesive tape or plaster. 6, After care Wash hands 8, Documentation a) site b) Type ¢) Size d)_ Type of bleeding fe). Eleansing agent and antiseptic used f) Response of the patient. 4). Signature References 4 httos://aww.clhgroup.co.uk/news-articke/2017/09/ 12/7-type> of wound dressings wher to. hitps://wwwgoogle,com ‘ : hitps://wwew.merriaun webster, com diction yfevounel Silliman University College of Nursing. Level 2 procedure manual httos://tourniquets.org/tourniquet cull applications Prepared by Asst. Prof. Rochie C. Cagara 9/16/19 Rae ridtore ~