DUY TAN UNIVERSITY

FACULTY OF NURSING

Wound Management
 Objectives

◆Demonstrate the principle and purpose of the

dressing a wound using the aseptic non-touch
technique. (ANTT)

◆ Present and strictly follow the technical process of

wound dressing.
 Protection

Reduce
bacterial Moisture
presence Wound
dressing

Haemostasis Manage
exudate
PRINCIPLES

Sterility

1:1

Priority
Wound Assessment

Wound charateristic
• Location
• Quantities
• Duration of presence

General health status

Nutrition
 CLASSIFICATION OF WOUNDS

Clean Wounds
• As a surgical wound that is not infected, does not
show inflammation, the treatment progresses well,
epithelization, or in the stage of premature skin.
Infected wound

• The wound has signs of

inflammation: swelling,
heat, redness, pain, oozing
fluid.
• If the infection lasts, there
is pus or necrosis.
• Necrosis, pseudomembranous
IDENTIFY?

RECOMMEND
ED TO DO
WHAT?

Huhhhhh…..
Phases Of Wound Healing
 PREPARING THE PATIENT

View records, compare, inform and identify

patient. (ask about pain)
Wound
Chart
Preparation of medical staff
Dsdha Dsdha
Prepare instruments
PREPARATION OF TOOLS

Dsdha
 2

Package of sterile equipment

Explain, motivate patients, put patients in
appropriate positions
- Spread plastic sheets under the wound,
reveal the location of the wound
- Place the kidney dish next to the wound
Cách tiếp bông
 How to Clean Stitches
- From top to bottom and inside and out
- Wash each stitch only
- Rolling (if necessary)
- Let wound dry
Removing Stitches
 Technical process

• Apply the medication to the wound (if indicated).

• Apply gauze to cover the wound, fix the
adhesive tape firmly
- T-shaped tube (Kehr tube) used to drain bile ducts.
 Technical process

- Wash from top to bottom and inside and out

- Wash each tube separately
- Wash from top to bottom and inside and out
- Wash the skin around the leg of the drainage tube 3 to 5cm
wide
- Wash the drainage tube body: up to 5cm from the leg of the
tube.
 DRAIN TUBE REMOVAL

•
 Technical process
• Use absorbent gauze and clean the fluid in the tube
placement hole
• Antiseptic to remove the drain
• Apply gauze and tape.
Changing bandages of an
INFECTED WOUND

• Infected wound has stitches

• Open infection wound

• Bacterial wound with holes, probe

 Open wound infections
- Wash the outer skin of wound: wash from the outer
to the edge of wound in a spiral many times to clean.
- Remove kelly 1 into the bucket of solution presept.
- Wash from the inside to the outer edge of the wound
with the second sterile Kelly , spiraling until clean.
- Use dry cotton to press the edge of the wound to clean.
- Wash from the inside out to the edge of the wound.
- Antiseptic outside the wound with povidine solution:
starting from the edge of the wound, antiseptic from inside to
outside in a spiral, permeable.
- Meche (ribbon gauze) used for deep wounds
 Deep wound and Ribbon
Gauze (Meche)

- Perform the same steps as you would to clean an infected

wound
-Cut the length of the meche appropriate to the wound.
- Use sterile forceps to pick up ribbon gauze/meche
soaked in 0.09% normal saline
- Pack Meche/ribbon gauze neatly into the wound.
 Clean up tools
• Clean dirty tools and bandages.
• Put patients at a comfortable posture, advise patients
• Record on care cards.
Ostomies and
Stomas
Objectives

- Help the incision recover quickly.

- Control and protect stoma and surrounding
skin.
- Detect complications for timely treatment.
Indications for a stoma
- Colon cancer that is in the late
stages and cannot be removed.
- Servere rectal ulcer bleeding.
-Excess colonic disease (Bệnh túi
thừa đại tràng).
- Rectal leak
- vaginal – rectal or rectal- Bladder
fistula.
-Injury
-Other dysfunctions.
Classification of stomas

Temporary- only used for a

short amount of time until the
colon heals.
A Stoma is used to remove
stools in the bowel due to
colorectal cancer which can be
removed.
-with the purpose of enemas to
prepare for a major surgery
after 1-2 weeks.
Stoma
bag
types
Document

- Documentation: Stoma’s mucosal

condition, color, properties, number
of stools, skin condition around the
stoma.
 Additional information

Some points to note:

- For reusable artificial stoma bags, stoma will be
maintained for 3-7 days.
- Clean bags when stool is full of 1 / 3 -1 / 2 bags.
- The first time should change bags or hygiene at
the time when the intestines least active. For
example, early in the morning before breakfast.
- Encourage the patient to rest on the spot for at
least 5 minutes after replacing the stoma bag.
Diet

Foods that cause

Foods that can cause
excess odour/gas
loose stools ● Onions
● Fruits, vegetables and salads ● Garlic
● Alcohol ● Fizzy drinks
● Fizzy drinks ● Fish
● Chocolate ● Beans
● Fruit juice ● Cucumber
● Fish ● Peas
● Spicy food ● Kale, broccoli,
● Nuts cauliflower, sprouts,
● Caffeine cabbage
● High fibre food such as bran ● Alcohol
● Foods high in saturated fat/ ● Chewing gum
processed foods/ fast foods