MEDICAL-SURGICAL NURSING SKILLS 1.

Acute wound: is traumatic or surgical and

LABORATORY moves through the stages of the healing
WEEK #3 process in a predictable time frame
WOUND CARE 2. Chronic wound: does not progress through
the stages of healing and is not resolved over
WOUND AND HEALING an expected period of time regardless of the
- A wound is a break in the skin (the outer cause
layer of the skin is called the epidermis).
Wounds are usually caused by cuts or Methods of Wound Healing
scrapes. Different kinds of wounds may - Wound healing is the process by which
be treated differently from one another, damaged tissue is restored to normal
depending upon how they happened and function
how serious they are. - Healing may occur by:
- Healing is a response to the injury that o Primary Intention
sets into motion a sequence of events. o Secondary Intention
With the exception of the bone, all o Tertiary Intention
tissues heal with some scarring. The
object of proper care is to minimize the PRIMARY INTENTION HEALING
possibility of infection and scarring - Involves the union of the edges of a
wound under aseptic conditions, for
PHASES OF WOUND HEALING example, a laceration or incision that is
I. Inflammatory Phase closed with sutures or skin adhesive
A. Immediate to 2-5 Days - The wound edges are sharp and
B. Hemostasis completely clean and free of microbes as
a. Vasoconstriction is the case with a wound produced via
b. Platelet aggregation surgical incision (in a sterile
c. Thromboplastin forms clot environment)
C. Inflammation - It is also possible to close some cuts
a. Vasodilation caused by trauma via primary intention
b. Phagocytosis but they need to be sutured within 4 to 6
II. Proliferative Phase hours after the incident in order for the
A. 2 days to 3 weeks wound edges not have become too
B. Granulation inflamed, colonized, or necrotic
o Fibroblasts lay bed of collagen - The advantage of primary healing is that
o Fills defect and produces new the time to closure is short which
capillaries reduces the risk of infection and,
C. Contraction furthermore, the scarring is limited. If
o Wound edges pull together to reduce the wound edges cannot be
defect approximated, the wound will need to
D. Epithelialization heal by second intention
o Crosses moist surface
o Cell travel about 3 cm from point of SECONDARY INTENTION HEALING
origin in all directions - It occurs when the wound’s edges cannot
III. Remodeling Phase be brought together
A. 3 weeks to 2 years - The wound is left open and allowed to
B. New collage forms which increases heal by contraction and epithelialization
tensile strength to wounds - Epithelialization encourages restoration
C. Scar tissue is only 80% as strong as of the skin’s integrity
original tissue - Wounds that heal by secondary intention
include surgical or traumatic wounds
CLASSIFICATION OF WOUNDS where a large amount of tissue has been
lost, heavily infected wounds, chronic
 wounds or, in some cases, where a better 3. Plastic disposable bag
cosmetic or functional result will be 4. Clean gloves
achieved 5. Sterile gloves

TERTIARY INTENTION HEALING II. Assessment:

- Refers delayed primary closure, occurs 1. Assess wound for moisture, debridement,
when a wound has been left open, and is infection, and cleanliness.
then closed primarily after a few days’ Rationale: to assess wound appropriately
delay, usually once swelling, infection or 2. Make sure drainage from wound site is
bleeding has decreased contained and adjacent skin is protected
- Delayed primary closure is a Rationale: To prevent microorganisms from
combination of healing by primary and entering wounds
secondary intention and is usually 3. Make sure skin sealant is used appropriately
instigated by the wound care specialist to Rationale: To maintain sterility during
reduce the risk of infection dressing changes
- In delayed primary closure, the wound is 4. Check that dressing is dry on air-exposed
first cleaned and observed for a few days site.
to ensure no infection is apparent before Rationale: To prevent bacterial proliferation
it is surgically closed 5. Make sure drainage system is operating.
- Examples of wounds that are closed in Rationale: To maintain drainage if a
this way include traumatic injuries such drainage system is used
as dog bites or lacerations involving
foreign bodies III. Wound Assessment Procedure
1. Wear Sterile gloves
FOUR STAGES OF WOUND HEALING 2. Examine wound. Note appearance of wound
1. Hemostasis bed. Check for exudate, drainage, necrotic,
2. Inflammation Phase tissue or sign of infection
3. Proliferation Phase 3. Assess surrounding area for problems in
4. Maturation Phase skin nutrition
o Atrophy, loss of hair, thickening of
New Trends: nails
- Major trend is to use moisture retentive o Edema of skin or scaly skin
dressing rather than drying the wound o Skin hydration
(this allows the tissue to granulate) o Skin integrity or maceration
- Moisture enhances cellular activity in all o Skin color (red – inflammation;
phases of wound repair, facilitates white – arterial insufficiency; black
autolytic wound debridement of necrotic – necrosis; brown – venous
tissues, enables epithelial cells to migrate insufficiency)
into the wound bed, insulates and o Skin temperature (cool, cold, warm,
protects nerve endings normal)
4. Assess extent of wound
Clinical Notes o Measure length and width of wound
- Document how long the client has had using disposable measuring device
wound o Measure depth of wound by using
- Determine previous treatment if there are the cotton-tipped applicator stick
any and treatment results o Check for tunneling or sinus tract by
- Check for allergies placing cotton-tipped applicator stick
into suspected area advancing until
WOUND ASSESSMENT resistance is met
I. Equipment Needed 5. Observe color of wound
1. Pliable disposable measuring device a. Black – necrotic tissue
2. Cotton-tip applicator stick b. Yellow – pus, fibrin, debris
 c. Red – wound ready to heal 3. Tape
6. Assess for wound drainage 4. Sterile round bowl
a. Type – dry or moist 5. Sterile emesis basin
b. Amount – minimum, moderate, 6. Sterile gloves
maximum 7. Absorbent pads
c. Color of drainage 8. Disposable bags
§ Clear – serous 9. Googles
§ Brown, brown-yellow –
slough Clinical Note
§ Yellow, yellow-green – pus - If a wound is clean and has granulation
from strep or staph tissue present, cleaning is
§ Blue-green – pseudomonas contraindicated
7. Assess for level of moisture in wound
o A moist environment allows wound Rationale: Wound healing can be delayed by
to heal without forming a scab destroying newly produced tissue. It can
8. Assess odor of wound also remove exudate that may have
a. Foul – infected (necrotic tissue has bactericidal properties
an odor if not infected II. Procedure
b. Sweet – pseudomonas infection 1. Check physician’s order for wound cleaning
Laboratory Assessment: solution. Sterile saline or noncytotoxic
- Laboratory values need to be assessed solution should be used.
routinely while the wound is healing Rationale: other products such as hydrogen
1. Increased WBC count indicates infection peroxide should be avoided as they are toxic
2. Low hemoglobin and hematocrit indicate to cells
anemia, which can decrease oxygen 2. Pour cleaning solution over gauze pads
transport to the wound o Do not use products that shed cotton
3. Altered serum glucose level fibers. This can lead to foreign body
reaction, thus delaying the healing
WOUND CLEANING process prolonging the inflammatory
phase
Principles of Wound Cleansing o If antimicrobial solutions are used,
be sure to dilute it
- The aim of wound cleansing is to help
o Warm solution to body temperature
create the optimum local conditions for
(this prevents lowering of wound
wound healing
temperature delaying the healing
1. Sodium Chloride (0.9%) is a
process)
physiologically balanced solution that has a
3. Wear sterile gloves
similar osmotic pressure to that already
o Pick up several gauze pads, pulling
present in living cells and is therefore
edges together to form a ball
compatible with human tissue
(prevents glove from touching the
o Although sodium chloride has no
wound)
antiseptic properties, it dilutes
o Sterile cleansing solutions can be
bacteria and is non-toxic to tissue
poured directly over wound before
2. Use of tap water for irrigating chronic
gauze pads are used for cleaning.
wounds; no significant difference has been
Place emesis basin on side of patient
shown in the healing and infection rates in
to catch excess cleansing solution
wounds irrigated with tap water or 0.9%
o Clean wound from cleanest to dirtiest
sodium chloride
o Clean from top to bottom using new
I. Equipment
gauze with each stroke
1. Sterile normal saline or any non-cytotoxic
WOUND IRRIGATION
wound cleanser
I. Equipment
2. Sterile dressing
1. Same as in wound cleaning
 2. Warm irrigation solution 1. 4X4 gauze
3. Syringe: 30 to 60 mL syringe 2. ABD pads
4. Clean and sterile gloves (2 pairs) 3. Sterile solutions
II. Procedure 4. Sterile gloves
1. Check orders for type and amount of 5. Clean gloves
irrigating solution to be used 6. Tape
2. Don sterile gloves and remove dressing, 7. Disposable bag
discard dressing and gloves in disposable II. Procedure
bag 1. Identify type and number of dressings
3. Open sterile supplies, pour warmed and type of solution needed
irrigating solution into sterile basin 2. Clean over-bed table; open sterile
4. Don sterile gloves. Draw up solution packages and place on overbed table.
into syringe Arrange packages making sure you do
5. Instill solution into wound not cross sterile field
6. Place sterile emesis basin next to wound o Cut tape strips and place on over-bed
to catch irrigation solution as it drains table
from wound 3. Ensure that two packages of 4x4 gauze
7. Repeat irrigation process until its returns pads are open for use in outer dressing
are clear and free from debris o Fanfold top linen to foot of bed.
8. Cleanse around wound with moist gauze Provide patient’s privacy
pads; dry thoroughly with dry gauze o Place bag for soiled dressing near the
pads table
9. Remove gloves and place in disposable 4. Pour sterile solution into 4x4 gauze
bag dressing container
10. Don sterile gloves and apply dressing 5. Wear clean gloves and remove dressing.
11. Remove gloves and place in disposable Place in disposable bag
bag 6. Obtain wound specimen for culture if
ordered.
DRESSINGS o Remove clean gloves and dispose in
III. Principles of Dressing a Wound appropriate container
1. Allows gaseous exchange
2. Maintains optimum temperature and pH in Collecting Wound Specimen
the wound - Rinse wound with sterile NSS
3. Forms an effective barrier to bacteria - Use non-cotton tipped swab
(contains cellular debris or exudate to - Rotate swab while obtaining specimen
prevent the transmission of microorganisms - Swab wound edges starting from top;
into and out of the wound) crisscross wound to bottom
4. Allows removal of the dressing without pain - Do not take specimen from exudate
or skin stripping - Remove gloves and place in disposable
5. Is acceptable to the patient bag
6. Is highly absorbent (for heavily exuding - Wash your hands
wounds)
7. Is cost-effective 7. Don sterile gloves and have materials
8. Requires minimal replacement or needed for dressing change available
disturbance 8. Wring out several gauze pads until
9. Appropriate to the wound; debridement slightly moist (if dressing is too moist
activity, hemostatic properties, odor risk of infection and maceration of
absorbing surrounding skin is increased)
o Fluff moistened dressing and lightly
A. Wet to Damp Dressing paced them in all crevices and
I. Equipment depressions in wound
 o Necrotic tissues are usually in deep o Discard cotton balls in disposable
crevices (tightly packed wound bag
dressing inhibit wound edges from o Advance drain if ordered
contracting and may compress 5. Place precut 4x4 gauze under Penrose
capillaries) drain
o Irrigate wound if grossly o Place several 4x4 gauze pads under
contaminated drain site
9. Apply dry sterile gauze over moist o Apply 4x4 gauze pads over drain
dressing (Pads absorbs drainage and prevents
Rationale: This will absorb excess drainage from accumulating into
exudates skin)
10. Place sterile ABD pads over wound site 6. Place ABD pads over sterile gauze pads.
Rationale: Pads protects wound from Remove gloves and place in disposable
trauma and external contamination bag
11. Tape wound securely. Tape wound 7. Tape ABD pads securely to skin.
dressing lengthwise, top and bottom of Montgomery tie tape should be use if
dressing frequent dressing changes are required or
B. Dry Dressing for Open Wound Drainage client has sensitive skin
I. Equipment Penrose Cleaning
1. Dressings (4x4 gauze, ABD pads) - To advance Penrose drain, complete the
2. Precut sterile 4x4 gauze pads (2) following steps
3. Forceps and cotton balls 1. Using sterile forceps, pull drain out of
4. Sterile cleansing solution and sterile wound number of centimeters ordered
container 2. Reposition safety pin so it is at level of
5. Sterile safety pin skin. Pin prevents drain from slipping
6. Sterile scissors back into wound
7. Sterile gloves 3. Cut off excess tubing with sterile
8. Clean gloves scissors. Leave at least 2 inches of
9. Disposable bag tubing on outside. This prevents drain
II. Procedure from being drawn back into wound
1. Wear clean gloves opening
2. Remove soiled dressing and place in
WOUND DRAINAGE
disposable bag
I. Purpose:
o Remove clean gloves
- Collecting drainage especially if it is
o Open sterile packages; place on
excessive
overbed table
o Pour sterile cleansing solution into - Measuring drainage
container - Protecting skin from drainage
o Observe wound closely for sign of - Containing drainage
infection or healing - Containing microorganisms to decrease
3. Don sterile gloves and closely observe their spread to other areas
pin in Penrose drain - Decreasing frequency of dressing
o If pin is crusted, replace with new changes
sterile pin. Be careful not to dislodge II. Procedure:
the pin 1. Don clean gloves
4. Clean drain site with sterile solution. Use 2. Remove dressing and place in disposable
forceps with cotton balls soaked in bag
cleansing solution. Start cleansing at 3. Measure drainage from pouches as
drain site, moving in circular motion ordered
towards periphery 4. Remove clean gloves and wear sterile
o Rationale: This prevents infection of gloves
the drain site
 5. Clean drain site with sterile cleansing
solution and forceps and cotton balls.
New cotton balls for each site
6. Apply sterile dressing as ordered,
drainage pouches may be left open for
assessment
III. Equipment:
1. Specimen cup for measuring drainage
2. Input and output bedside record
3. Absorbent pad
4. Clean gloves
IV. Procedure
1. Wear clean gloves. Expose catheter
insertion site while keeping client draped
o Place drainage system on absorbent
pad or towel (to protect bed from
being soiled)
o Examine Jackson Pratt or Hemovac
catheter for patency, seal and
stability. If occluded, notify
physician
2. Empty Hemovac drainage system by
removing Hemovac plus from pouring
spout
o Pour drainage into specimen bottle
SAFETY ALERT: To maintain patency,
compress Jackson Pratt or Hemovac container
every 4 hours
3. Compress Hemovac by pressing top and
bottom together with your hands. Keep
pump tightly compressed while you
reinsert plug
4. Disconnect tubing from Jackson Pratt
system. Pour drainage into specimen
container
5. Compress bulb on Jackson-Pratt system
o Hold bulb tightly compressed and
connect to tubing
6. Place drainage system on bed (this
facilitates observation and drainage of
wound)
o Measure and record amount of
drainage
o Observe color, consistency, and odor