wound_dressing

Wound Dressing

Wound dressing is a method of carrying out surgical dressing and operative treatment with an aim to prevent the entry of Micro organisms into the wound.

 

Wound : A cut or break in the normal continuity of the skin or body structure internally or externally

OR A wound is a cut or break in the continuity of any body tissue.

Classification of wounds

According to

  •  Manner of production
  • Bacterial content
  • According to extent.
  • Time
 Manner of production.

Abraded wound or Abrasion. Is one produced by friction which removes the superficial layer of the skin. E.g. Falling in the sand or rough surface etc.

Incised wound: is the one as a result of sharp cutting instrument which produces a clean and simple separation of tissue e.g. Operation wounds.

Contused wounds: Is one made by a blunt object which is characterized by considerable injury of the soft part resulting in hemorrhage and swelling E.g. injury by a blow or falling weight on the body.

Lacerated wound: Is one in which the tissue are tone and the edges are irregular and ragged E.g. Injury by glass, metal e t c.

Penetrating Wounds: Is one that passed through deep lying tissues to enter an important deep body cavity or organ e.g. Stab injury with knife, long nail.

Punctured wound: is one made with a sharp pointed narrow instrument E.g. piercing Nail, Glass pieces etc in the leg or any other part of the body.

According to bacterial content.

Clean wound: is one in which no pathogenic organism are present when an incision is made under aseptic conditions, the wound remains clean e.g. such wounds made in surgery usually heal without infection. However the skin cannot be completely rendered sterile, it is therefore impossible to have a completely sterilized wound; they are thus protected and some micro organisms made harmless by the body’s depressive mechanism.

Contaminated wound: is one in which considerable number of micro organisms is present in the wound. All wounds acquired by accident are contaminated since no preventive measures such as aseptic techniques have been applied.

Septic Wound: is one which is affected by pathogenic micro – organism. It contains large numbers of pathogenic organisms which have caused the destruction of tissues in the affected area with subsequent development of pus. A clean or contaminated wound may become infected very rapidly that the defensive body mechanism of the tissue involved is infective due to many reasons like unsterile technique during wound dressing.

According to extent

Open Wound: is one in which there is cut or break in the continuity of the skin or mucous membrane as caused by a sharp instrument or object, communicates with other body tissues and there is a possibility of entry of organisms and foreign particles.

Closed Wound: is one in which there is no break in the continuity of the skin and mucous membranes but accompanied by damage of the tissue under the skin as caused by a blunt object.

Time

Acute wound: is any surgical wound that heals within or before 4 weeks.
Chronic wound:  is a wound that fails to progress healing or respond to treatment over the normal expected healing time frame (4 weeks) and becomes “stuck” in the inflammatory phase. 

WOUND HEALING

Wound healing refers to body’s replacement of destroyed tissue by living tissue.

Factor affecting wound healing.

  • Age.
  • Nutritional status.
  • Type of wound.
  • Blood supply to the affected area.
  • Presence of foreign bodies
  • Infection and Foreign bodies in the wound.
  • Lack of rest of the affected part.
  • Haemorrhage.
  • Presence of dead space in the wound.
  • Malnutrition- inadequate supply of protein, carbohydrates, lipids and trace elements and vitamins essential for all phases of wound healing
  • Medications- NSAIDs, chemotherapy, immunosuppressive drugs, corticosteroids
  • Stress, anxiety and depression
  • Underlying disease- diabetes, autoimmune disorders, anaemia and malignancy
  • Infection
Types of Wound Healing (Classification of Wounds Closure)
  1. By primary intention or by First intention. This is where wound surface has been approximated by sutures and the wound kept at rest.
  2. By secondary intention or granulation; occurs when there has been tissue damage or infection. The space of the wound fills with a red, soft tissue, well supplied with blood capillaries (granulation) and healing is complete when the epithelium grows over those granulations; this mode of wound healing requires daily wound dressing since the wound might get infected.

Phases of Wound Healing

When the skin is injured, our body sets into motion an automatic series of events, often referred to as the “cascade of healing,” in order to repair the injured tissues. The cascade of healing is divided into these four overlapping phases: Hemostasis, Inflammation, Proliferative, and Maturation.

(a) Haemostasias– is the rapid response to physical injury and is necessary to control bleeding. It involves the following components:  Vasoconstriction, Platelet response, Biochemical response

(b)  Tissue Repair & Regenerationinvolves 3 phases:

  1. Inflammation occurs when the damaged endothelial cells release cytokines that increase expression of integrands in circulating lymphocytes. Histamine, serotonin, and kinins cause vessel contraction (thromboxane), decrease in blood loss, and act as chemotactic factors for neutrophils, the most abundant cells in the initial 24 hour period.
  2. Proliferative phase occurs next, after the neutrophils have removed cellular debris and release further cytokines acting as attracting agents for macrophages. Fibroblasts now migrate into the wound, and secrete collagen type III. Angiogenesis occurs by 48 hours. The secretion of collagen, macrophage remodeling and secretion, and angiogenesis continues for up to 3 weeks. The greatest increase in wound strength occurs during this phase.
  3. Maturation phase is the final phase and starts from the 3rd week and continues for up to 9-12 months. This is where collagen III is converted to collagen I, and the tensile strength continues to increase up to 80% of normal tissue.
wound dressing Phases-of-the-wound-healing-process

Care of wounds:

  • Dressing method.
  • Non dressing method.

Advantages of dressing

  1. To absorb drainage.
  2. To prevent contamination from feaces, urine, vomit’s etc.
  3. For splinting or immobilization of wound.
  4. To protect the wound from mechanical injuries.
  5. To promote the haemostasis, hence preventing bleeding.
  6. For patient’s comfortability both psychologically and physically.

Advantages of non-dressing method

  1. To eliminate the conditions for the growth of bacteria such as warmth, moisture and darkness.
  2. Allows better observation and daily detection of abnormalities in the wound.
  3. Facilitates bathing of the patient.
  4. Avoid adhesive tape reaction.
  5. It is more economical.
  6. Appears to be more comfortable to the patients and facilitates his activity.

Disadvantages of non-dressing

  • The sight of a large wound and the number of sutures may be fearful to the lay persons.
  • The rate of contamination may be increased due to unhygienic environment and carelessness of the patient and relatives such as dirty bed linen scratching the wound site etc

Qualities of a good dressing

    • Should be sterile.
    • Should be light.
    • Should be porous.
Types of dressing
  1. Dry dressing– are used in clean wounds. Clean wounds are dressed by the application of 4 to 8 layers of gauze folded into suitable size and shape; the surrounding of the wound is cleaned by some antiseptic and dried. Usually dry dressings are applied after application of medicine to the wound.
  2. Wet dressing: Are used if wounds are infected and there is a lot of pus, meant to soften the discharge and to promote drainage. Often the dressings are made wet with an antiseptic, made of many layers of gauze or cotton pad covered with gauze.
  3. Pressure dressing. These are made of a thick pad of a sterile gauze applied over the wound with afirm bandage or binder in case where there is bleeding or oozing from the wound.

General rules for wound dressing

Wounds become infected with microorganisms on ward mainly from the following sources.

  • The air with dust or infected droplets of moisture from the nose and the mouth of patient and staffs.
  • Hands of Nursing and medical staff.
  • Imperfect technique in handling and dressing.
  • Use of unsterile instrument during dressing.

To prevent these risks or dangers of wound infection, the following rules must be observed.

  1.  All bed making, mopping of the floor and dusting must be finished at least one hour before the
    dressing round is started.
  2.  To prevent spread of infections.
  3.  Before the dressing round, wash the trolley with soap and water and dry it.
  4.  Before each dressing, wipe the trolley shelves with disinfectant using a mopper.
  5.  Sterile articles are placed on the top shelf, unsterile articles on the bottom shelf.
  6.  Clean wounds are always dressed first
  7.  Limit movements in the ward and windows near to the patient to being dressed must be closed.
  8.  Do not carry out dressing when having a focal wound or droplet infection.
  9.  If possible 2 nurses should be available to carry out dressing.
  10.  To prevent cross infection.
  11.  To prevent contamination and save time.
  12.  Apply universal infection prevention and control before and after each procedure.
  13.  To prevent spread of infections
  14.  Nails must be short, watch and rings should be removed.
  15.  Masks are worn if required and once in position they must not be handled.
    >   When removing the mask, handle only the tapes and dispose of immediately.
    >   Never put a used mask in the uniform pocket.
  16.  Lotions: The dressing assistant should pour only enough lotion for one dressing. Unused lotion must be disposed of when clearing the trolley.
  17.  The trolley is reset for each dressing.
  18.  All used equipment must be decontaminated, washed with soap water, brushed, dried and sterilization.
  19.  The trolley is cleaned with disinfectant

Dressing a Clean wound

A clean wound is a superficial wound produced by uncontaminated sharp objects, either electively–e.g. surgical procedure or by accident, being cut by sharp glass or metal–e.g. broken glass.

Purpose

  •  To keep wound clean
  • To prevent the wound from injury and contamination
  • To keep in position drugs applied locally
  • To keep edges of the wound together by immobilization
  • To apply pressure

Dressing trolley for clean wounds

Top shelf.

>  Dressing pack with the following;-

  • 2 pairs of none toothed dissecting forceps.
  • 2 pairs of dressing forceps (or artery forceps)
  • Stitch scissors if required
  • Clip removers if required.
  • Two gallipots- one for lotion and one for swabs (cotton and gauze)
  • Drapper
  • Hand towel
  • Probe and sinus forceps if necessary

>  Receiver containing 2 dissecting forceps, 1 dressing forcep , forcep
and 1 artery forcep.
Receiver for used swabs and for instruments

>  Gallipot of sterile cotton swabs
>  Gallipot of sterile gauze swabs
>  Gallipot containing a dressing lotion
>  Dressing towels
>  Sterile drape
>  Sterile hand towels

Bottom shelf.

  •  Bottles of lotions
  • Adhesive tape
  • Pair of sterile gloves
  • Apron
  • Small mackintosh and towel
  • Pair of scissor and strapping.
    A tray containing:
  • Two 10 ml sterile syringes
    with needles
  • Two 2 mls sterile syringes
    with needles
  • Two pairs of sterile gloves
  • Antiseptic solution like iodine,
    methylated spirit or alcohol.
  • Dressing mackintosh and towel
  • 2 drums of gauze dressings and
    swabs
  • Laboratory request forms
  • Cheatle forceps

Bed-Side

  • Hand washing equipment
  • Screen
  • Safety box
  • A good source of light 

Technique of dressing wounds

Aseptic technique to prevent infection

Procedure

  1. Explain procedure to the patient
  2.  Clean trolley or tray; assemble sterile equipment on one side and clean items on the other side. Make sure it is covered.
  3.  Drape and put patient in comfortable position.
  4.  Place rubber sheet and its cover under the affected side.
  5.  Remove the outer layer of the dressing e.g. adhesive tape bandage.
  6.  Remove the inner layer of the dressing using the first sterile forceps and discard both the soiled dressing and the forceps.
  7.  Take the second sterile forceps. Clean wound with cotton balls soaked in antiseptic solution, starting from inside to the outside.
  8.  Again use the second forceps to clean the skin around and remove adhesive with benzene or ether.
  9.  Apply medication if any and dress the wound with sterile gauze.
    Method of Application
    >   Ointment and paste must be smeared with spatula on gauze and then applied on the wound.
    >   Solutions or powder can be applied direct on the wound.
    >   Make sure that the wound is properly covered.
    >   Fix dressing in place using adhesive tape or bandage.
  10.  Leave patient comfortable and tidy
  11.  Record state of wound
  12.  Clean and return equipment to proper place
    NB: The above-mentioned equipment can be prepared in a separate pack if central sterilization department is available.
Dressing of Septic Wound

Septic wound is characterized by presence of pus, dead skin, offensive odour in the wound.
Purpose
>   Absorb materials being discharge from the wound
>   Apply pressure to the area
>   Apply local medication
>   Prevent pain, swelling and injury

Need irrigation: As for clean wounds and dirty wounds which may not need irrigation, however with addition of the following, on top shelf.

  • Bowl containing irrigation lotion (hydrogen peroxide)
  • Saline 0.9%
  • Receiver containing large syringe and affine catheter
  • Receiver for used lotion.

Procedure

  1.  Explain procedure to the patient
  2. Clean trolley o tray and assemble sterile equipment on one side and surgically clean items on the other side. Make sure the tray or trolley is covered.
  3. Drape patient and position comfortably.
  4. Place rubber sheet and its cover under the affected part
  5. First remove the outer layer of the dressing
  6. Wear gloves if necessary. Use, forceps to remove the inner layer of the dressing smoothly and discard there for caps.
  7. Observe wound and check if there is drainage rubber or tube.
  8. Take specimen for culture or slide if ordered (Do not cleanse wound with antiseptic before you obtain the specimen.)
  9. Start cleaning wound from the cleanest part of the wound to the most contaminated part using antiseptic solution.
  10. (Hydrogen peroxide 3%) is commonly used for septic wound). Discard cotton ball used for cleaning after each stroke over the wound.
  11. Cleanse the skin around the wound to remove the plaster gum with benzene or ether
  12. Use cotton balls for drying the skin around the wound properly
  13. Dress the wound and make sure that the wound is covered completely
  14. Fix dressing in place with adhesive tape or bandages
  15. Leave patient comfortable and tidy
  16. Cleanse and return equipment to its proper places
  17. Discard soiled dressings properly to prevent cross infection in the ward.
    NB.
    >   If sterile forceps are not available, use sterile gloves
    >   Immerse used forceps, scissors and other instrument in strong antiseptic solution before cleansing and discard soiled dressing properly.
    >   In a big ward it is best to give priorities to clean wounds and then to septic wounds, when changing dressings, as this night lessen the risk of cross infection.
    >   Consideration should be given to provide privacy for the patient while dressing the wound.
    >   Wounds should not be too tightly packed in effort to absorb discharge as this may delay healing.

Wound Irrigation

 Wound irrigation is the process of removing foreign material, decrease bacterial contamination of the wound, and to remove cellular debris or exudate from the surface of the wound.

Wound irrigation must be vigorous enough to perform the above goals but gentle enough to avoid further tissue trauma or passage of bacteria and foreign material deeper into the wound.
Wound irrigation involves body fluids which may splash and spray due to the use of pressure; therefore, proper personal protective equipment is essential to the safety of wound care providers performing wound irrigation.
Essential steps of wound irrigation
>   Assessing the wound
>    Wound anesthesia
>    Wound periphery cleansing
>    Irrigation with the solution under pressure.

Indications
Wound irrigation is indicated in the management of both acute and chronic wounds, and especially those that will be undergoing suturing, surgical repair, or debridement.


Contraindications
Irrigation may not be necessary for certain highly vascular areas such as the scalp. Wounds with fistulas or sinuses with unknown depth should undergo careful evaluation before irrigation is performed to avoid forcing bacteria and debris containing fluids further into the wound or other body spaces.

Multiple wound cleansing agents are available as described below:
>   Povidone-iodine Solution: strong, broad bactericidal action against gram-positive and gramnegative bacteria; mildly toxic to healthy cells and granulating tissues.
 Chlorhexidine: Strongly bactericidal against gram-positive bacteria, less bactericidal against gram-negative bacteria
>   Hydrogen peroxide: Strongly bactericidal against gram-positive bacteria, less bactericidal against gram-negative bacteria


Multiple irrigation solutions are available for wound irrigation as described below:
>   Normal Saline – non-toxic to tissues and similar in tonicity to physiologic fluids; most commonly used
 Sterile Water – non-toxic to tissues but is hypotonic and may cause cell lysis
>   Potable Water – used in  environments where sterile water or saline is not available; no difference found in the use of potable water vs. sterile water in wound infection rates

Procedure

Equipment
In additional to the equipment for dressing a septic wound
>   2 receiver
>   Rubber sheet and its cover
>   Rubber sheet and its cover
>   Solutions (Hydrogen Peroxide or normal saline are commonly used)
>   Adhesive tape or bandage
>   Bandage scissors


Procedure of wound irrigation
  1. Explain the procedure to the patient and organize the needed items.
  2. Drape and position patient
  3. Put rubber sheet and its cover under the part to be irrigated
  4. Remove the outer layer of the dressing
  5. Remove the inner layer of the dressing using the first sterile forceps.
  6. Put the receiver under patient to receive the out flow
  7. Use syringe with desired amount of solution fitted with the catheter.
  8. Use forceps to direct the catheter into the wound.
  9. First inject the solution such as hydrogen peroxide at body temperature gently and wait for the flow. This must
    be followed by normal saline for rinsing.
  10. Make sure the wound is cleaned and dried properly.
  11. Dress the wound and check if it is covered completely
  12. Secure dressing in place with adhesive tape or bandage
  13. Leave patient comfortable and tidy
  14. Record the state of the wound
  15. Clean and return equipment to its proper place.
    NB: Keep patient in a convenient position. According to the need so that solution will flow from wound down to the receiver.


Complications
>   Wound irrigation should not be performed if the wound is actively bleeding, as irrigation may dislodge any clots that are forming.
>   Incomplete wound irrigation can lead to the persistence of debris or purulent discharge left inside the wound, especially in abscesses that may end up in sinus formation. When using povidoneiodine, care must be exercised not to pour it profusely inside the wound however, it should be
used on the wound edges.

Suturing

The application of stitch on body tissues with the surgical needle and thread.

Purpose
>   To approximate wound edges until healing occurs
>   To speed up healing of wound
>   To minimize the chance of infection
>   For esthetic purpose

Types of sutures
The sutures are classified into interrupted and continuous sutures.

In interrupted type, each suture is tied and knotted separately. The interrupted suture is the most commonly used technique in wound closure. Its name is derived from the fact that the individual stitches are not connected. Sutures performed with this technique have the advantage of being easy to place and have a high tensile strength. In addition, individual sutures can be removed (e.g in cases of infection) without jeopardizing the closure. However, they require a relatively long time to be placed and, as each suture requires its own knot, are at a greater risk of inducing infection.

In continuous sutures, one thread runs in a series of stitches and is tied only at the beginning and at the end of the run. In the continuous suture, the stitches are connected along the wound. This technique tends to be faster, particularly for long wounds. However, the wound is at greater risk
of dehiscence if the suture material breaks.
NB: Retention sutures are very large plain interrupted sutures that are seen in some incisions in addition to the skin sutures. These large sutures involve not only the skin but also the underlying tissues of fat and muscles. They are used to give support to the incisions in obese individuals or in situations in which wound dehiscence is suspected. The retention surfaces may have rubber tubing over them to prevent these sutures cutting through the skin. Usually they are left in place longer than the skin sutures (14 to
21 days).
According to the pattern of suturing, it can be classified into Plain interrupted, Plain continuous, Mattress interrupted, Mattress continuous, Blanket continuous.
When suturing the wound, each suture should be placed as deep as it is wide. The distance between the sutures should be equal the depth and the width.

Suture Material

A suture is a stitch made to join together the open parts of a wound


Suture materials can be broadly classified into
>   Absorbable (surgical gut or catgut)
>   Non absorbable (cotton silk, nylon wire, Dacron etc).
Advantages of a Surgical Gut are:
1). It is absorbed readily.
2). It is easily handled.
3). Available in multitude of sizes ( the size may range from 0000000 to No. 5)
4). It can be used to suture tissues beneath the skin.
Advantages of Non-absorbable Suture are:
1). They have a high tensile strength. (they are not easily broken)
2). They are relatively inexpensive.
3). Less tissue reaction.

4). They are used on the skin and are removed.
5). They are used as ligatures. (A ligature or a tie is a free piece of suture material used for purpose of tying blood vessels that have previously been clamped with an artery forceps)
NB: Surgical gut can be classified into plain gut and chromic gut. Plain gut is absorbed in 5 to 10 days.
Chromic gut has a prolonged absorption time of 10 to 40 days.

Suture Needles

Suture needles are classified in different ways:
Straight and Curved Needles
>  When the wound is deep, a curved needle is used. It is used with a needle holder. Curved needles are again classified into curved, half circle etc.
>  For suturing the layers of the skin, a straight needle is used. Straight needles are generally used without a needle holder.


Cutting Needle and Non-cutting Needle (Round Body Needles)
>  Cutting needles are three edged triangular needles. These needles may cut into the tissues to allow for the easier passage of the suture. So they are used for the suturing of dense tissues such as skin, cervix of the uterus and tendons.
>  Non-cutting needles are used for suturing the tissues beneath the skin.


Traumatic and Atraumatic Needles
>   Traumatic needles or eye needle has an eye or opening on one end through which the suturing material is drawn to thread it.
>  Atraumatic needles are specially made needles with no eye. The suturing materials are inserted within the metal of the needle during the manufacturing process, so that the diameter of the suture is not greater than the needle. It has several advantages. They produce minimum tissue
trauma and there is less damage to the suture strand. So they are used for suturing such delicate structures as intestines, brain, mucus membranes and nerves.

Wound Suturing

In additional to the equipment for dressing a septic wound

  •  Sterile needle holder
  • Sterile round needle (2)
  • Sterile cutting needle (2)
  • Sterile silk
  • Sterile cat- gut
  • Sterile tissue forceps
  • Sterile suture scissors
  • Sterile dressing forceps

Nurse’s responsibility in the suturing of wounds

In almost all the hospitals, suturing of the wound is the responsibility of the doctors. However occasionally, the nurse is held responsible for suturing small wounds. This depends upon the policy of the institution.
Preliminary Assessment
1. Assess the circumstances under which the wound was produced. This will help to evaluate the possibility of wound contamination.
2. Assess the nature of the wounding object e.g., blunt, sharp, etc. this will help to assess the depth of penetration of the object and also to identify the puncture wounds.
3. Assess the duration of time after the injury. This will help to assess the healing process. If the wound is exposed for a prolonged period, there always is the possibility of wound infection.
4. Check the presence of existing illness in the patient that may influence the healing process e.g. Diabetes mellitus.
5. Prior healing history is to be assessed. This will help us to find out abnormal bleeding time,  wound dehiscence in the past, formation of excessive scar tissue etc.
6. Check the drugs, the injured person has been taking e.g., cortico-steroids. This will delay the healing process.
7. Take a history of allergies in the past, especially allergic reaction to local anaesthetics.
8. Date of most recent tetanus immunization. All patients with a roadside injury should be given tetanus toxoid to prevent tetanus.
9. Wound location and the type of wound. A penetrating wound should be sutured under general anaesthesia. There is the possibility of injury of the underlying organs.
10. Watch for the presence of foreign bodies, presence of penetrating objects etc. penetrating objects should not be disturbed until everything is ready for suturing, for fear of bleeding.
11. Assess the presence of devitalized tissues. This necessitates debridement prior to suturing.
12. Presence of bleeding. The bleeding points have to be ligated before suturing to prevent further bleeding.
13. Presence of complications such as fractures, shock, tendon injuries, nerve injuries etc. this necessitates further treatment.
14. Check the consciousness of the patient and the ability to follow.


Preparation of the Patient and the Environment
1. Explain the procedure to win the confidence and co-operation of the patient. Explain the sequence of the procedure and tell the patient how he can co-operate with you. Reassure the patient and his relatives.
2. Get the signature of the patient or his guardian in case anaesthesia is to be given.
3. Prepare the wound area as for a surgical procedure. Shave the hairy regions. Clean the surrounding skin thoroughly with an antiseptic. While shaving and cleaning the area, place a sterile cotton pad or gauze piece over the wound to prevent future contamination of the wound.
4. Give analgesics if the patient is in pain.
5. Provide privacy with curtains and drapes, if necessary.
6. Protect the bed with mackintosh and towel.
7. Call for assistance if necessary e.g., to hand over the sterile supplies, to restrain the patient etc.
8. Place the patient in a comfortable position. See that the doctors or the nurse is also in a comfortable position to do the procedure.
9. Apply restraints in case of children.
10. See that the unit is in order with no unnecessary articles. Clear the bedside table or over-bed table and arrange the articles conveniently.
11. See that there is sufficient light. Adjust the spot light to provide maximum light in the wound area.
12. Turn the patient’s head away from the wound to prevent the patient from seeing the wound and getting worried.

Procedure of wound suturing

1. Explain procedure to patient
2. Adjust light
3. Wash your hands
4. Clean the wound thoroughly
5. Wash your hands again
6. Put on sterile gloves
7. Drape the Wound with the hold- sheet
8. Infiltrate the edges of the wound to be sutured with local anesthesia.
9. Approximate the edges of the fascia with the help of the tissue forceps and using the round needle and cat- gut. Suture the fascia layer first.
10. Using the cutting needle and silk, suture the outer layer of skin approximating the edges with the help of the tissue forceps.
11. Clean with iodine and cover with sterile gauze.
12. Remove the hole- Sheet
13. Make patient comfortable
14. Remove all equipment, wash and return to its proper place or send for sterilization.


After Care of the Patient and the Articles
1. Following wound closure, clean the wound again and apply a multilayered dressing to absorb drainage and to arrest bleeding by exerting pressure.
2. Secure the dressings with a roller bandage or adhesive tapes. As far possible, avoid covering the wound area with adhesive straps, completely, because it may foster accumulation of moisture and subsequent maceration of the wound edges.
3. Keep the wound as dry as possible.
4. Remove the mackintosh and towel. Replace the bed linen. Change the garments if necessary.
Make the patient comfortable by adjustable his position in bed.
5. Ask the patient to rest in bed to prevent fainting attacks.
6. Elevate the injured part above the heart level to minimize the oedema and pain. Mild analgesics may be given to reduce pain.
7. Take all the articles to the utility room. Discard the soiled dressing and send for incineration.
Wash and clean the articles first in the cold water and then with warm water and soap. Wash them thoroughly and dry them. Reset the suturing tray and send for autoclaving. Replace all articles to their proper places.
8. Wash hands. Record on the nurses record with date and time the type of the wound, the number of sutures applied, type of drainage tube applied, if any etc.
9. Return to the bedside to assess the comfort of the patient and to observe the condition of wound.
Watch for any bleeding from the wound area. Change the dressing if there is an excessive bleeding. Report to the doctor.
10. Watch for the vital signs regularly to detect early signs of shock and collapse on the first day and signs of infection on subsequent days.
11. Unless signs of infection occur, the dressing should be left undisturbed until time for suture removal. Changing the dressing frequently causes friction on the wound edges and increases the
possibility of the wound infection.
12. Inject tetanus toxoid, if it is not given previously.
13. On discharge of the patient, the patient should be given the instructions about the care of the wound, and the time when he has return for the removal of sutures.


Removal of Sutures
The sutures may be removed by the surgeons or by the nurses according to the hospital customs. In all cases the surgeon gives the written order for the removal of the sutures.
The skin sutures are left in place for a varied length of time. The usual timings are:
>   Scalp and face: 2 to 5 days
>   Abdominal wounds: 7 to 10 days
>   Lower limbs: 10 to 14 days


General Instructions
1. Confirm the doctor’s orders for the removal of the sutures.
2. The suture removal is done in conjunction with a dressing change.
3. Toothed dissecting forceps and a pair of scissors with a short, curved, cutting tip that readily slide under the suture are used.
4. The suture line is cleansed before and after suture removal.
5. While removing interrupted sutures, alternate ones are removed first. The remaining sutures are removed a day or two later. If wound dehiscence occurs, the remaining sutures may then be left in place.
6. Suture material that is beneath the skin is considered free from bacteria, and those visible outside is in contact with the resident bacteria of the skin. It is important that no part of the stitch which is above the skin level enter and contaminate the tissues under the skin.
7. Suture material left beneath the skin acts as a foreign body and elicits the inflammatory response.
While removing sutures, care to be taken to remove them completely. Each suture should be examined for its completeness. Every interrupted suture will have one knot and four ends when removed completely. The number of sutures should be counted before and after removal.
8. If wound dehiscence occurs during the removal of the sutures, inform the surgeon immediately.
In case of abdominal wounds, resuturing is imperative to prevent evisceration. In other places, if  resuturing is not necessary, adhesive tapes should be applied to approximate the wound edges as closely as possible.
9. After the removal of sutures, even if the wound is dry, a small dressing is applied for a day or two to prevent infection. The patient should be told about the care of the wound. He is advised to take rest after removal of sutures of an abdominal wound. The patient should be told not to
strain the part e.g., not to cough or lift heavy weight after removal of sutures from the abdomen.
This will prevent wound dehiscence.
10. If wound discharge occurs, the patient should be instructed to contact the surgeon. Presence of pain and swelling at the wound line are the signs of complications.
11. Abdominal belts or many tailed bandages may be applied on the abdomen after removal of abdominal sutures in obese patients to prevent wound dehiscence and evisceration.
Suture Removal

  •  To remove the interrupted sutures, grasp the suture at the knot with a toothed forceps and pull it gently to expose the portion of the stitch under the skin. Cut the suture with a sharp scissors between the knot and the skin on one side either below the knot or opposite the knot. Then pull the thread out as one piece. The suture which is already above the skin should not be drawn under the skin.
  • After removal of sutures, every suture should be examined for its completeness. The number of sutures should be counted before and after removal. (it is not uncommon to find some sutures
    laid bury under the skin).
  • Mattress interrupted sutures have two threads underlying the skin. The visible part of the suture opposite the knot should be cut and the suture is removed by pulling it in the direction of the knot.
  • If a continuous suture is applied, it is cut through, close at each skin orifice on one side and the cut sections are removed through the opposite side by gentle traction.

Clips

Metal suture used to stitch the skin

Purpose
Some as suturing with stitch
Equipment
In additional to the equipments for dressing a septic wound
Sterile clip removal forceps
>   Receiver
>   Benzene or ether
>   Adhesive tape or bandage
Removing Clips
1. Explain procedure to the patient and organize the needed equipment
2. Drape and position patient
3. Protect bedding with rubber sheet and its cover
4. Remove old dressing and discard.
5. Cleans wound with antiseptic solution starting from the cleanest part of the wound to the most contaminated part and discard the cotton ball.
6. Place sterile gauze to receive removed clips.
7. Take clip remove with the right hand and dissecting forceps with the left hand.
8. Insert the lower blade of the clip remove below the middle of the clip using the dissecting forceps as a support of old the clips in place, and close the blade firmly as this will cause disagreement of the clips from the skin.
9. Receive clips on sterile gauze
10. Apply iodine on the skin punctures if required
11. Dress the area if required
12. Secure dressing in place with adhesive tape
13. Leave patient comfortable and tidy
14. Record the state of scare
15. Clean and return used equipment to its proper place.

Wound Assessment

When conducting initial and ongoing wound assessments the following considerations should be taken into account to allow for appropriate management in conjunction with the treating team:

  1.  Type of wound- acute or chronic
  2.  Aetiology- surgical, laceration, ulcer, burn, abrasion, traumatic, pressure injury, neoplastic
  3.  Location and surrounding skin
  4.  Tissue Loss
  5. Clinical appearance of the wound bed and stage of healing
  6. Measurement and dimensions
  7. Wound edge
  8. Exudate
  9. Presence of infection
  10. Pain
  11. Previous wound management

Considerations for Wound Assessment

Type of wound: There is different terminology used to describe specific types of wounds: such as surgical incision, burn, laceration, ulcer, abrasion. They can be generally classified as either acute or chronic wounds.
Tissue loss: The degree of tissue loss may be referred to in broad terms as:

  •  Superficial wound– involving the epidermis
  • Partial wound– involves the dermis and epidermis
  • Full thickness wound-involves the epidermis, dermis, subcutaneous tissue and may extend to
    muscle, bones and tendons.


Wound bed clinical appearance:

  1.  Granulating– is when healthy red tissue is observed and is deposited during the repair process. It
    presents as pinkish/red coloured moist tissue and comprises of newly formed collagen, elastin
    and capillary networks. The tissue is well vascularized and bleeds easily.
  2. Epithelializing– is a process by which the wound surface is covered by new epithelium, this begins when the wound has filled with granulation tissue. The tissue is pink, almost white, and only
    occurs on top of healthy granulation tissue.
  3. Sloughy– the presence of devitalized yellowish tissue is observed and is formed by an accumulation of dead cells. Must not be confused with the presence of pus.
  4. Necrotic– describes a wound containing dead tissue. The wound may appear hard, dry and black.
    Dead connective tissue may appear grey. The presence of dead tissue in a wound prevents healing.
  5. Hyper granulating– this is observed when granulation tissue grows above the wound margin. This occurs when the proliferative phase of healing is prolonged usually as a result of bacterial
    imbalance or irritant forces.


Wound measurement

All wounds require a two-dimensional assessment of the wound opening and a three-dimensional assessment of any cavity or tracking’ (Carville, 2017)
 Two-dimensional assessment– can be done with a paper tape to measure the length and width in millimeters. It is often required for chronic wounds. 
 Three-dimensional assessment– the wound depth is measured using a dampened cotton tip applicator.


Wound edges: The edges of the wound are assessed for-

  •  Colour- pink edges indicate growth of new tissue; dusky edges indicate hypoxia; and erythema indicates physiological inflammatory response or cellulitis
  •  Evidence of contraction- wound edges coming together indicate the healing process is occurring.
  • Raised or rolled edges-raised (where the wound margin is elevated above the surrounding tissue) may indicate hyper granulation tissue and rolled (where the edges are rolled down towards the wound bed) can inhibit healing.
  •  Changes in sensation- increased pain or the absence of sensation should be further investigated.


Exudate: Is produced by all acute and chronic wounds (to a greater or lesser extent) as part of the natural
healing process. It plays an essential part in the healing process in that it:

  •  Contains nutrients, energy and growth factors for metabolizing cells
  • Contains high quantities of white blood cells
  • Cleanses the wound
  • Maintains a moist environment
  • Promotes epithelialization

It is important to assess and document the type, amount, colour and odour of exudate to identify any changes. Excess exudate leads to maceration and degradation of skin while too little can result in the wound bed drying out. It may become more viscous and odorous in infected wounds.


Surrounding skin: The surrounding skin should be examined carefully as part of the process of assessment and appropriate action taken to protect it from injury.


Presence of infection: Wound infection may be defined as the presence of bacteria or other organisms, which multiply and lead to the overcoming of host resistance. Infection can disrupt healing and damage tissues (local infection) or produce spreading infection or systemic illness. Infection adversely affects wound healing and may be the cause of wound dehiscence.


Local indicators of infection-

  •  Redness (erythema or cellulitis)
  •  Exudate- a change to purulent fluid or an increase in amount of exudate
  • Malodor
  • Localized pain
  • Localized heat
  • Oedema
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