Wound Healing, Wound Types, Wound Dressings, & Drainage Devices
ST230Concorde 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.
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
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 WoundType II Clean-contaminated WoundType III ContaminatedType 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 WoundSkin Intact / Underlying tissue damaged
Examples:
Blister Simple Fracture
Wound Types & Wound Healing
Open Traumatic WoundSkin Disrupted
Examples:
Laceration Compound Fracture
Wound Types & Wound Healing
Simple Traumatic WoundSkin Disrupted/No loss or destruction of
tissue/No foreign body implanted
Examples:
Minor penetration Cut with sharp object
Wound Types & Wound Healing
Complicated Traumatic WoundSkin
disrupted/Underlying tissue lost or
destroyed/Foreign body implanted
Examples:
Severe burn Stab or bullet wound
Wound Types & Wound Healing
Clean Traumatic WoundSimple wound caused by a sharp edged object
Expected to be sutured and heal by first
intention without infectionExample:
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 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
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 closedEquation 2+1=3
(Second Intention plus First Intention equals
Third Intention)
Wound Types & Wound Healing
Factors Affecting Wound HealingThree 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
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 SpaceReduce 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
Wound Types & Wound Healing
Wound Types & Wound Healing
Knot Tying Basics
Knot Security Knot Tying Principles Square Knot (Two
Hand Technique) Surgeon’s Knot
Wound Types & Wound Healing
Knot SecurityKnot 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 KnotFirst step
Right over left
Repeat right over left
Then tighten
Wound Types & Wound Healing
Surgeon’s KnotSecond Step
Left over right
Tighten
DONE!!It should look like
this...
Wound Types & Wound Healing
Tissue Approximation
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
ContinuousPROS
Quick placement Less foreign body in
wound Tension evenly
distributed
Suture LineCONS
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
InterruptedPROS
Secure closure Remaining sutures
should hold wound edges together if one stitch fails
Microbes less likely to move along interrupted suture line
Suture LineCONS
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
Wound Types & Wound Healing
Layers of the Abdominal Wall
Wound Healing, Wound Types, Wound Dressings, & Drainage Devices
ST230Concorde Career College
Laparotomy Tapes, packs, laps
Ray-Tec ray
Cottonoids Patties
Tonsil Kittner Peanut ** must be counted**
Sponges
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Sponges
Lap sponge
Tonsil
Peanut
Ray-Tec
Have a radiopaque strip so they can be located by X-ray
Sponges
Dirty sponges are placed in kick bucket or sponge tree
Discarded
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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
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Dressing One-layer Three-layer Pressure Bulky Rigid Specialty Packing
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Dressing One-layer dressing
Cover small incisions Frequently used to cover IV access Transparent polyurethane film/adhesive backing
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Dressing One-layer dressing
OP-site Collodion Aerosol adhesive sprays, foams, gels Skin closure tapes
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Dressing Three-layer dressing
Inner (contact) layer Intermediate (absorbent) layer
Absorbs drainage 4X4, kerlix, fluffs
Outer ( securing) layer Tape, stockinette
Nonpermeable Occlusive xeroform
Semipermeable Semi-occlusive Exu-derm, aqua-gel
Permeable Nonocclusive Telfa, adaptic Wicking action
3 layer dressing/ Contact Layer
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Dressing Pressure dressing
Immobilization of an area Support Absorption of excessive drainage Even pressure distribution Elimination of dead space Reduced edema Reduced hematoma formation
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Dressing Bulky dressing
Three-layer dressing Additional material is added to the intermediate
layer Used to immobilize an area Provide support Absorb excessive drainage
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Dressing Rigid dressing
Casts Encircles Provide support Prevent movement Often incorporates the joint
Splints Applied to one side of a structure Support Prevent unidirectional movement
Bolster Wet-to-dry Wet-to-wet Drain Ostomy Peri-pad
Specialty Dressing
Packing Assist with hemostasis Provide pressure Provide support Eliminate dead space
Dressing
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Catheters• Used to remove fluid
or other objects• Used to monitor body
functions • Insert fluids
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Catheters• Remove air and fluids• Decompression• Maintain patency• Administration of
oxygen, anesthetic, medications, fluids
Cystostomy catheter
Passive Drains air or fluid moves from an area of high pressure to
one of lower pressure. Penrose Cigarette T-tube Gastrostomy Cystostomy Nephrostomy
Drains
Penrose Drain
Active Drains Negative pressure Connected to a collection device
Hemovac Jackson-Pratt Stryker
Drains
Jackson Pratt(JP) drain
Hemovac Drain with trocar
Used to remove air and fluids Decompression Maintain patency of a lumen Administer oxygen, anesthetics, and other
gases Administer medications
Tubes
Gastrostomy tube
Nephrostomy tube
Hypodermic 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
Irrigate vessels Spinal
3-4 inches Beveled stylet within the cannula
Non-suture needles
Luer lock Luer slip ( slip tip) 3-60 cc Three ring or control syringe Bulb Asepto
Syringes