WOUND HEALING1. INFLAMMATORY PHASE2. PROLIFERATIVE OR GRANULATION PHASE3. MATURATION, OR WOUND REMODELING, PHASE

WOUND CARE

Wound Classification BY CAUSE 1. intentional 2. unintentional CLEANLINESS 1. clean 2. contaminated 3. infected DEPTH 1. superficial 2. partial thickness 3. full thickness COLOR - by using the RYB

Classification.

The RYB Classification System Classifies open wound s that are healing

by secondary or delayed primary intention in both chronic or acute wounds.

It can be used to determine the state of healing.

Red wound s- can be in inflammatory, proliferative or maturation stage.

Yellow wound – infected, contain fibrogenous slough.

Black wound – contain necrotic tissue. Not ready to heal.

Types of Wound Healing Primary Intention – simplest form of wound

healing. Skin is cleanly incised. e.g. surgical incision or traumatic laceration. Closed with suture or staples.

Secondary Intention – The wound heals by granulation. Granulation tissue builds, it fills the gap under the skin and cells epithelize from edge of the wound to create the closure.

e.g. burns, pressure ulcers and wounds with large piece of skin missing.

Tertiary Intention – leaves open wound to heal. Wound cannot be sutured. Dehiscence occurred or wound is infected.

Major Factors Affecting Wound Healing

Nutrition General Physical Health Medications

Goals of Wound Care

Remove necrotic tissue and promote wound healing.

Prevent, eliminate, or control infection.

Absorb drainage (exudate). Maintain a moist wound

environment. Protect the wound from further

injury. Protect the surrounding skin from

infection and trauma.

Associated With Wound Healing Complication

Adhesions Incisional strangulated internal

hernias Contractures – shortening of the scar

tissue. Wound Infections

Wound Infection prevention

Use of semi-occlusive dressing reduced incidence of infection, promotes moist environment.

Observation of Standard Precaution. Proper Hand Hygiene. Maintaining Asepsis during wound dressing. Using sterile supplies and equipment.Clinical S/S of Infection generally begin 3-5

days post-operatively or following the injury.

S/S of Wound Infection

Progressively more tender wound Painful Edematous WBC count of 12, 000/mm3 or

greater lasting longer than 72 hours. Foul smelling and purulent drainage.

Microorganism Causing Wound Infection

Staphylococcus Aureus - major Escherichia Coli Streptococcus faecalis Proteus Vulgaris Klebsiella Enterobacter Pseudomonas Aerogenusa Wound Specimen for Culture – Dx

test.

Measures to Prevent Infection Completing Surgical hand Hygiene Donning Sterile Gloves Pouring from Sterile Container Equipment: Sterile container Non sterile

container Sterile SolutionProcedure: See accompanying

procedure.