Wound Care
Helen Harkreader, R.N., Ph.D.
Austin Community College
Types of wounds
• Surgical wounds
• Acute trauma
• Lesions
• Chronic: eg. Pressure ulcers
Purposes of Wound Dressings
• Protection
• Absorb drainage
Surgical wounds
• Edges approximated
• No redness, bruising, drainage
• Healing ridge
• After 2-3 days leave dry and open to air
• Light dressing for protection
Staples or sutures
• Removed 4-7 days
• Apply Steri-strips (spray Tincture of Benzoin)
Removing Sutures/staples
• Sterile technique
• Staple remover
• Suture removal: scissors and forceps
• Documentation
Follow up care after staple removal
• Steri-strips for about 5 days. Shower and when they fall off, remove
• keep the wound clean and dry.
• At the time of suture removal, the wound has only regained about 5-10% of its tensile
strength.
Other follow up care
• protect the wound for 1 month.
• protection from ultraviolet rays-several months.
• Use sunscreen if area exposed
• vitamin E topically may help in the healing process: only once the skin edges are
healed and are closed together.
Traumatic wounds
• Dirty
• Clean thoroughly
• May be sutured or left to heal by secondary intention
Chronic wound
• Pressure ulcers
• Infected surgical wounds
• Arterial ulcers
• Venous stasis ulcers
• Are considered contaminated, not necessarily infected
Assessment: the chronic wound should be
moist with exudate, but not macerated;
free of clinical infection and excessive slough;
free of toxic chemicals, particles or fibers;
at the optimum temperature for healing;
undisturbed by the need for frequent changes;
at the optimum pH value.
The ideal chronic wound dressing would
• Maintain a moist environment at wound interface
• Remove excess exudate without allowing 'strike through’ to surface of dressing
• Provide thermal insulation and mechanical protection
• Act as a barrier to micro-organisms
And/or…..
• Allow air exchange
• Be non adherent; easily removed without trauma
• Leave no foreign particles in wound
• Be non-toxic, non-allergenic and non-sensitizing
• No single dressing is appropriate for all wound types and all stages of healing
Choose sterile/clean technique
Demonstrate ability to change wound dressings correctly.
• Simple surgical wound (healing by primary intention)
• Surgical wound with penrose/other drain
• Healing by secondary intention
Caring for Drains and Wound Suction Apparatus
• Penrose
• Jackson pratt
• Hemovac
Documentation
• Appearance of wound
Drainage, redness, warmth
Size
• Dressings used
Culture a Wound