Hemostasis, Wound Healing & Wound Closure Flashcards
Wound Classification for the following Ex. Coronary Artery Bypass Graft, Total Hip, Breast Biopsy & Craniotomy
lap, mastectomy, neck
dissection, thyroid, vascular, hernia & splenectomy
Clean (Class 1)
Uninfected, uninflamed operative wound in which the respiratory, alimentary, genital or uninfected urinary tracts are not entered.
. Primary closure
. No inflammation is encountered
. Closed wound drainage device if necessary
. Incision made under ideal surgical conditions
. No break in sterile technique during procedure
. No entry to aerodigestive or genitourinary tract
– Respiratory, GIT, GUT not touched
– 1-5% infection rate
Wound Classification for the following Ex. Appendectomy, Cholecystectomy & Tonsillectomy
Thoracic lobe, hernia, Vag.
Hyster., liver transplant(txp),
gastric sx, thyroidectomy,
colon surgery, rhinoplasty
Clean Contaminated (Class 2)
Uninfected operative wound; respiratory, alimentary, genital, or urinary tract is entered under controlled circumstances without unusual contamination
. Primary closure
. Open/ mechanical drainage
. Minor break in sterile technique occurred
. Controlled entry to aerodigestive (includes biliary tract) or genitourinary tract
– Infection rate 8-11%
Wound Classification for the following Ex. Open fracture, Colon Resection with Gross Spillage of GI contents & Penetrating Trauma
Inflamed appy, bile
spillage in chole, diverticulitis, Rectal surgery
Contaminated (Class 3)
Acute, nonpurulent, inflamed operative wound or open, fresh wound, or any surgical procedure with major breaks in sterile technique or gross spillage from GI tract.
. Acute inflammation present
. Major break in sterile technique occurred
. Open traumatic would (less than 4 hours old) with retained necrotic tissue
. Entry to aerodigestive (includes biliary tract) or genitourinary tract with spillage
– Infected bile/urine
– Infection rate 15-20%
Wound Classification for the following Ex. Resection of ruptured appendix
Abscess I&D, perforated
bowel, peritonitis, wound
debridement, positive cultures pre-o
Dirty (class 4)
Clinically infected operative wound or perforated viscera or old, traumatic wounds with retained necrotic tissue
. Perforated viscus
– Perforated bowel, viscus, purulent inflammation, foreign body, fecal mater (e.g. Intestine)
. Microbial contamination prior to procedure
– Contamination prior to procedure (necrosis, rupture or spillage of intestinal contents)
. Open traumatic wound (more than 4 hours old)
– Infection rate 27-40%
When is the final wound classification assigned?
At the end of the procedure and is included in the intraoperative documentation
Intentional Wounds
– Chemical wounds
– Surgical incision: Intentional cut through intact tissue
– Surgical Excision: Removal of tissue
CLOSED WOUNDS
– skin is intact
- simple fractures, torn
ligaments, blister
OPEN WOUNDS
– skin is broken (sacral decubitus ulcer [bed sore])
SIMPLE – only the skin is
injured
. COMPLICATED – skin and
underlying tissues are injured
. CLEAN – cared for within 6
hours
. CONTAMINATED – cared for after 6 hours
ABRASION
– caused by rubbing or
scraping the skin
AVULSION
– portion of skin or soft tissue is partially or
completely torn away
CONTUSION
– a bruise; skin is not
broken
CRUSHED
– has been squeezed or
forced by pressure
INCISED
– made by a cutting instrument and has smooth
edges
LACERATION
– torn wound with irregular edges
PUNCTURE
– made by a sharp, pointed
instrument
PERFORATION
– made by an object
entering and exiting
the body
Inflammatory Process
. Heat (calor)
. Pain (dolor)
. Redness (rubor)
. Swelling (tumor)
. Loss of function (functio laesa)
First intention (primary union)
Happens when the wound
edges are approximated e.g.
by sutures, staples or glue.
– Lag/inflammatory response
. Injury – 3/5 day
– Proliferation
. 3rd – 20th day
. 25% - 30% strength
– Maturation /differentiation
. 14th – 12mos
. Side to side
Lag/inflammatory response
. Injury – 3/5 day
Proliferation
. 3rd – 20th day
. 25% - 30% strength
Maturation /differentiation
. 14th – 12mos
. Side to side
Second intention (granulation)
. A wound that is extensive and involves considerable tissue loss, and in which the edges cannot be brought together by sutures, heals in this manner.
Secondary intention healing
differs from primary intention healing in three ways:
- The repair time is longer.
– Large wounds
– Infected wounds
– “proud flesh” excessive
granulation
Third intention (delayed
primary closure)
A method of closing a
grossly contaminated
wound in which the
wound is left open until
contamination has been
markedly reduced,
granulation has occurred
(maturation) and
inflammation has
subsided and then is
closed by first intention.
Principles of Wound Closure
. Handle tissue gently
– Use toothed forceps ex: Adson
. Do not use smooth forceps
– Since these crush tissue because they
require greater pressure to grasp
Factors affecting wound healing
. Post op complications
– Edema, patients with COPD
– Nosocomial infections
. Physical activity
– Early ambulation vs. Late ambulation
. Surgical technique
. Immunosuppressed status (radiation)
Methods of preventing infection
. Reduce the source of contamination
– Pre-op bathing, careful pre-op shaving,
adequate use of skin prep.
.Use of Standard Precautions
. Normothermia
– Hypothermic state causes vasoconstriction
. Use of antibiotic prophylaxis
– Given 60 min. prior to surgery
. Adequate oxygenation
– Good oxygenation allows killing of bacteria via oxidation
. Use of Bowel technique during GI surgeries
. Copious irrigation
. Wound drain
. Correct dressing
Dehiscence
– a surgical complication in
which a wound ruptures along a surgical incision
Evisceration
– partial protrusion of the viscera through the edges of a separated wound
Adhesion
– Abnormal attachment of two structures
Herniation
– a condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it
Fistula
– Tract between two structures which is open on both ends
Sinus tract
– Tract between two structures which is closed at one end
Stitch spitting
– Suture spitting
– Failure in absorption of
suture
Keloid scar
– Hypertrophic scar
Cicatrix
– scar left by a healed wound
Collagen
– Interwoven fibers, increases textile strength. White protein in connective tissue and bones
Debridement
– removal of damaged
tissue or foreign
material, leaving an
open clean wound
Disruption
– When the suture line breaks down, decreasing
support
Fibrinogen
– Constituent of blood
that aids in
coagulation
Granulation
– Formation of new
capillary tissue, scar
tissue
Granulation tissue
– Fibrous connective
tissue containing blood
vessels and lymphatic
Hematoma
– Tumor or swelling with clotted blood
Hemostasis
– Control of bleeding
Ischemia
– Decrease of blood supply to tissue (tissue approximation is too tight)
Necrosis
– Death of tissue (cells)
Proud flesh
– Overgrowth of
granulated tissue
Serosanguinous
– Blood tinged or
colored serous drainage
Trauma
– Injury to body tissue by
violence, chemical, thermal agent
Purulent –
- Containing pus
Dead space
– Space that remains in tissue as a result of failure of proper wound closure
Friable
– Easily ripped or
torn tissue/skin
Eventration
– Protrusion of abdominal organs through the abdominal wall
Dressings purpose for post op wound care
- Protect from trauma and contamination
- Maintain an environment Conceal the wound
- Absorbs drainage and secretion
- Support the incision Providing pressure
