Clinical management of Wounds

Question 1

Factors that delay healing

5

Answer 1

Disease, disorders & syndromes

Drugs

Poor nutritional states

Micro-environment of wound

Other ie. Obesity and stress

Question 2

Stages of wound assesment

Answer 2

Client allergies to wound cleaning agents

appearance and size of the wound

General – cause of wound, location, size, depth and shape, open/closed, presence of haematoma or oedema

Exudate (Drainage) – amount, colour, consistency, nature/type (blood, pus), volume (increase or decrease)

Odour – Level, increase or decrease

Type of tissue present – Black, yellow, red, pink, green

Signs of infection – Swelling, heat and redness at wound site, generalized pyrexia, increases in pain, exudate and odour, swab culture result

Pain – type of pain, amount, severity (pt self-assessment), site, frequency, impact on daily living, effectiveness of treatments, pain related to dressing changes

Condition of surrounding skin – colour, dry, scaly, oedema, erythema, dressing or tape allergy, pre-existing skin conditions

Episodes of bleeding – Amount, frequency, aggravating factors.

Question 3

Definition of an ideal wound dressing

Answer 3

‘A material which, when applied to the surface of a wound, provides and maintains an environment in which healing can take place at the maximum rate’

Question 4

Purpose of a wound dressing

6

Answer 4

1 - To promote wound healing by primary intention

2 - To prevent infection .

3 - To assess the healing process

4 - To protect the wound from mechanical trauma .

5 - To absorb drainage.

6-To prevent contamination from bodily discharge.

Question 5

5 elements of wound bed cleaning

Answer 5

Remove dead tissue (necrotic)

Controlling oedema (swelling)

Good circulation to the wound

Decreasing the bacterial burden

Minimising/eliminating wound exudate (discharge).

Question 6

4 stages of wound healing

Answer 6

Bleeding

Inflammation

Proliferative

Remodelling

Question 7

treatment of a nose bleed

Answer 7

Sit the casualty down and tilt head forward
This is to allow the blood to drain from the nostril
Ask him to breathe through their mouth
Apply pressure
Pinch the soft part of the nose for 10 minutes
Advise
No speaking, swallowing, coughing, spitting or sniffing

After 10 minutes release pressure
If still bleeding – reapply pressure for two further periods of 10 minutes