Holistic Wound Assessment and Management Flashcards
What is an acute wound? How can it be caused? How do they heal?
It is the result of tissue damaged by trauma. This may be deliberate, as in surgical wounds of procedures, or be due to accidents caused by blunt force, projectiles, heat, electricity, chemicals or friction. An acute wound is by definition expected to progress through the phases of normal healing, resulting in the closure of the wound.
What is a chronic wound? How do they heal?
A Chronic Wound fails to progress or respond to treatment over the normal expected healing time frame (4 weeks) and becomes “stuck” in the inflammatory phase. Wound chronicity is attributed to the presence of intrinsic and extrinsic factors including medications, poor nutrition, co-morbidities or inappropriate dressing selection.
What is a wound?
A wound by true definition is a breakdown in the protective function of the skin; the loss of continuity of epithelium, with or without loss of underlying connective tissue(i.e. muscle, bone, nerves).
What are 4 types of wound?
- Traumatic
- Intentional
- Ischaemia
- Pressure
Describe wound healing in acute and chronic wounds?
Acute wound healing follows an orderly sequence of biological events, requiring minimal intervention.
In chronic wounds this sequence of events is disrupted or fixed at one or more of the stages of wound healing and wound-bed preparation is required for healing to occur.
What are the stages of wound healing?
- Vascular Response
- Inflammatory
- Proliferation
- Maturation
What are the 5 stages of the wound assessment cycle?
- Patient and wound assessment
- Agree treatment objectives
- Refer to specialists when required
- Select wound management products and any additional treatments
- Reassess patient, wound, and care plan
What should the nurse look at during patient assessment?
- Cause of wound (remove where possible)
- Identify factors that could delay healing
- Past medical history
- Past wound history & treatment
- Environment of care/carers
- Individual concerns/emotional wellbeing
- Local problems at the wound site
How does the nurse assess a wound? (there’s a lot!!!)
- Where is the wound?
- What is the cause?
- What colour is it?
- How wet/dry is it?
- What type and amount of exudate is there?
- What size is it?
- How deep is it?
- Does it smell?
- What do the wound margins look like?
- How does the surrounding skin appear/feel?
- How long has the patient had the wound?
- Are there any underlying condition which may affect the wound?
Describe necrotic tissue
- Dead tissue
- Comprises of hard black/ brown leathery eschar
- Increases bacterial burden
- Prolongs chronic inflammation
- Delays healing
- Has to be removed (debrided) before wound healing can take place
Describe slough
- Debris on wound surface comprising of dead leucocytes, bacteria and fibrous tissue
- Yellow, creamy appearance
- Can be thick/stringy or more viscous
- Obstructs granulation tissue formation
- Increases risk of infection
describe granulating tissue
- Deep red or pink
- Uneven ‘beefy’ appearance
- Fine capillary loops
- Bleeds easily
describe epithelialising tissue
- Healthy tissue in final stages of healing
- Pink, white in colour
- Migrates from wound edges/ base of hair follicles
describe hypergranulation
- Deep red
- Raised/bumpy
- Prevents epithelialisation
describe haemotoma
- Localised collection of blood within the tissues
- Dark brown/black/purple in colour
- Swollen
What should the nurse check surrounding skin for?
- Macerated
- Oedematous
- Excoriated
- Erythema
- Fragile
- Dry/scaly
- Healthy/intact
describe a periwound
- Widespread hyperproliferation at wound margin
- Inhibition of apoptosis
- Fibroblasts from chronic wounds found to be senescent
what should the nurse look at when assessing wound exudate?
Quantity: Dry, Low, Moderate, High
Characteristics: Serous- Straw coloured thin fluid, Haemoserous- Blood stained, Purulent- Green/Brown/Yellow thick fluid
Moisture Imbalance: Desiccation slows cell migration, Excessive fluid causes maceration of wound margin
what is chronic wound exudate? why is it bad?
Chronic wound exudate has a different chemical composition which may cause a problem in itself. It not only contains water but also bacteria and dead white cells. There are high levels of inflammatory mediators and protein digesting enzymes. Chronic wound exudate is detrimental to healing and more corrosive to peri-wound skin.
what 9 things increases risk of wound infection?
- Foreign bodies
- Haemotoma
- Diabetes
- Rheumatoid arthritis
- Immunosuppression
- Necrotic tissue
- Poor nutrition
- Steroids
- Wound location
define wound infection
Wound infection is the presence of replicating microorganisms within a wound with subsequent host injury
what are 6 signs of wound infection?
- Heat to surround tissue
- New slough/necrosis (deteriorating wound bed)
- Increasing pain
- Increasing exudate
- Increasing odour
- Friable granulation tissue
what is the criteria for identifying wound infection?
- Abcess
- Cellulitis
- Discharge
- Delayed healing
- Discolouration
- Friable, bleeding granulation tissue
- Unexpected pain/tenderness
what is the ideal healing environment for wounds?
warm and moist
what is debridement
removal of necrotic/sloughy tissue
what is absorption (in wound healing)
removal of excess fluid from wound bed
what is hydration (in wound healing)
addition of moisture to dry wound bed
what is protection (in wound healing)
from mechanical/biological factors which may delay/prevent healing
a moist wound healing environment enhances re-__________ in wounds but excessinve fluid can slow down healing and cause _______. Acute wound fluid is different from chronic wound fluid. Chronic wound fluid is seen as a _______ _____
a moist wound healing environment enhances re-EPITHELIALISATION in wounds but excessinve fluid can slow down healing and cause MACERATION. Acute wound fluid is different from chronic wound fluid. Chronic wound fluid is seen as a WOUNDING AGENT
how does ineffective management of wound exudate effect healing?
it will have a negative effect on wound healing, and surrounding skin either by allowing the tissues to get too dry or too wet.
what would a wound with low exudate appear like? what dressing type does it need?
Wound tissues moist, moisture evenly distributed in wound, <25% of dressing soiled
Do not apply a foam dressing. Apply a simple dressing.
what would a wound with moderate exudate appear like? what dressing type does it need?
Wound tissues saturated, drainage may not be evenly distributed in wound, 25% - 75% of dressing soiled.
Apply dressing designed to manage moderate exudate and provide bacteriostatic barrier.
Foam not always required.
what would a wound with heavy exudate appear like? what dressing type does it need?
Wound tissues bathed in fluid, drainage freely expressed, may not be evenly distributed in wound, >75% of dressing soiled
Apply dressing designed to manage heavy exudate. Foam probably required
what would a wound with excessive exudate appear like? what dressing type does it need?
Exudate not contained by highly absorbent foam
Consider if wound requires primary dressing.
Apply highly absorbent dressing or drainable appliance
how should infection be managed?
Treat infection systematically
Treat local characteristics affecting wound bed
Treat surrounding skin
when should you NOT routinely take swabs? why?
if the wound is a chronic ulcer, a pressure ulcer, wound over a month old, sinuses and fistulae, and stoma sites
This is because these wounds will always have growth since they will be colonised with the patients own flora/environmental organisms
when should you take a wound swab?
evidence of spreading cellulitis, clinical signs of infection (temp, WCC, etc), immunosuppression (diabetes, steroids, malignancy)
define wound cleansing
Wound cleansing is “the process of using fluids to remove loose wound debris and remnants of dressings. This process should not be confused with wound debridement.”
what 5 things need considered when selecting a wound dressing?
- What is the action of dressing?
- When should it be used?
- Any contraindications?
- Application and removal methods
- Is a secondary dressing required?
what should ideal dressings provide?
- Moist environment
- Thermal insulation
- Low or non adherent
- Absorbs exudates
- Cost effective
- Protection
- Pain relief
