W4: Wounds and Dressings Flashcards
What to consider dressing moisture scale: Absorb Moisture
- alginates
- hydro fibres
- foams
-absorbent pads - natural fibre dry dressings
What to consider dressing moisture scale: Neutral
- transparent films
- non-adherent dry dressings
- silicone dressings
What to consider dressing moisture scale: Add Moisture
- hydrocolloids
- hydrogels
- wound fillers
- tulle gras dressings
If the wound has non-viable tissue then…..
debride it
If the wound is dry then….
add moisture
If the wound has drainage then….
absorbit
General things to consider about dressing and wounds
Wound dressings should be changed as needed to meet the
characteristics of the woundbed.
If a wound fails to respond, consider changing products to one with a
different mechanism ofaction.
More than one dressing may be required on a wound, ie hydrogel,
non-stick pad, combine pad and secured with tape or tubular
bandage
Making judgements
& decisions:
- Black wounds
- Necrotic tissue or
eschar tissue - Require debridement (removal of dead tissue)
- rehydrate the wound bed (hydrogel, hydrocolloid)
and body’s own enzymes break down tissue;
autolytic debridement
Making judgements
& decisions:Yellow wounds
Slough – moist,
devitalised, thick,
stringy, adhered
OR
Purulent exudate
Remove non-viable tissue & manage
exudate
- clean by swabbing or irrigating
- promote autolytic debridement; absorb exudate
(alginate); may need to add moisture (hydrogel)
- If colonisation of microorganisms and
biofilm consider topical antimicrobial
dressing Iodine, Silver)
Making judgements
& decisions: Red/pink wounds
Vascular granulation
tissue
OR
Epithelialisation
Protect regenerating tissue
- gentle cleaning; protect peri-wound
- fill dead space (hydrogel or alginate)
- cover (hydrocolloid, transparent film,
clear absorbent acrylic dressing)
- aim for infrequent dressing change
What to consider if there is an infected wound
Antimicrobial dressings
Silver dressing
Iodine dressing
Odour absorbing dressings
Charcoal
What to consider about silicone dressings
Conforms to different anatomical
shapes
Atraumatic to wound and
surrounding skin
Absorbent of up to moderate
exudate
Can be used on infected wounds
if appropriate antibiotic
treatment provided
➢ Mepilex Border
➢ Allevyn Gentle Border
➢ Biatain Foam
What are 5 Hydrocolloid dressings advantages
-Waterproof which allows patients to
shower
- Absorbs exudate
-Gel that forms from the wound fluid
provides a moist wound environment
- Reduces pain
- The moist environment promotesthe
formation of new tissue
What are 4 Hydrocolloid dressings disadvantages
- sometimes have a distinctive malodour that
is mistaken for pus - May be difficult to keep in place
- Use with caution on fragile or compromised skin as the adhesive may
cause trauma - Care should be taken when using
hydrocolloids as they can encourage the
growth of anaerobic bacteria
What dressings for Granulating &
epithelialising
wounds
- Hydrocolloids
- Soft silicone dressing
- Transparent films
A low absorbent dressing will help
protect this wound (Granulating &
epithelialising
wounds)
Good for low exudating,
primary intention wounds
Economical
Primary dressing with an
adhesive secondary dressing
➢ Island dressings
➢ Primapore
➢ Opsite
What should we do to deal with over granulation/hypergranulation
Compress the tissue
What are foam dressings good for
- Low to heavily exudingwounds
- Granulating and epithelialisingwounds
What to consider with a slough wound
Remove non-viable tissue
Rehydrate wound
Absorb exudate
What dressings with sloughy wound
Alginate
Impregnated
hydrogel
Hydrofibres
What are secondary dressings
Used to
secure primary
dressing
Used to protect
and absorb
exudateand odour
Facilitates
What are examples of secondary dressings
Non-stick dressing
Absorbent pads
Charcoal
Bandages
Tapes
What to consider with necrotic/eschar wounds
Debride (remove dead tissue)
- rehydrate the wound bed &
body’s own enzymes break
down tissue
- Manage odour
