Week 4: Simple Wound Management Flashcards
Benefits for Moist wound Healing: Facilitates the debridement process
- Encourages autolysis, the breakdown of
devitalised tissue
Benefits for Moist wound Healing: Acts as a lubricant
To facilitate and accelerate themigration
of epithelial cells across the wound
surface
Benefits for Moist wound Healing: Acts as a transport medium
To deliver oxygen, nutrients and mobilise
cellular constituents to support the healing
process
Benefits for Moist wound Healing: Prevents the formationof scab
Wounds are dressed with a covering
impermeable to bacteria
Benefits for Moist wound Healing: Prevents the formation of scab
Reduces scar tissueformation,
cosmetically aesthetic
Benefits for Moist wound Healing: Reduces pain
Prevents exposed nerve endings from
drying out following the loss of epithelial
layers. Less traumatic dressing removal.
Optimised patientcomfort
What is the acronym for goals of wound management
- Tissue Management
- Infection and inflammation control
- Moisture malance
- Epithelial (Edge) Advancement
What to consider for Tissue Management
- Assessment viable and non-viable tissue
- remove non-viable tissue via debridement
- protect viable tissue
What is non-viable tissue?
- slough
- necrosis
- eschar
What is viable tissue?
- granulating tissue
- epithelialising tissue
What is debridement?
- removal of non-viable tissue from a wound?
What are some of the methods of debridement?
- surgical
- sharp
- mechanical
- biological/larval
- autolytic
- enzymatic
What to consider for inflammation and infection control?
- methods to remove infection
- prevent inflammation
What is contamination wound state?
the presence of
non-replicating organisms on a wound.
What is colonisation wound state?
presence of
replicating micro- organisms on the
wound without tissuedamage
What is local infection/critical colonisation wound state?
an intermediate stage, with micro- organism replication and the
beginning of local tissue responses.
What is invasive infection wound state?
is defined asthe
presence of replicating organisms
within a wound with subsequent host
injury
How to obtain a bacterial wound swab?
- Assess pain and administer analgesia.
- Therapeutic communication.
- Gloves to remove the old dressing.
- Clean the wound to remove any exudate,
biofilm, debris and dressing products from
the bed of the wound allowing for a
‘cleaner’ sample. - Gently move the swab across the wound
bed surface without touching the edges or
the surrounding skin. Use a zig-zag motion
whilst rotating the swab tip.
3.Immediately and carefully, return the swab
to the collection container.
Label the specimen and send to pathology asap.
* Dress the wound.
what does TIME stand for?
- tissue management
- inflection/inflammation
- moisture balance
- epiletial edge
What is Autolytic debridement?
- can be slow
What is Enzymatic debridement?
- can be
Selecting correct dressing:
wound condition: Hard dry black (necrosis)
- hydrogel
- hydrate, separate eschar
Selecting correct dressing:
wound condition: pink/red (epithelial)
- transparent film
- allow epithelialisation, reduces shear
Selecting correct dressing:
wound condition: moist red (granulating)
- hydrocolloid
- provide barrier and control humidity
Selecting correct dressing:
wound condition: Exudating yellow (slough)
- alginate
- absorb exude, debridement
What factors impact choice of product?
Wound – location, size, type
* Manage exudate
* Promote debridement
* Manage infection
* Frequency of dressing change, ease/difficulty
* Cost
Wound type
- colour
What are basic elements of wound care?
- cleanse debris/microbes
- protect from trauma/infection
- warm, moist environments
- decried
- manage pain and discomfort
- manage exudate and odour
- promote granulation and epithelialisation
Biological/Larval debridement
Why do we clean the dressing trolley furthest point away from
ourselves working towards ourselves?
Why do we avoid placing the packaged equipment on the top surface
of the dressing trolley?
Why do we stand back when opening extra equipment to add to our
aseptic field?
Where is the ‘field’ hand positioned? Where is the ‘working’ hand
positioned?
Why do we clean the middle of the wound and then work towards
the edges?
Why should the blue forceps tips not touch when exchanging gauze
to clean the wound?
What is the width of the contamination border?
What happens to the aseptic field if I add clean equipment to it?
What is the cue for the aseptic handwash?
What factors do we assess as part of the wound assessment?
Observe forclassic signs and
symptoms:
- pain, heat, redness, swelling and purulence
- fever, leukocytosis
- Delayed healing
- Odour
- Friable (bleeds easily),
absent or abnormal granulation
Signs and Symptoms of Infection - Change in colour of the wound
- Wound breakdown
What to consider with M- Moisture Balance
- Controlling
exudate - Controlling
exudate
-Supports
growth of
new tissue
Factors that Impact on
Wound Healing
- dry wound
- neutral wound
- excessively moist wound
What to consider E-Epithelial (Edge) Advancement
- support the healthy granulation tissue to assist proliferating epidermal cells to migrate
- epidermal cells require repeated cell deviance at edge of wound for epithelisation to occur
Nursing process for wound management
- asses the patient, wound first
- bring in multidiclinary team e.g wound specialist
- control or treat underlying causes and barriers to wound healing
- decide appropriate treatment
- evaluate and reassess the treatment and wound management outcomes
Making
judgements
& decisions red/pink wounds:
vascular granulation tissue or epithlialistation
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
