Wound assessment Flashcards
tpy polyclinic
MEASURE tool
- Measure
- Exudate
- Appearance
- Suffering
- Undermining
- Re-evaluation
- Edge
Measure
Length
Width
Depth
Greatest length perpendicular to depth of wound
Exudate
Quantity: None; Small/ Scant; Moderate; Large
Odor: No odour; slight; moderate; strong
Quality:
Bloody:
* Red, thin & watery
* Indicates new blood vessel growth or disruption of blood vessels
Haemoserous/serous
* Light or light red to pink
* Thin watery
* Normal during inflammatory and proliferative phase of healing
Haemopurulent:
* Cloudy, yellow and tan colour
* Thin and watery
* Maybe impending of wound infection
Purulent/Pus:
* Yellow, tan to green
* Thick, opaque
* Indication of wound infection
* Associated with odor
Appearance
Assess on types of tissue over wound bed and amount
Granulation:
* Red, firm and moist in appearance
* Vascularised tissue has a granular appearance
Friable tissue:
* Brittle
* Easily damages
* Bleeds easily
* High bio-burden with bacterial load
Biofilm:
* Appears as shiny and smooth above the wound
* Containing bacteria or fungi
* Resistant to antimicrobial agents
Hypergranulation/ Overgranulation:
* Bright red tissue
* Excess of granulation tissue growths above the level of surrounding skin
* Inflamatory in nature
Slough:
* Viscous yellow layer that partial or loosely adherent or strongly adherent to wound bed
Eschar/ Necrotic:
* Black, soft and wet o Or hard and dry necrotic tissue
* Due to inadequate blood supply
Epithelialization
* Appears as pink or red skin migrating from wound margin
* Process of epidermal resurfacing
Suffering
Pre/ during / Post treatment
* Location
* Pain score
* Duration/ Frequency
* Additional information
Use of Wong-Baker FACES scale
Undermining
Occurs when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound’s edge.
* Probe or cotton tipped applicators are used for measurement
* Recording based on the clock system: 12 o’clock representing patient’s head direction, with the body in the anatomic position
Re-evaluation
Monitor wound parameters at every dressing change
Perform wound assessment weekly, complex wound every visit
Edge (Condition of wound edge)
Epithelializing
* Process of becoming covered with epithelial cells.
* New epithelial cells advance across the wound until meet epithelial cells moving in from the opposite direction
Epithelialized
* Total coverage of wound bed with epithelial cells
Rolled wound edge
* EVidence of impaired wounc healing
* Soft-to-firm and flexible to touch
Callus
* Painless thickening of the stratum corneum (outmost layer of skin)
* Often located over foot due to external pressure or friction
Edge (Condition of peri-wound skin)
Bruise
* Black/blue/ purple
* Extravasation of blood into the subcutaneous tissue due to trauma
Excoration
* Injury to epidermis or dermis o Caused by scratching, friction, chemical ( urine/ faeces)
Induration
* Hardening and firmness of tissue
* Due to edema/ inflammation
Inflammation
* Protective response of body irritation or injury.
* Signs include redness, swelling, pain and heat
Maceration
* Softening or break down of skin
* Due to prolong exposure to moisture.
Skin presents as moist, red/ white or wrinkled
Frequency of dressing change - Heavily exudating or infected
Daily or EOD
Frequency of dressing change - Slough and necrotic
Every 2-3 days
Frequency of dressing change - Clean granulating wounds
Every 3 to 5 days
Frequency of dressing change - Epithelialising & clean suture wound
Every 5 to 7 days
Wound pdts for wound contact layer
Are non-adherent single layer of woven or perforated net sheets.
Directly apply onto the wound to protect wound bed.
They are porous, hence allowing wound exudates to be absorbed by a secondary dressing.
May be used as primary dressing and for wounds with minimal to heavy exudate
e.g.
* Melolin
* Mepitil
* Urgotul
* Urgotul Ag
* Inadine
What are Hydrocholloid/ Hydrogel dressing used for?
- Water-or glycerine-based dressings that are designed to hydrate wound.
- Available in gel or sheets forms, for dry to minimal exudating wounds.
As autolytic debridement agent for necrotic tissue to help to loose slough.
Hydrofiber dressing
- Absorbs and interacts with wound exudate to form a soft, hydrophilic gel that traps bacteria and conforms to the contours of the wound whilst providing a micro-environment
- For moderate to heavily exudating wound.
- Can be used for fungating, infected and non-infected wounds
- Useful for cavity and/or wounds with tunnel, sinus tract or undermining (to pack loosely)
Note: It’s possible to apply dressing moisten with sterile water or saline to lightly exuading wounds
NaCl Imperegnated dressing
Pure crystalline sodium chloride impregnated dressing made of an absorbent, nonwoven viscose/polyester material.
It facilitates the cleansing of exudating, sloughy and infected wounds. It absorbs debris and bacteria from wounds, wicks excess fluid and may help to relieve edema.
Used for heavily discharging and infected wounds, deep cavity wound such as pressure sore or dehisced surgical wound
Good for hypergranulating wound
Foam dressing
They are made from polyurethane or silicone and provide a moist environment for wound healing and thermal insulation.
For wounds with minimal to heavy exudate.
Used for absorption and insulations as primary dressing
Used for wound with packing to enhance exudate management as secondary dressing
Alginate dressing
- Derived from seaweed which will work on an ion exchange mechanism to adsorb wound exudates to form a gel.
The gel will conform to the shape of the wound, which will then create a moist wound healing environment.
- It contains heamostatic effect
- Can be used in all wound types (inclusive fungating, infected and non-infected wounds).
- Useful for cavity and/or wounds with tunnelling, sinus tract or undermining (to pack loosely).
lodine based wound products
- Consist of cadexomer beads - modified starch microbeads, which are biodegradable.
- Helps to remove excess exudate and slough from wound bed
- Reduce bacteria by transforming to a soft moist gel
- Can used for all wound types such as infected wound
