Wound Assessment and Management Flashcards

1
Q

What are the parameters in the tissue?

A

Epithelial = Pink or pearly white and wrinkles when touched (Final stage of healing).

Granulating = Deep red and moist. (Healthy tissue, in remodelling phase)

Slough = Yellow, brown or grey (devitalised tissue of dead cells or debris)

Necrocratic = Black, hard and dry (unstageable). Dead tissue prevents wound healing.

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2
Q

What should the care be in the parameters of tissue?

Epithelial and granulating

Slough and Necrocratic

A

Epithelial and granulating = Viable > Protect

Slough and Necrocratic = Non-viable > non-debride.

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3
Q

What are the parameters of the inflammation/ infection?

A
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4
Q

What should the care be in the parameters of inflammation/infection?

A
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5
Q

What are the parameters of the Odour?

A
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6
Q

What additional clinical presentations to odour or infection, should you look out for? And the care involved if they are?

A

If there is any odour or infection (including fever, pain, discharge or cellulitis). A medical review should be initiated, and a Microscopy & Culture Wound Swab (MCS).

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7
Q

What are the parameters in moisture/exudate?

A
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8
Q

What should the care be in terms of moisture/exudate parameters?

A
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9
Q

What are the parameters in edges?

A
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10
Q

What should the care be in terms of edge parameters?

A
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11
Q

What factors that affect wound healing -Extrinsic/ local factors?

A
  • Wound management practices and moisture balance (e.g. wound dehydration or maceration)
  • Stable temperature (approximately 37oC)
  • Neutral or acidic pH
  • Infection
  • Wound location
  • Mechanical stress, pressure or friction
  • Presence of foreign bodies
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12
Q

What factors that affect wound healing -Intrinsic/ systemic factors?

A
  • Nutrition
  • Underlying or chronic disease
  • Decreased mobility
  • Impaired perfusion (blood flow)
  • Medications (including immunotherapy, chemotherapy, radiation or NSAIDs)
  • Mental health (including stress, anxiety or depression)
  • Patient knowledge, understanding or compliance
  • Age of patient
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13
Q
A

Wound healing may be by:

Primary intention: the wound edges can be pulled together e.g. surgical incision (using sutures, staples, steristrips or glue), small wounds, paper cuts

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14
Q
A

Secondary intention: the wound edges don’t come together and need dressing products to promote granulation

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15
Q
A

Tertiary intention/ delayed primary intention: the wound is cleaned before it can be closed due to a high risk of infection e.g. contaminated wounds

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16
Q
A

Negative pressure wound therapy: Topical negative pressure or vacuum assisted closure (VAC) is a foam dressing attached to a device to assist with wound closure, proliferation, moisture removal and stabilisation of the wound environment. Typically used in open or dehisced wounds, grafts, flaps or pressure injuries.
Frequency of dressing changes:

17
Q
A

The frequency of dressing changes is led by the treating team or indicated by product manufacturers

It is advised that wounds are reviewed at least every 7 days to monitor wound healing and reassess goals of wound management

18
Q

Wound Cleansing

A

Wound Cleansing

Cleansing solutions:
Ensure cleansing solutions are at body temperature.

Potable (drinkable tap) water
Washing under a shower may be appropriate after carefully considering the risks associated with contamination from pathogenic microorganisms
Sterile water
Normal saline
Surfactants or antiseptics for biofilm or infected wounds e.g. Prontosan™

19
Q
A

Cleansing technique:
Avoid immersion or soaking wounds in potable water
Washing the wound must be separated from washing the rest of the body
Use a scrubbing or irrigation technique rather than swabbing to avoid shedding fibres

20
Q
A

Principles of Aseptic Technique:
Standard or surgical aseptic technique is used as per the RCH Procedure Aseptic Technique.

Standard aseptic technique: selected for simple wound dressings, usually procedure of less than 20- minute duration. Involves few key parts or key sites. Use nonsterile gloves, a general aseptic field and non-touch techniques (or sterile gloves when directly touching a key part or key site).
Surgical aseptic technique: selected for large or complex wound dressings that involve a longer duration and more key parts or key sites. Use sterile gloves, a critical aseptic field, and sterile solutions.

21
Q
A

Debridement:
Debridement is the removal of dressing residue, visible contaminants, non-viable tissue, slough or debris. Debridement can be enzymatic (using cleansing solutions), autolytic (using dressings) or surgical.

Determining when debridement is needed takes practice. If you are not familiar with wound assessment/debridement confer with a senior/expert nurse.

For complex wounds any new need for debridement must be discussed with the treating medical team.

22
Q

Primary Dressings:
Dressings that have direct contact with the wound and have the ability to change the wound (e.g. moisture donation/ retention, debridement and decreasing bacterial load)

A

https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Wound_Assessment_and_Management/#:~:text=TIME%20is%20a%20valuable%20acronym,the%20wound%20or%20Epithelial%20advancement.