Wound Assessment and Management Flashcards
What are the parameters in the tissue?
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.
What should the care be in the parameters of tissue?
Epithelial and granulating
Slough and Necrocratic
Epithelial and granulating = Viable > Protect
Slough and Necrocratic = Non-viable > non-debride.
What are the parameters of the inflammation/ infection?
What should the care be in the parameters of inflammation/infection?
What are the parameters of the Odour?
What additional clinical presentations to odour or infection, should you look out for? And the care involved if they are?
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).
What are the parameters in moisture/exudate?
What should the care be in terms of moisture/exudate parameters?
What are the parameters in edges?
What should the care be in terms of edge parameters?
What factors that affect wound healing -Extrinsic/ local factors?
- 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
What factors that affect wound healing -Intrinsic/ systemic factors?
- 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
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
Secondary intention: the wound edges don’t come together and need dressing products to promote granulation
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