Wound Care Flashcards
What are the cause of wounds?
Surgical incisions Traumatic (lacerations, abrasions) Pressure (pressure ulcers) Friction (blisters) Poor circulation (ulcers)
How do you assess a wound?
Location Size Tissue type on wound bed Odour -pseudomonas common for wound odour Surrounding skin Exudate Pain Clips/sutures Clinical signs signs of infection Photographs
What are systemic factors of wound healing?
Age Nutrition Trauma Metabolic diseases Immunosuppressive Obesity Smoking
What are the local factors affecting wound healing?
Type,size and location Vascular supply Infection Pressure Necrotic tissue Contamination
What is epithelialising and what dressings are appropriate?
Process by which wound surface cover my new epithelium skin cells
Non-adhesive dressings - prevent healing to new developing skin
What are granulating wounds and what dressing is used?
Healthy red tissue seen - newly form collagen, very delicate to bleeding
Non adhesive dressings
What is a sloughs wound and what dressing is used?
Yellow tissue due to dead cells
Surgical debridement may be option to clean wound
Aliginate/ honeycomb dressing dressing and adhesive dressing + extra padding
What are necrotic wounds?
Contain black dead tissue prevents wound healing
Requires surgical debridement reassess after due to not knowing extent before may leave cavity wound
Cavity wound may be packed with alginate dressing - healing from down upwards + gauzes adhesive dressing
Why may a surgical wound be opened or open up?
Called dehiscence:
- Infection
- Poor nutritional state
- increase body habitus
Dressed with alginate or TNP dressings
What are the benefits of TNP/VAC therapy?
Increase wound healing time
Reduce risk of pathogenic infection
Reduce number of dressing changes
Increase blood flow to wound area while simultaneously drawing out excess fluids
Patients more mobile
Community support for pts reducing Length of stay
What is maggot therapy?
In maggot debridement therapy, larvae of therapeutic fly species are used to treat and manage wounds
Used when surgical debridement not possible, pts need to counselled, reassure pt maggot secure in bag and warn about mobilising, need to change every three days and require regular checks
What are the principles of wound care?
Cleaning and irrigation Remove excess exudate Debride necrotic tissue Protecting wound Prevent infection
