Wound Care and Asepsis

Question 1

What are the 4 stages of wound healing?

Answer 1

Haemostasis

• begins immediately
• works to stop blood loss
• vasoconstriction
• platelet plug
• clotting cascade

Inflammation

• 0 to 3 days
• cellular and vascular response
• vasodilation and increased capillary permeation
• neutrophils remove dying tissue

Proliferation

• 2 to 24 days
• epithelial cells deposit fibroblasts and collagen fibres, allowing for growth of blood vessels

Maturation

• 24 days to 1 year
• tissue grannulates
• remodelling regulated by growth factors

Question 2

What causes skin tears?

Answer 2

• friction and or shear

- epidermis is separated from the dermis

Question 3

What are the 5 classifications of skin tears?

Answer 3

1a - edges can be realigned without undue stretching and the skin is not pale, dusky or darkened
1b - edges can be realigned with undue stretching and the skin is pale, dusky or darkened
2a - edges cannot be realigned and skin/flap is not pale, dusky or darkened
2b - edges cannot be realigned and skin/flap is pale, dusky or darkened
3 - skin flap is completely absent

Question 4

What wounds are suitable to be cleansed with tap water?

Answer 4

• Surgical wounds healing by primary intention
• Lacerations or grazes
• Chronic wounds with no undermining or underlying structures on view

Question 5

What wounds are NOT suitable to be cleansed with tap water?

Answer 5

• Actively bleeding
• Undermined
• If vessel, bone, tendon or underlying structures on view
• If patient is severely immuno-compromised
• Venous access devices e.g. invasive lines or catheters