wound healing Flashcards
What things do we need to know and do when assesing a wound
- How long has the wound been there for
- What medication the patient is on - to identify any underlying health issues
- Photo the wound applying patient details and date
- Size, site, length, width, and depth
- Levels of exudate Low/Moderate/High
- (Low = weekly dressing changes dry or lighlty soiled)
- (Moderate = 2-3 day dressing changes soiled but not soaked)
- (Daily dressing changes that are soaked)
- Infection - any signs of infection present take a swab of the area and send off for microscopy
- Start patient on a broad spectrum antibiotic and consualt doctor
- Pain - What levels of pain are apparnet
What is the TIME principle of wound healing
T- Tissue debridement removal of non viable tissue
I- Infection/inflamattion remove infected tissue via topical systemic antibiotoics or reduce inflamattion with anti inflamattory
M- Moisture imbalance apply moisture balancing dressings e.g. compression OR negative pressure therapy
E- Edge of the wound non advancing or undermined. Re asses cause
* Debridement
* Peri wound protectant
* Other corrective therapies
What are the 4 types of wound drainage
Serous - clear or light yellow, thin watery
Sanguineous - Red with fresh blood, Thin
Serosanguineous - Pink to light red, Thin watery
Purulent - Creamy yellow, green white or tan, Thick opaque
What are the charecteristics of Antimicrobial dressing
Antimicrobial:
* capable of killing bacteria
* Used for exuding lesions
* No use for dry wounds
What are the charceteristics of foam dressings
Foam:
* Exudate management (absorb and retain exudate)
* Reduce maceration and promote moist wound healing
* Used for infected wounds and moderate exudate
What are the charcetristics of Hydrogel dressings
Hydrogeel:
* Water based gel used to debride necrotic tissue and dry slough
What are the charecteristics of alginate dressings
Alginate:
* Absorbent dressing comprissed of Calcium alginate used to manage exudate
What is a wound contact layer
Wound contact layer:
* layer that goes directly over the wound and allows exudate to pass through and prevents other dressings from sticking to the wound bed
What is a Hydrocollid dressing
Hydrocollid dressing:
* Used for mildly exuding wounds
* Provide a moist insulating environment to promote wound healing
* Waterproof
How would you manage the wound
- So clean with sterile saline solution and sterile gauze
- debride any non viable tissue where neccesary
- apply a sterile non adherent dresssing using a non touch technique
- give the patient the appropriate after care advice