Wound Management Flashcards
What is a wound?
An injury to living tissue caused by a cut, blow or other impact typically one in which the skin is broken or cut
Colour of wounds
Pinky wounds – indicates depth of granulation tissue. Epithelisation is the final step in wound healing
Red wounds – Healthy looking tissue is clean and granulating. Beefy red could signify a possible infection.
Yellow wounds – Compromised of injured tissue which dies and forms a soft yellow mass. The removal of cellular debris by cleansing and debridement must take place for healing to start
Green wounds – Clinically infected. Infected material needs to be removed for healing to occur
Black wounds – necrotic. Debridement required.
How wounds heal?
Three main phases: inflammatory, proliferative (repair) and maturation (degeneration) Wounds can get stuck in a phase Need a moist environment 1. Haemostasis Formation of platelet plug Formation of a stable fibrin clot 2. Inflammatory stage Removal of bacteria and cellular debris Chemotaxis 3. Proliferative stage Angiogenesis Re-epithelisation 4. Remodelling Type I collagen predominates Collagen cross-linking
Methods of healing
Primary – structures, adhesives, clips
Secondary – wound left open to allow granulation to occur and heal eventually
Tertiary – wound left open for granulation to occur and then stitched together
Factors which affect the healing process
Good nutritional status Adequate skin perfusion Age, smoking, well controlled underlying condition Avoid medication detrimental to healing process Moist environment Wound temperature maintained at 37 °C Adequate oxygenation of tissue pH as determined by oxygen concentration Low bacterial count on wound surface Wound surface clean Avoid antiseptics
The ideal dressing for wounds
Maintains a moist environment
Absorbs excess exudates and toxic substances
Allow gaseous exchange
Demonstrate impermeability to microorganisms
Insulate from low temperatures
Allow removal without trauma
Dressings
1. Foam Absorbs and retains fluids Creates a moist wound environment 2. Hydrocolloid Adhesive dressing that forms a gel over the wound Donates moisture to the wound and provides a barrier 3. Hydrogel Hydrates a dry wound Keeps the wound bed moist Gel or sheet form 4. Alginates Absorb exudates Turns into gel Remains intact For shallow wounds 5. Aquafiber Absorbs exudates Turns into gel Remains intact Used for cavity wounds
