Wound Care

  1. Wound
    A wound is a defect or break in the skin that resulting from physical, mechanical or thermal damage or as a result of the presence of an underlying medical or physiological condition.
  2. Acute wound
    Wound that heals in a timely manner going through all the stages of a wound healing process. Generally minimal skin loss and healed by primary intention. Often wound edges joined with sutures/staples.

    Mechanical- abrasion, contusions, lacerations, trauma, grafting, bites, surgical wound

    Burns-  thermal, cold condition, chemical woulds, electrical wound, radiation
  3. Chronic wound
    A wound that gets stuck in a stage and remained unhealed for more than 6 weeks

    Eg: pressure ulcers, leg ulcers, diabetic foot ulcers, post op open wounds
  4. factors affecting wound healing
    • Nutrition
    • depressed immune system
    • age
    • Illnesses
    • autoimmune diseases
    • medication
    • decreased oxygen supply
    • Vascular circulation
    • lifestyle factors - smoking, alcohol, drugs, deficiency.
    *slows down bleeding due to vaso-constricting of blood vessels

    *platelets is released and a clot is formed
    This is your body’snormal response to injury. This phase activates protective measures through chemical activity causing HEAT, REDNESS, PAIN, SWELLING,LOSS OF FUNCTION. Wound ooze may be present and this is also a normal body response.
    This is the time when your wound is healing. Your body makes new blood vessels,which cover the surface of the wound. The result is that your wound will become smaller as it heals.

    • *Fibroblasts continue to make collagen
    • *Capillaries continue to regenerate
    • *granulation continues
    • *wound edges begin to join together
    • *scar is forming
    This is the final phase of healing, when scar tissue is formed.
  9. TIME FRAMEWORK assessmemt tool
    The TIME framework is a useful practical tool based on identifying the barriers to healing and implementing a plan of care to remove these barriers and promote wound healing.

    Used to assess a wound bed.
  10. TIME
    Tissue - viable or non-viable

    Infection - infection or inflammation

    Moisture - imbalance

    Edge - epithelium advancing our undermining
    A framework for wound assessment, it encapsulates key wound parameters that should be addressed in the wound assessment and management of chronic wounds.
  12. M easure
    As the wound heals growth of granulation tissues decreases the wound depth and volume. Measures of wound size are important indicators of healing. 

    may use a ruler to measure length, width, depth (use of sterile swabs), area
  13. E xudate

    Quality and Quantity- serous, heamoserous, purelent. Odor?
    Acute wound: fluid contributes to would healing process as it contains growth factors which help with tissue regeneration. Also inhibit bacteria growth and help degrade necrotic tissue

    Chronic wound: may contain high levels of inflammatory cytokine levels and decreases glucose which are associated with non- healing wound.
  14. A ppearance
    Appearance of the wound bed, tissue type and amount. 

    • Wound bed colour:
    • *Black- dehydrated
    • *Yellow- fibrous tissue or slough
    • *Red- presence of granulation, bright red and moist indicates healthy granulating
    • *Paler appearance may indicate infection or anaemia
    • *pink - final stages of wound healing, the wound is epithelising
  15. S uffering
    Assessment of pain is important, patient comfort or indicator of wound infection. 

    Management can be challenging

    Consider underlying conditions and pain associated with these conditions.
  16. U ndermining
    Need to look, measure the internal wound area.

    The wound will not heal unless the edges are firmly attached to the wound bed
  17. R eevaluate
    Time varies with different wound. Need to loo at both short and long term goals. 

    Assess for signs of infection and deterioration, must be done at every dressing change.
  18. E dge
    The wound edge and surrounding skin provide important information that can assist in the wound treatment
  19. The ideal dressing
    • Remove excess exudate
    • Maintains a moist enviroment
    • Impermeable to micro-organisms and free from irritants
    • Does not shed particles into the wound
    • Does not adhere to skin tissue
    • Performs as a semi permeable membrane
    • Provides thermal insulation
    • Easy to apply and cost effective
  20. Alginate dressings
    Image Upload 1
    • Form a gel like covering when come in contact with exudate
    • Helps maintain optimum moisture and temperature
    • Made of soft non-woven fibres derived from seaweed
    • Form of pads, ropes or ribbons
    • Best used with moderate to heavily exudating wounds
  21. Foam dressings
    Image Upload 2
    • Work by absorbing exudate and maintain a moist environment
    • Provide thermal insulation
    • Suitable for minimal to heavily exudating wounds
    • Not suitable for dry epithelializing wounds or dry scars
    • Have added advantage of providing cushioning and comfort
  22. Hydrogel dressings
    Image Upload 3
    • Work by donating and absorbing liquid within wound bed
    • Promote autolysis of dead tissue
    • Promote a moist environment
    • Requires secondary dressing when applied as gel
    • Suitable for light to moderately exudating wounds
    • Re-hydrates dry and necrotic wounds
    • Cleanse sloughy wounds by enhancing autolytic debridemet
  23. Semi permeable dressings
    Image Upload 4
    • Waterproof but allow passage of oxygen and water vapour to and from the wound site
    • Prevent wound contamination by bacteria
    • Help maintain a moist environment and retain growth factors from exudate close to the wound bed
  24. Hydrocolliod dressings
    Image Upload 5
    • Absorb liquid and form a gel
    • Used for light to moderately exudating wounds
    • Do not adhere to wound beds
  25. Hydrofibres

    Image Upload 6
    • Absorb exudate 
    • Form a soft gel on contact with exudate
    • Gel aids the removal of non-viable tissue from wound
  26. Name two functions of the subcutaneous layer
    Act as a shock absorber and insulator where it stores fats for energy reserves.
  27. Describe why a moisture balance is important to wound healing
    A moist wound environment encourages healing by promoting granulation an the body's own ability to debride a wound. Must be maintained to keep wound form becoming dry or too moist, both of which can contribute to wound healing
  28. Why is it important to examine the edges of a wound
    This helps to determine whether the epithelium tissue is advancing or whether the wound is undermining
  29. Insensible perspiration involves water loss by
    Diffusion through skin
  30. Explain delayed primary closure
    • Sometimes called tertiary closure 
    • Wounds such as bite wounds or dehisced surgical wounds
    • Wounds that are infected and need infection clearer prior to primary closure
  31. What does dehiscence mean?
    This describes a surgically closed wound that has partially or completely separated resulting in a cavity wound. This occurs when the wound has failed to develop sufficient strength to  withstand the forces placed upon it. Although it is generally seen 5-10 days postop, it can occur up to one month after surgery. The primary causes of dehiscence are:

    • *Poor suturing/stapling technique
    • *Haematoma formation between the opposed tissues, which can prevent normal healing
    • *Wound infection
  32. localised symptoms of an infected wound?
    • warm
    • pain
    • swelling/edema
    • erythema
    • inflammation
    • high temperature
    • decreased appetite
    • wound not healing
    • fatigue
    • cellulitus
Card Set
Wound Care