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Wound Assessment . Assessment, Treatment and examples. WOUND HEALING. Primary Intention: surgical wounds, approximated edges, minimal scarring. Secondary Intention: Wound must use granulation to heal. Wound “fills” from the bottom up. Can be a result of infection.
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Wound Assessment Assessment, Treatment and examples
WOUND HEALING Primary Intention: surgical wounds, approximated edges, minimal scarring. Secondary Intention: Wound must use granulation to heal. Wound “fills” from the bottom up. Can be a result of infection. Tertiary Intention: Infected wound is left open to resolve and closed when infection resolved http://www.youtube.com/watch?v=0AIDCV9MyiQ
WOUND EVALUATION • Cause: determine etiology (physician determined) • Local wound characteristics: - Location: Be specific! Distal, Medial, etc… - Size: (length x width x depth) Know your facility policy. -Head-to-toe? -Longest points? - Wound bed (black, yellow, red, pink, undermined) -think percentages!
WOUND EVAL. CONT. - Exudate: (copious, moderate, mild, none) type of drainage: -Serous: Clear, watery slight red or clear tinge -Purulent: Yellow, green, tan, “pus” -Sanguineous:Bright red “frank” blood - Serosanguineous: Red, watery mixture of serous and sanguineous
WOUND EVAL. CONT. - Wound edge: -Callus: Tissue overgrowth around a wound -Maceration: Maceration of the skin occurs when it is consistently wet. The skin softens, turns white, and can easily get infected with bacteria or fungi -Erythema: characterized by redness or rash -Edema: swelling around wound - Odor (absent, present) • Patient concerns: pain (persistent, temporary)
PRESSURE ULCERS • STAGES OF TISSUE DETERIORATION • PER NPUAP Staging (National Pressure Ulcer Advisory Panel, 1989)
STAGE I • A Stage I pressure ulcer is an observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.
STAGE II • Partial-thickness skin loss involving the epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
STAGE III • Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue, which may extend down to but not though underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
STAGE IV • Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (such as tendon or joint capsules) .Undermining and sinus tracts also may be associated with stage IV pressure ulcers.
BASIC DRESSINGS Dry gauze dressings:Cover incisions, absorb drainage cover another dressing. NOT used in moist enviornment, used to aid mechanical debridement.
Wet-to-dry dressings: Usually used with gauze where wound packing is moistened place in wound and dries out. Removing dressing also removes nacrotic tissue. Can be painful and can accidentally remove healthy tissue
Impregnated gauze Wet-moist dressings Transparent adhesive films:Allow exchange of air and water vapor from wound, but prevent bacteria from entering. Can be moist if non-permeable or dry if permeable
Hyrdogels: Used to moisten a wound or tissue in the wound bed. Come in amorphous (gel) spray, granuals, etc…Used to hydrate a wound, fill space, autolytic debridement:
Alginates:Alginates are made of soft non-woven fibers derived from seaweed. They are usually in the forms of pads, ropes or ribbons. Alginates absorb wound exudate and form a gel-like covering over the wound, maintaining a moist wound environment. Most alginates absorb many times their own weight. The dry dressing, however, is extremely lightweight
Collagens:Collagen plays an integral part during each phase of wound healing and is an excellent hemostatic agent. It absorbs 40 - 60 times its weight in fluid. The most abundant and well characterized collagen is type 1 extracted from bovine (cow) hide. Other sources include porcine (pig), chicken tendon, bovine tendon, etc. When applied to a wound, collagen initially acts as a hemostatic agent. Continued application seems to aid and hasten the body's own repair mechanisms.
Foams: For heavily exudating wounds - especially during the inflammatory phase following debridement and desloughing, when drainage is at its peak . Deep cavity wounds - as packing to prevent premature closure while absorbing exudate and maintaining a moist environment. Also used for weeping ulcers, such as venous stasis
Hydrocolloids:Hydrocolloids are occlusive and adhesive wafer dressings which combine absorbent colloidal materials with adhesive elastomers to manage light to moderate amounts of wound exudate. Most hydrocolloids react with wound exudate to form a gel-like covering which protects the wound bed and maintains a moist wound environment. Hydrocolloid powders and pastes are also available with increased absorptive capacity.
