Wound care

Exudates

What comes out of a wound

Exudate amount:None

Dressing is dry

Exudate amount:Slight

Small amount in center of dressing

Exudate amount:Moderate

Contained within the dressing

Exudate amount:Copious

Extends beyond the dressing onto clothing or bedding

Serous

Thin, watery

qSerosanguineous

– thin, pale red or pink

qPurulent

– thick, opaque, tan, may have odor

nMaceration: 

caused by excessive moisture

4 Types of dressing

nPrimary: directly over wound and needs to be sterile

nSecondary:  indirect contact; cling wrap

nOcclusive:  forms a seal

nNon-occlusive:  breathable (use when infection present!  Occlusive may increase amount of bacteria due to greenhouse effect)

Contact Precautions

Prevent transmission of infectious agents

Prevent spread by direct or indirect contact

Use of single-patient room

Gown and gloves for all interactions

Droplet Precautions

Prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions

Single-patient room

Mask

Respiratory hygiene/cough etiquette

Droplet viruses

nRhinovirus, flu, mumps, measles, TB, whooping cough, scarlet fever

nAirborne Precautions

qPrevent transmission of infectious agents when suspended in the air

qAirborne infection isolation room (AIIR)

qSpecial air handling required

qSingle-patient room

qN95 respirators or masks

nMeasles, chickenpox (shingles), TB, SARS, Anthrax, COVID-19

Airborne viruses

nMeasles, chickenpox (shingles), TB, SARS, Anthrax, COVID-19

qSlough

– soft, moist tissue that adheres to wound bed in strings and clumps (yellow, tan, green)(Infection)

qNecrosis/eschar

– brown/black and adheres to wound surface(Can be dry or moist)

qGranulation

– pink/red moist tissue; may have buds of new collagen fibers(What Is wanted)

qEpithelium –

new pink tissue that grows in from the edges or appears as islands