Wound management

define wound

breakdown in the protective function of the skin

o the loss of continuity of epithelium, with or without loss of underlying connective

tissue (i.e. muscle, bone, nerves) following injury to the skin or underlying

tissues/ organs caused by surgery, a blow, a cut, chemicals, heat/ cold, friction/

shear force, pressure or as a result of disease, such as leg ulcers or carcinomas

Describe the phases of wound healing: haemostasis,

inflammation, proliferation, remodelling:

Haemostasis ( immediate): initial

vasoconstriction, release of clotting factors and fibrin clot formation

• Inflammation (days 1-4): Vasodilation, delivery of macrophages, phagocytosis, blood

clot formation, loosely united wound edges

• Proliferation/Granulation ( days 4-21): epithelial cells migrate bridging the wound,

Angiogenesis-growth of new capillaries, fibroblasts migrate along firbin strands

synthesising scar tissue

• Remodelling ( days 21-2 years): develop tensile strength, collagen remodelling, vascular

maturation and regression.

Which Factors affect wound healing:

Co-morbidities, Pressure Ulcer Risk, Nutritional status, Mobility status,

Continence status, Vascular supply, Anaemia, Size, sleep, Poverty, Lack of

knowledge, Depression, Advancing age, Cognitive impairment, Patient

What does TIMES mean

Tissue: determine the phase of wound healing, treatment and dressing

Infection: hot, oedema, pus, pain, odor, not healing, redness, pyrexia and more exudate- topical silver, systemic flucloxacillin

Moisture: Heavy exudate is bad, white edge= too much moisture, if its too dry we apply gel OR if too wet then we apply dressing

dressing to reduce it)

Edge of wound: tracking wound edges with sterile cotton tipped swab against a ruler

Surrounding skin: Excess wound exudation is bad, balance is moist is essential

What is a pressure ulcer and how to treat it

A pressure ulcer is localised damage to the skin and/or underlying tissue, usually over a

bony prominence (or related to a medical or other device), resulting from sustained

pressure (including pressure associated with shear). The damage can be present as

intact skin or an open ulcer and may be painful.

Describe the 3 causes of Moisture associated skin damage and their treatment

red diffused, multiple superficial spots aka

kissing lesion in skin folds, natal cleft, under the breasts

Incontinence-associated dermatitis (IAD):

exposure to urine or faeces or body

fluids, use barrier cream

Intertrigo: Inflammation caused by skin-to-skin friction, groin, bet. folds etc

Fungal:Around legs and bottom-antifungal cream ( avoid soap for washing, use emointment washer to take away moisture)

Describe Peri-Stoma and its treatment

Leakage of stomal effluent onto the peristomal skin

will cause inflammation and even skin erosion

use powder to keep dry

Describe Peri-wound and its treatment

Excess wound exudation may result to the peri-wound skin to become macerated (edges white), excoriated and further skin break down.

Cavilon spray can be applied to peri-wound as skin

protection

What are the functions of the skin

Control of body temperature, Keeping out infection, Monitors pain, A waterproof barrier, Communication, Production of Vitamin D, Protects delicate organs, Mends itself when damaged

What dressing to use for high-exudate dressing

Hydrofibre, foam dressing, Alginate dressing, SurgyHoney RO( reactive o destroys the exudate)m

What dressing to use for infections?

silver dressing, odour absorbing dressing

What to use for peri-wound

cavilon spray, barrier cream

What to use for fungal infection

antifungal cream, clotrimazole, emmointmnet wash ( to reduce moisture)

What to use for incontinence associated dermititis

barrier cream

What dressing to use for pressure ulcer?

Hydrofibre dressing, barrier cream

What to use for viable granulation

non-adherent dressing

What dressing to use for necrotic tissue

Hydrocolloid, Hyrogels - promote moisture