Wound Management
HLTEN506B Apply Principles of Wound management in the clinical environment Assessment 2 – Short answer questions Define a wound A wound is a break in the integument or underlying structures that results from physical, mechanical or thermal damage or develops as a result of an underlying disorder. List the functions of the skin Functions of skin includes: a) Protection – An anatomical barrier from pathogens and damage between the internal and external environment in bodily defense. b) Sensation – Contains a variety of nerve endings that jump to heat and cold, touch, pressure, vibration, and tissue injury. ) Thermoregulation – Eccrine glands and dilated blood vessels aid heat loss, while constricted vessels greatly reduce cutaneous blood flow and conserve heat. Erector pill muscles in mammals adjust the angle of hair shafts to change the degree of insulation provided by hair or fur. d) Control of evaporation – The skin provides a relatively dry and semi-impermeable barrier to fluid loss. e) Absorption – Oxygen, nitrogen and carbon dioxide can diffuse into the epidermis in small amounts. f) Water resistance – Act as a water resistant barrier so essential nutrients aren’t washed out of the body.
The skin has three (3) layers, name these three layers and give a brief description of each layer. 1) Epidermis – Provides waterproofing and serves as a barrier to infection, also helps the skin regulate body temperature. 2) Dermis – Serves as a location for the appendages of skin. It provides tensile strength and elasticity to the skin through an extracellular matrix composed of collagen fibrils, microfibrils and elastic fibers, embedded in proteoglycans. 3) Hypodermis – Attach skin to underlying bone and muscle as well as supplying it with blood vessels and nerves.
It consists of loose connective tissue and elastin. Name phases of wound healing and give an explanation of what occurs in each phase. I. Inflammatory Phase – Immediate to 2-5 days; Hemostasis (Vasoconstriction, Platelet aggregation, Thromboplastin makes clot); Inflammation (Vasodilation, Phagocytosis ) II. Proliferative Phase – 2 days to 3 weeks; Granulation (Fibroblasts lay bed of collagen, Fills defect and produces new capillaries); Contraction (Wound edges pull together to reduce defect); Epithelialization (Crosses moist surface, Cell travel about 3 cm from point of origin in all directions)
III. Remodeling Phase – 3 weeks to 2 years; new collagen forms which increases tensile strength to wounds; Scar tissue is only 80 percent as strong as original tissue. Many wounds that are in the inflammatory phase of wound healing are often mistaken for being infected. Why is this so? How can we determine whether the wound is infected of in the infected or in the inflammatory phase? Both type of wounds look similar in appearance. The inflammatory phase is a vital stage in the wound-healing process, without which healing will not progress. Inflammation is apparent in all wounds at some point.
However, its presence may also signal the onset of infection, an allergic reaction or dermatitis. When assessing infected wounds, some groups of people will not produce the classical symptoms associated with wound infection. In this instance we should look for additional signs. For example, a person with diabetes may also fail to produce the classical symptoms of infection owing to reduced neutrophil activity. What is your understanding of granulation and epithelialisation? Granulation is a part of the healing process in which lumpy, pink tissue ontaining new connective tissue and capillaries forms around the edges of a wound. Granulation of a wound is normal and desirable. Epithelialisation is the natural act of healing dermal and epidermal tissue in which epithelium grows over a wound. Epithelium is a membranous tissue made up of one or more layers of cells that contains very little intercellular substance. In your own words explain your understanding of the term “wound management”. Wound management is the evaluation, treatment, and prevention of open injuries. It includes short team/ long team goals. What is meant by the following terms? ) Healing by primary intention – Primary intention healing is healing of a wound where the wound edges heal directly touching each other. This result in a small line of scar tissue, the goal whenever a wound is sutured closed. In primary intent healing, the goal is to minimize the need for granulation tissue by holding wound edges tightly together. This way, scarring is minimized. 2) Secondary intention – may be the only possibility if the wound is infected or contaminated. In this case, the wound edges cannot be held together because the infection would grow in the space between.
The wound is instead left open to fill with granulation tissue, and the granulation tissue will subsequently turn into scar tissue. This is not ideal, because scar tissue contracts significantly as it matures, often times resulting in cosmetic or disfiguring problems. However, if contamination or infection is bad enough, healing by primary intent may not be an option. 3) Tertiary intention – This type of wound healing is also known as “delayed” or “secondary closure” and is indicated where there is a reason to delay suturing or closing a wound some other way, for example when there is poor circulation to the injured area.
These wounds are closed later. Wounds that heal by tertiary intention require more connective tissue (scar tissue) than wounds that heal by secondary intention. An example of a wound healing by tertiary intention is an abdominal wound that is initially left open to allow for drainage but is later closed. List seven (7) things that we document about a client’s wound. 1) Length of the wound 2) Width of the wound 3) Depth of the wound 4) Exudate amount and type 5) Pain score 6) Swap taken 7) Surrounding skin status Wounds can be described by their color. What are the five (5) colors used to describe the wounds and what does each color mean? ) Black – Necrotic – Caused by presence of dehydrated dead tissue. May extend over the whole wound or be confined to a single area. Prolongs wound healing and may harbor infection. 2) Yellow – Slough – Caused by dead cellular debris. May lead to odour/ infection if not removed. Prolongs healing process if not removed. 3) Green – infected – Excessive, purulent and malodorous exudate. Clinical signs of infection present. Prolongs healing process. 4) Red – granulation – Bright red, moist in appearance as capillary loops develop from wound base. Extremely fragile, trauma delays healing process. ) Pink – epithelialisation – Pink-white tissue at wound margins or as islands within the wound. List five (5) things that need to be documented about a wound’s exudate. 1) Amount 2) Type 3) Swab 4) Smell 5) Colour When assessing a wound it is important to look at the surrounding skin. Why is this so? Make sure it is not affecting the surrounding skin. Wound is healing towads the middle but not towards the edge of the wound. Most pressure ulcers can be prevented. Suggest three (3) preventative measures that you as an enrolled nurse can put into place to prevent pressure ulcers in your older clients. ) Pressure area care – change of positions for patient regularly 2) Encourage patient to mobile to regulate blood flow 3) Correctively use of pressure sockings Describe four (4) stages of pressure ulcers. 1) Stage I – Non-blanchable erythema of intact skin the heralding lesion of skin ulceration. In individuals with darker skin, discoloration, warmth, edema, induration, or hardness may be indicators. 2) Stage II – Partial thickness skin loss involving epidermis, dermis, or both. The lesion is superficial and presents clinically as an abrasion, blister, or shallow center. ) Stage III – Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The sore presents clinically as a deep crater with or without undermining of adjacent tissue. 4) Stage IV – Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There are many factors that delay wound healing. Please define extrinsic and intrinsic factors that prevent wound healing and give five (5) examples of each. 1) Extrinsic – impinge on the patient from the external environment.
Examples: Mechanical stress, Debris, Temperature, Desiccation and maceration, Infection. 2) Intrinsic – directly affect the performance of body functions through the patient’s own physiology or condition. Examples: Health status, age factors, body build, Nutritional status, Systemic diseases. Moist healing has been shown to be significantly more effective that dry healing. Give an example of when moist healing is not recommended. Necrotic digits due to ischaemia and / or neuropathy should be kept dry or monitored very closely. What is the key to preventing nosocomial infections? Infection control.
E. g. Good hand hygiene practice that is effective and promotes compliance, such as the use of alcohol-based products, is important in preventing nosocomial infection. How long does a routine hand wash take? Around 15 seconds. From your research provide information about the following dressing product types. Give an explanation of how each dressing type works and provide an example of the type of wound it may be used on. 1) Alginates – it can promote autolytic debridement of the wound. Alginates have the unique ability to absorb up to 20 times their weight in fluid, depending on the manufacturer.
Depending on the type of seaweed species from which the alginate is made, the dressing may either gel or swell in the wound after absorption of wound fluid. Calcium alginates tend to swell, whereas sodium alginates tend to dissolve or gel in the wound bed. Wound type: Cavity wounds 2) Films – can be used to cover and protect catheter sites and wounds, to maintain a moist environment for wound healing or to facilitate autolytic debridement, as a secondary dressing, as a protective cover over at-risk skin, to secure devices to the skin, to cover first and second degree burns, nd as a protective eye covering. Wound type: Pressure Ulcers 3) Foams – antimicrobial foam dressings provide an ideal healing environment by simultaneously managing moisture and bacteria in the dressing. As the foam dressing absorbs exudate, a powerful yet safe antiseptic, targets and kills bacteria on contact. Wound type: Heavily exudating wound 4) Hydrocolloid – works to absorb the exudate from a wound and convert it to a gel that is either stored within the dressing, or pushed through the surface of the dressing away from the wound itself.
Wound type: can be used very appropriately on dry wounds as any slight moisture produced by the skin creates a gel that in turns helps to keep the skin’s surface in that area soft and supple, aiding in healing. 5) Hydrogel – Wound gels are excellent for helping to create or maintain a moist environment Some hydrogels provide absorption, desloughing and debriding capacities to necrotic and fibrotic tissue. Wound type: loughy or necrotic wounds What are primary and secondary dressings? Primary: are applied directly to a wound and may contain some medication.
Secondary: secure the primary wound dressing in place. They are not secondary in importance, for if the primary wound dressing cannot be kept or applied where intended, then no matter what is placed on the wound might not work. State two (2) types of leg ulcers giving an explanation of the clinical signs of each one. 1) Venous – swollen ankles filled with fluid that temporarily hold the imprint of your finger when pressed (known as pitting oedema); discolouration and darkening of your skin around the ulcer (known as haemosiderosis); hardened skin around the ulcer, which may make your leg eel hard and resemble the shape of an upside-down champagne bottle (known as lipodermatosclerosis), small, smooth areas of white skin, which may have tiny red spots (known as atrophie blanche) 2) Arterial – patient will experience an increase in a cramp like pain due to the reduction in arterial blood supply. It can also be presented on leg elevation. If the reduction in blood supply left untreated, it can cause death of tissue in the area being fed by the affected artery. The limb will appear pale and there will be a noticeable lack of hair.
When wound you not use compression bandaging as a treatment for a leg ulcer? Arterial ulcers – treatment is often urgent. Compression bandages must not be used, as this will reduce the blood supply even further. Surgery may be needed to clear out the blocked artery (angioplasty). In some cases, the section of blocked artery may require surgical replacement (by-pass surgery). In severe cases, the lower leg may have to be amputated. How do you know if a wound product is working? The wound has signs of improvement such as growth of new tissues/ minimising of exudate.
At what point does an acute wound become a chronic wound? In healthy individuals with no underlying factors an acute wound should heal within three weeks with remodeling occurring over the next year or so. If a wound does not follow the normal trajectory it may become stuck in one of the stages and the wound becomes chronic. Chronic wounds are thus defined as wounds, which have failed to proceed through an orderly and timely process to produce anatomic and functional integrity, or proceeded through the repair process without establishing a sustained anatomic and functional result.
So Chronic wounds are stuck in either prolonged inflammatory stage or proliferative stage. Many clients experience pain in and around the site of their wound. List facts that need to be included in pain assessment and provide some examples of things that can be done to reduce a client’s pain. In the pain assessment, we should assess the wound and document the pain score that the patient is experiencing. Also, we need to record the description of the pain (i. e. burning, tingling, stabbing etc. ) and will the pain affect the healing process. Furthermore, we also need to document how we treat the pain.
Such as medication or any therapy that has been used. There are things that we can do to reduce a client’s pain: * Cover the wound to protect it from further injury. * Change the bandage daily, and keep the wound clean to prevent infection. * Take ibuprofen or acetaminophen to ease initial wound pain. If pain lasts for more than a day or two, consult your doctor. * For a foot or ankle wound, stay off your feet as much as possible to ease pain and encourage healing. * Be sure to get plenty of sleep and follow a healthy diet to help your body heal.
