Holistic Wound Assessment and Management

Question 1

What is an acute wound? How can it be caused? How do they heal?

Answer 1

It is the result of tissue damaged by trauma. This may be deliberate, as in surgical wounds of procedures, or be due to accidents caused by blunt force, projectiles, heat, electricity, chemicals or friction. An acute wound is by definition expected to progress through the phases of normal healing, resulting in the closure of the wound.

Question 2

What is a chronic wound? How do they heal?

Answer 2

A Chronic Wound fails to progress or respond to treatment over the normal expected healing time frame (4 weeks) and becomes “stuck” in the inflammatory phase. Wound chronicity is attributed to the presence of intrinsic and extrinsic factors including medications, poor nutrition, co-morbidities or inappropriate dressing selection.

Question 3

What is a wound?

Answer 3

A wound by true definition is a breakdown in the protective function of the skin; the loss of continuity of epithelium, with or without loss of underlying connective tissue(i.e. muscle, bone, nerves).

Question 4

What are 4 types of wound?

Answer 4

• Traumatic
• Intentional
• Ischaemia
• Pressure

Question 5

Describe wound healing in acute and chronic wounds?

Answer 5

Acute wound healing follows an orderly sequence of biological events, requiring minimal intervention.

In chronic wounds this sequence of events is disrupted or fixed at one or more of the stages of wound healing and wound-bed preparation is required for healing to occur.

Question 6

What are the stages of wound healing?

Answer 6

1. Vascular Response
2. Inflammatory
3. Proliferation
4. Maturation

Question 7

What are the 5 stages of the wound assessment cycle?

Answer 7

1. Patient and wound assessment
2. Agree treatment objectives
3. Refer to specialists when required
4. Select wound management products and any additional treatments
5. Reassess patient, wound, and care plan

Question 8

What should the nurse look at during patient assessment?

Answer 8

• Cause of wound (remove where possible) 
• Identify factors that could delay healing 
• Past medical history
• Past wound history & treatment
• Environment of care/carers
• Individual concerns/emotional wellbeing 
• Local problems at the wound site

Question 9

How does the nurse assess a wound? (there’s a lot!!!)

Answer 9

• Where is the wound?
• What is the cause?
• What colour is it?
• How wet/dry is it?
• What type and amount of exudate is there?
• What size is it?
• How deep is it?
• Does it smell?
• What do the wound margins look like?
• How does the surrounding skin appear/feel?
• How long has the patient had the wound?
• Are there any underlying condition which may affect the wound?

Question 10

Describe necrotic tissue

Answer 10

• Dead tissue
• Comprises of hard black/ brown leathery eschar
• Increases bacterial burden
• Prolongs chronic inflammation
• Delays healing
• Has to be removed (debrided) before wound healing can take place

Question 11

Describe slough

Answer 11

• Debris on wound surface comprising of dead leucocytes, bacteria and fibrous tissue
• Yellow, creamy appearance
• Can be thick/stringy or more viscous
• Obstructs granulation tissue formation
• Increases risk of infection

Question 12

describe granulating tissue

Answer 12

• Deep red or pink
• Uneven ‘beefy’ appearance 
• Fine capillary loops
• Bleeds easily

Question 13

describe epithelialising tissue

Answer 13

• Healthy tissue in final stages of healing
• Pink, white in colour
• Migrates from wound edges/ base of hair follicles

Question 14

describe hypergranulation

Answer 14

• Deep red
• Raised/bumpy
• Prevents epithelialisation

Question 15

describe haemotoma

Answer 15

• Localised collection of blood within the tissues
• Dark brown/black/purple in colour
• Swollen

Question 16

What should the nurse check surrounding skin for?

Answer 16

• Macerated
• Oedematous
• Excoriated
• Erythema
• Fragile
• Dry/scaly
• Healthy/intact

Question 17

describe a periwound

Answer 17

• Widespread hyperproliferation at wound margin
• Inhibition of apoptosis
• Fibroblasts from chronic wounds found to be senescent

Question 18

what should the nurse look at when assessing wound exudate?

Answer 18

Quantity: Dry, Low, Moderate, High 

Characteristics: Serous- Straw coloured thin fluid, Haemoserous- Blood stained, Purulent- Green/Brown/Yellow thick fluid

Moisture Imbalance: Desiccation slows cell migration, Excessive fluid causes maceration of wound margin

Question 19

what is chronic wound exudate? why is it bad?

Answer 19

Chronic wound exudate has a different chemical composition which may cause a problem in itself. It not only contains water but also bacteria and dead white cells. There are high levels of inflammatory mediators and protein digesting enzymes. Chronic wound exudate is detrimental to healing and more corrosive to peri-wound skin.

Question 20

what 9 things increases risk of wound infection?

Answer 20

• Foreign bodies
• Haemotoma
• Diabetes
• Rheumatoid arthritis
• Immunosuppression
• Necrotic tissue
• Poor nutrition
• Steroids
• Wound location

Question 21

define wound infection

Answer 21

Wound infection is the presence of replicating microorganisms within a wound with subsequent host injury

Question 22

what are 6 signs of wound infection?

Answer 22

• Heat to surround tissue
• New slough/necrosis (deteriorating wound bed)
• Increasing pain
• Increasing exudate
• Increasing odour
• Friable granulation tissue

Question 23

what is the criteria for identifying wound infection?

Answer 23

• Abcess
• Cellulitis
• Discharge
• Delayed healing
• Discolouration
• Friable, bleeding granulation tissue
• Unexpected pain/tenderness

Question 24

what is the ideal healing environment for wounds?

Answer 24

warm and moist

Question 25

what is debridement

Answer 25

removal of necrotic/sloughy tissue

Question 26

what is absorption (in wound healing)

Answer 26

removal of excess fluid from wound bed

Question 27

what is hydration (in wound healing)

Answer 27

addition of moisture to dry wound bed

Question 28

what is protection (in wound healing)

Answer 28

from mechanical/biological factors which may delay/prevent healing

Question 29

a moist wound healing environment enhances re-__________ in wounds but excessinve fluid can slow down healing and cause _______. Acute wound fluid is different from chronic wound fluid. Chronic wound fluid is seen as a _______ _____

Answer 29

a moist wound healing environment enhances re-EPITHELIALISATION in wounds but excessinve fluid can slow down healing and cause MACERATION. Acute wound fluid is different from chronic wound fluid. Chronic wound fluid is seen as a WOUNDING AGENT

Question 30

how does ineffective management of wound exudate effect healing?

Answer 30

it will have a negative effect on wound healing, and surrounding skin either by allowing the tissues to get too dry or too wet.

Question 31

what would a wound with low exudate appear like? what dressing type does it need?

Answer 31

Wound tissues moist, moisture evenly distributed in wound, <25% of dressing soiled Do not apply a foam dressing. Apply a simple dressing.

Question 32

what would a wound with moderate exudate appear like? what dressing type does it need?

Answer 32

Wound tissues saturated, drainage may not be evenly distributed in wound, 25% - 75% of dressing soiled. Apply dressing designed to manage moderate exudate and provide bacteriostatic barrier. Foam not always required.

Question 33

what would a wound with heavy exudate appear like? what dressing type does it need?

Answer 33

Wound tissues bathed in fluid, drainage freely expressed, may not be evenly distributed in wound, >75% of dressing soiled Apply dressing designed to manage heavy exudate. Foam probably required

Question 34

what would a wound with excessive exudate appear like? what dressing type does it need?

Answer 34

Exudate not contained by highly absorbent foam Consider if wound requires primary dressing. Apply highly absorbent dressing or drainable appliance

Question 35

how should infection be managed?

Answer 35

Treat infection systematically Treat local characteristics affecting wound bed Treat surrounding skin

Question 36

when should you NOT routinely take swabs? why?

Answer 36

if the wound is a chronic ulcer, a pressure ulcer, wound over a month old, sinuses and fistulae, and stoma sites This is because these wounds will always have growth since they will be colonised with the patients own flora/environmental organisms

Question 37

when should you take a wound swab?

Answer 37

evidence of spreading cellulitis, clinical signs of infection (temp, WCC, etc), immunosuppression (diabetes, steroids, malignancy)

Question 38

define wound cleansing

Answer 38

Wound cleansing is “the process of using fluids to remove loose wound debris and remnants of dressings. This process should not be confused with wound debridement.”

Question 39

what 5 things need considered when selecting a wound dressing?

Answer 39

* What is the action of dressing? 􏰀 * When should it be used? * Any contraindications? * Application and removal methods 􏰀 * Is a secondary dressing required?

Question 40

what should ideal dressings provide?

Answer 40

* Moist environment * Thermal insulation * Low or non adherent 􏰀 * Absorbs exudates * Cost effective 􏰀 * Protection * Pain relief