Week 4: Simple Wound Management

Question 1

Benefits for Moist wound Healing: Facilitates the debridement process

Answer 1

• Encourages autolysis, the breakdown of
  devitalised tissue

Question 2

Benefits for Moist wound Healing: Acts as a lubricant

Answer 2

To facilitate and accelerate themigration
of epithelial cells across the wound
surface

Question 3

Benefits for Moist wound Healing: Acts as a transport medium

Answer 3

To deliver oxygen, nutrients and mobilise
cellular constituents to support the healing
process

Question 4

Benefits for Moist wound Healing: Prevents the formationof scab

Answer 4

Wounds are dressed with a covering
impermeable to bacteria

Question 5

Benefits for Moist wound Healing: Prevents the formation of scab

Answer 5

Reduces scar tissueformation,
cosmetically aesthetic

Question 6

Benefits for Moist wound Healing: Reduces pain

Answer 6

Prevents exposed nerve endings from
drying out following the loss of epithelial
layers. Less traumatic dressing removal.
Optimised patientcomfort

Question 7

What is the acronym for goals of wound management

Answer 7

• Tissue Management
• Infection and inflammation control
• Moisture malance
• Epithelial (Edge) Advancement

Question 8

What to consider for Tissue Management

Answer 8

• Assessment viable and non-viable tissue
• remove non-viable tissue via debridement
• protect viable tissue

Question 9

What is non-viable tissue?

Answer 9

• slough
• necrosis
• eschar

Question 10

What is viable tissue?

Answer 10

• granulating tissue
• epithelialising tissue

Question 11

What is debridement?

Answer 11

• removal of non-viable tissue from a wound?

Question 12

What are some of the methods of debridement?

Answer 12

• surgical
• sharp
• mechanical
• biological/larval
• autolytic
• enzymatic

Question 13

What to consider for inflammation and infection control?

Answer 13

• methods to remove infection
• prevent inflammation

Question 14

What is contamination wound state?

Answer 14

the presence of
non-replicating organisms on a wound.

Question 15

What is colonisation wound state?

Answer 15

presence of
replicating micro- organisms on the
wound without tissuedamage

Question 16

What is local infection/critical colonisation wound state?

Answer 16

an intermediate stage, with micro- organism replication and the
beginning of local tissue responses.

Question 17

What is invasive infection wound state?

Answer 17

is defined asthe
presence of replicating organisms
within a wound with subsequent host
injury

Question 18

How to obtain a bacterial wound swab?

Answer 18

• Assess pain and administer analgesia.
• Therapeutic communication.
• Gloves to remove the old dressing.

1. Clean the wound to remove any exudate,
   biofilm, debris and dressing products from
   the bed of the wound allowing for a
   ‘cleaner’ sample.
2. Gently move the swab across the wound
   bed surface without touching the edges or
   the surrounding skin. Use a zig-zag motion
   whilst rotating the swab tip.

3.Immediately and carefully, return the swab
to the collection container.
Label the specimen and send to pathology asap.
* Dress the wound.

Question 19

what does TIME stand for?

Answer 19

• tissue management
• inflection/inflammation
• moisture balance
• epiletial edge

Question 20

What is Autolytic debridement?

Answer 20

• can be slow

Question 21

What is Enzymatic debridement?

Answer 21

• can be

Question 22

Selecting correct dressing:
wound condition: Hard dry black (necrosis)

Answer 22

• hydrogel
• hydrate, separate eschar

Question 23

Selecting correct dressing:
wound condition: pink/red (epithelial)

Answer 23

• transparent film
• allow epithelialisation, reduces shear

Question 24

Selecting correct dressing:
wound condition: moist red (granulating)

Answer 24

• hydrocolloid
• provide barrier and control humidity

Question 25

Selecting correct dressing: wound condition: Exudating yellow (slough)

Answer 25

- alginate - absorb exude, debridement

Question 26

What factors impact choice of product?

Answer 26

Wound – location, size, type * Manage exudate * Promote debridement * Manage infection * Frequency of dressing change, ease/difficulty * Cost

Question 27

Wound type - colour

Question 28

What are basic elements of wound care?

Answer 28

- cleanse debris/microbes - protect from trauma/infection - warm, moist environments - decried - manage pain and discomfort - manage exudate and odour - promote granulation and epithelialisation

Question 29

Biological/Larval debridement

Question 30

Why do we clean the dressing trolley furthest point away from ourselves working towards ourselves?

Question 31

Why do we avoid placing the packaged equipment on the top surface of the dressing trolley?

Question 32

Why do we stand back when opening extra equipment to add to our aseptic field?

Question 33

Where is the ‘field’ hand positioned? Where is the ‘working’ hand positioned?

Question 34

Why do we clean the middle of the wound and then work towards the edges?

Question 35

Why should the blue forceps tips not touch when exchanging gauze to clean the wound?

Question 36

What is the width of the contamination border?

Question 37

What happens to the aseptic field if I add clean equipment to it?

Question 38

What is the cue for the aseptic handwash?

Question 39

What factors do we assess as part of the wound assessment?

Question 40

Observe forclassic signs and symptoms:

Answer 40

- pain, heat, redness, swelling and purulence - fever, leukocytosis - Delayed healing - Odour - Friable (bleeds easily), absent or abnormal granulation Signs and Symptoms of Infection - Change in colour of the wound - Wound breakdown

Question 41

What to consider with M- Moisture Balance

Answer 41

- Controlling exudate - Controlling exudate -Supports growth of new tissue

Question 42

Factors that Impact on Wound Healing

Answer 42

- dry wound - neutral wound - excessively moist wound

Question 43

What to consider E-Epithelial (Edge) Advancement

Answer 43

- support the healthy granulation tissue to assist proliferating epidermal cells to migrate - epidermal cells require repeated cell deviance at edge of wound for epithelisation to occur

Question 44

Nursing process for wound management

Answer 44

1. asses the patient, wound first 2. bring in multidiclinary team e.g wound specialist 3. control or treat underlying causes and barriers to wound healing 4. decide appropriate treatment 5. evaluate and reassess the treatment and wound management outcomes

Question 45

Making judgements & decisions red/pink wounds: vascular granulation tissue or epithlialistation

Answer 45

Protect regenerating tissue - gentle cleaning; protect peri-wound - fill dead space (hydrogel or alginate) - cover (hydrocolloid, transparent film, clear absorbent acrylic dressing) - aim for infrequent dressing change