What are the benefits of a moist wound healing?
- Facilitates the debridement process
- Acts as a lubricant
- Acts as a transport medium
- Reduces likelihood of infection
- Prevents the formation of scab
- Reduces pain
What are the basic elements of wound care?
- Promote granulation and epithelialisation
- Cleanse debris/microbes
- Protects from trauma/ infection
- Warm, moist environment
- Debride
- Manage pain and discomfort
- Manage exudate and odour
What is the goals of wound management?
T - Tissue management
I - Inflammation and Infection control
M - Moisture balance
E - Epithelial advancement
What is tissue management
*Protect viable tissue
- Granulating tissue
- Epithelialising tissue
* Remove non-viable tissue via debridement
- Slough
- Necrosis
- Eschar
What is debridement?
Removal of non-viable tissue from a wound
What are the methods of debridement
- Surgical
- Sharp
- Mechanical
- Biological/Larval
- Autolytic
- Enzymatic
What are the various wound state
- Contamination
- Colonisation
- Local infection / critical colonisation
- Invasive infection
Define contamination in wounds
the presence of non-replicating organisms on a wound
Define colonisation in wounds
presence of replicating micro- organisms on the wound without tissue damage
Define local infection / critical colonisation in wounds
an intermediate stage, with microorganism replication and the beginning of local tissue responses.
Define invasive infection in wounds
the presence of replicating organisms within a wound with subsequent host injury
Define biofilm and which organism forms it
- Bacteria, fungi and protists
- Biofilms are bacterial colonies surrounded by protective coatings
- Mature biofilms develop protected micro environments and are more resistant to conventional antibiotic treatment
What are the signs and symptoms of infection
- Observe forclassic signs and symptoms:
- pain, heat, redness, swelling and purulence
- fever, leukocytosis
- Also consider:
- Delayed healing
- Odour
- Friable (bleeds easily),absent or abnormal granulation
- Change in colour of the wound
- Wound breakdown
How to obtain a bacterial wound swab
- Clean the wound to remove any exudate,
biofilm, debris and dressing products from
the bed of the wound allowing for a
‘cleaner’ sample. - 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. - Immediately and carefully, return the swab
to the collection container.
How keep a wound moisture balance
- Controlling exudate
- Keep wound bed at optimal moisture level
- Supports growth of new tissue
What are factors that impact on wound healing
- Dry wound
- Neutral wound
- Excessively moist wound
What is epithelial (edge) advancement
- Support the healthy granulation tissue to assist proliferating epidermal cells to migrate
- Epidermal cells require repeated cell division at edge of wound for epitheliasation to occur
