wound care

Question 1

What things do we need to know and do when assesing a wound

Answer 1

• How long has the wound been there for
• What medication the patient is on - to identify any underlying health issues
• Photo the wound applying patient details and date
• Size, site, length, width, and depth
• Levels of exudate Low/Moderate/High
• (Low = weekly dressing changes dry or lighlty soiled)
• (Moderate = 2-3 day dressing changes soiled but not soaked)
• (Daily dressing changes that are soaked)
• Infection - any signs of infection present take a swab of the area and send off for microscopy
• Start patient on a broad spectrum antibiotic and consualt doctor
• Pain - What levels of pain are apparnet

Question 2

What is the TIME principle of wound healing

Answer 2

T- Tissue debridement removal of non viable tissue

I- Infection/inflamattion remove infected tissue via topical systemic antibiotoics or reduce inflamattion with anti inflamattory

M- Moisture imbalance apply moisture balancing dressings e.g. compression OR negative pressure therapy

E- Edge of the wound non advancing or undermined. Re asses cause
* Debridement
* Peri wound protectant
* Other corrective therapies

Question 3

What are the 4 types of wound drainage

Answer 3

Serous - clear or light yellow, thin watery
Sanguineous - Red with fresh blood, Thin
Serosanguineous - Pink to light red, Thin watery
Purulent - Creamy yellow, green white or tan, Thick opaque

Question 4

How would you manage the wound

Answer 4

• So clean with sterile saline solution and sterile gauze
• debride any non viable tissue where neccesary
• apply a sterile non adherent dresssing using a non touch technique
• give the patient the appropriate after care advice