The 3 classifications of wound dressings are identified as?
- Passive
2.Interactive
3.Bio-active
Both the Interactive and Active dressings create a moist environment at the interface of the wound with the dressing.
What are passive dressings?
Passive dressings have only a protective function while maintaining a moist environment. These include those that just cover the area (e.g. gauze, tulle, DuoDerm)
What are Interactive dressings?
Interactive dressings are capable of absorbing wound exudate while (1) maintaining a moist environment in the wound area. (2) allowing the surrounding skin to remain dry. These include hydrocolloids, alginates and hydrogels.
What are Bio-Active dressings?
Active dressings improve the healing process and decrease healing time. These include skin grafts and biological skin substitutes.
What are the 5 rules of wound care?
- Categorisation -the best dressing is may be created by combining products in different categories to acheive several goals at the same time.
- Selection- the nurse selects the safest and most cost effective dressing possible.
- Change - the nurse changes dressings based on a pt, wound and dressing assessment, not on standardised routines.
- Evolution - as the wound progresses through the phases of wound healing, the dressing protocol is altered to optimise wound healing.
- Practice- practice with the dressing material is required by the nurse.
What is Autolytic debridement?
Autolytic debridement is a process that uses the body’s own digestive enzymes to break down necrotic tissue.
The 4 major objectives of therapy are to?
- prevent additional damage
- prevent secondary infection
- reverse the inflammatory process
- relieve the symptoms
What does the acronym TIME stand for?
This focuses on wound bed preparation.
T=Tissue assessment and management - non-viable or viable tissue
I= Inflammation and infection control - inflammation is a normal part of healing
M= Moisture balance maintenance - moisture balance is the aim
E= Epithelial advancement of wound edges
What is debridement?
Debridement is the removal of devitalised/contaminated/dead/foreign tissue.
Wounds heal by different mechanisms, dependant on the condition of the wound. Name the 3 mechanisms.
- First-intention (primary) healing= granulation tissue is not visible and scar formation is minimal.
- Second-intention healing (granulation)= occurs in infected wounds, traumatic wounds or in wounds which edges have previously been poorly approximated.
- Third-intention healing (delayed primary closure) = is used for he purpose of walling an area of gross infection or where extensive tissue was removed and where the two opposing granulation surfaces are later approximated.
What should be be written in your wound documentation?
- hx/aetiology/location
- pain/smell
- slough/necrotic/granulating/exudate
- healing process
- drawing/diagram/photo
Explain the steps of doing a dressing?
- check WMP
- collect equipment
- discuss requirements with pt =analgesia,toilet
- prepare environment = privacy, warmth, PPE, lighting,position…
- shower the wound or not shower the wound???
- remove old dressing
- hand hygiene
- establish sterile field = sterile gloves and hand hygiene again
- wound care/apply dressing
- clean up/ restock
- documentation
Explain what passive wound care is and dressing(s) used?
Passive wound care = cover, protect and maintain a moist wound environment.
-duoderm/ tullegras/ gauze/ melolin
Explain what Interactive wound care is and the dressing(s) used?
Interactive wound care = absorb exudate, moist healing environment, keep surrounding skin dry.
- hydrocolloids/ alginates/hydrogels
Explain what bio-active wound care is and what dressing(s) may be used.
Active wound care = improve the healing process while decreasing the healing time.
- skin grafts (SSGs)/ artificial skin products
What does “complex wounds” mean and what would you need to consider?
Complex wounds generally means “chronic “wounds.
You will need to consider:
-which dressing to use
-which cleaning solution?
-how often it will need to be done?
-what dressing or device may be required.
