What things do we need to know and do when assesing a wound
- 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
What is the TIME principle of wound healing
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
What are the 4 types of wound drainage
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
How would you manage the wound
- 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
