Wound Management

HLTEN506B Apply Principles of Wound way in the clinical environs Assessment 2 Short answer questions coif a ache A infract is a break in the integument or key structures that results from physical, mechanical or thermal damage or develops as a result of an underlying disorder. List the functions of the climb Functions of disrobe includes a) Protection An anatomicalal barrier from pathogens and damage between the internal and outer environment in bodily defense. b) Sensation Contains a variety of middle endings that jump to dash fire and cold, touch, pressure, vibration, and wander injury. ) Thermoregulation Eccrine glands and dilated declination vessels aid heat loss, while constricted vessels greatly shave cutaneous blood run away and conserve heat. Erector pill muscles in mammals adjust the angle of hair shafts to diverseness the degree of insulation fork everywhered by hair or fur. d) Control of vapor The flake off provides a relatively dry and semi-impe rmeable barrier to fluid loss. e) density Oxygen, nitrogen and carbon dioxide give the sack diff uptake into the epidermis in humiliated amounts. f) Water resistance Act as a water resistant barrier so essential nutrients arent washed out of the body.The skin has three (3) layers, name these three layers and reach a brief definition of each layer. 1) Epidermis Provides waterproofing and serves as a barrier to infection, excessively attend tos the skin regulate body temperature. 2) Dermis Serves as a location for the appendages of skin. It provides tensile strength and elasticity to the skin through an extracellular hyaloplasm composed of collagen fibrils, microfibrils and elastic fibers, embedded in proteoglycans. 3) Hypodermis Attach skin to underlying bone and muscle as well as tallying it with blood vessels and nerves.It consists of loose connective thread and elastin. Name phases of exasperate reanimateing and give an explanation of what occurs in each phase. I. Inflammatory build Immediate to 2-5 old age Hemostasis (Vasoconstriction, Platelet aggregation, Thromboplastin makes clot) Inflammation (Vasodilation, Phagocytosis ) II. Proliferative Phase 2 eld to 3 weeks granulation (Fibroblasts lay bed of collagen, Fills defect and take a shits new capillaries) concretion (Wound edges pull to fixateher to shrivel defect) Epithelialization (Crosses moist muster up, Cell travel active 3 cm from point of origin in alone directions) tierce. Remodeling Phase 3 weeks to 2 years new collagen forms which increases tensile strength to hurts punctuate tissue is only 80 percent as strong as original tissue. Many displeases that are in the incendiary phase of suffer restoreing are often mistaken for being infected. Why is this so? How can we determine whether the suffer is infected of in the infected or in the inflammatory phase? Both eccentric of piques verbal expression like in bulgeance. The inflammatory phase is a vital stage in the wound- better process, without which meliorate leave non progress. Inflammation is apparent in all wounds at some point.However, its presence may in addition signal the intrusion of infection, an allergic reaction or dermatitis. When assessing infected wounds, some groups of people go forth not produce the classical symptoms associated with wound infection. In this instance we should look for additional signs. For object lesson, a person with diabetes may also fail to produce the classical symptoms of infection owing to reduced neutrophil activity. What is your understanding of granulation and epithelialisation? Granulation is a part of the healing process in which lumpy, knock tissue ontaining new connective tissue and capillaries forms close to the edges of a wound. Granulation of a wound is normal and desirable. Epithelialisation is the natural act of healing epidermic and epidermal tissue in which epithelium grows over a wound. epithelial tissue is a membranou s tissue made up of one or more layers of cells that contains precise little intercellular substance. In your own linguistic process explain your understanding of the term wound management. Wound management is the evaluation, treatment, and prevention of yield injuries. It includes short team/ long team goals. What is meant by the undermentioned terms? ) Healing by first-string intention ancient quill intention healing is healing of a wound where the wound edges heal at a time touching each other. This result in a crushed line of scar tissue, the goal whenever a wound is sutured closed. In primal intent healing, the goal is to minimize the need for granulation tissue by contriveing wound edges tightly together. This way, scarring is minimized. 2) Secondary intention may be the only possibility if the wound is infected or contaminated. In this case, the wound edges cannot be held together because the infection would grow in the space between.The wound is instead left ope n to fill with granulation tissue, and the granulation tissue will subsequently turn into scar tissue. This is not ideal, because scar tissue contracts significantly as it matures, often times resulting in cosmetic or disfiguring problems. However, if contamination or infection is bad enough, healing by primary intent may not be an option. 3) Tertiary intention This causa of wound healing is also known as delayed or supplemental closure and is indicated where there is a reason to delay suture or closing a wound some other way, for example when there is poor circulation to the injured landing field.These wounds are closed later. Wounds that heal by tertiary intention require more connective tissue (scar tissue) than wounds that heal by secondary intention. An example of a wound healing by tertiary intention is an abdominal wound that is initially left open to allow for drainage but is later closed. List seven (7) things that we enumeration roughly a clients wound. 1) Length of the wound 2) comprehensiveness of the wound 3) Depth of the wound 4) Exudate amount and type 5) hurt score 6) Swap taken 7) Surrounding skin status Wounds can be described by their color. What are the vanadium (5) colors employ to describe the wounds and what does each color mean? ) B deprivation necrotic Ca apply by presence of dehydrated baseless tissue. May extend over the all told wound or be confined to a single area. Prolongs wound healing and may harbor infection. 2) Yellow Slough Caused by dead cellular debris. May lead to odour/ infection if not removed. Prolongs healing process if not removed. 3) Green infected Excessive, purulent and malodorous exudate. clinical signs of infection present. Prolongs healing process. 4) Red granulation Bright red, moist in appearance as capillary loops develop from wound base. Extremely fragile, distress delays healing process. ) Pink epithelialisation Pink-white tissue at wound margins or as islands within the wound. List five (5) things that need to be documented about a wounds exudate. 1) Amount 2) Type 3) Swab 4) looking at 5) Colour When assessing a wound it is important to look at the ring skin. Why is this so? Make sure it is not affecting the touch skin. Wound is healing towads the middle but not towards the edge of the wound. intimately pressure ulcers can be prevented. Suggest three (3) preventative measures that you as an enrolled nurse can put into place to prevent pressure ulcers in your older clients. ) Pressure area care change of positions for persevering on a regular basis 2) Encourage patient to mobile to regulate blood flow 3) Correctively use of pressure sockings Describe four (4) stages of pressure ulcers. 1) Stage I Non-blanchable erythema of constitutional skin the heralding lesion of skin ulceration. In individuals with darker skin, discoloration, warmth, edema, induration, or hardness may be indicators. 2) Stage II Partial thickness skin loss involving epidermis, derm is, or both. The lesion is superficial and presents clinically as an abrasion, blister, or shallow center. ) Stage III Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The sore presents clinically as a deep volcanic crater with or without undermining of adjacent tissue. 4) Stage IV Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or encouraging structures. There are many factors that delay wound healing. Please go under extrinsic and intrinsic factors that prevent wound healing and give five (5) examples of each. 1) Extrinsic impinge on the patient from the external environment.Examples Mechanical stress, Debris, Temperature, desiccation and maceration, Infection. 2) Intrinsic directly affect the performance of body functions through the patients own physiology or condition. Examples Health status, age factors, body build, nutritionary sta tus, Systemic diseases. Moist healing has been shown to be significantly more powerful that dry healing. Give an example of when moist healing is not recommended. Necrotic digits due to ischaemia and / or neuropathy should be kept dry or monitored very closely. What is the key to preventing nosocomial infections? Infection control.E. g. Good hand hygiene practice that is effective and promotes compliance, such as the use of alcohol-based products, is important in preventing nosocomial infection. How long does a routine hand wash take? Around 15 seconds. From your research provide information about the issue forthing medical dressing product types. Give an explanation of how each dressing type works and provide an example of the type of wound it may be used on. 1) Alginates it can promote autolytic debridement of the wound. Alginates find the unique ability to absorb up to 20 times their weight in fluid, depending on the manufacturer.Depending on the type of seaweed species fr om which the alginate is made, the dressing may either gel or swell in the wound after absorption of wound fluid. atomic number 20 alginates tend to swell, whereas sodium alginates tend to dissolve or gel in the wound bed. Wound type Cavity wounds 2) Films can be used to chase after and protect catheter sites and wounds, to maintain a moist environment for wound healing or to facilitate autolytic debridement, as a secondary dressing, as a custodial cover over at-risk skin, to secure devices to the skin, to cover first and second degree burns, nd as a protective eye covering. Wound type Pressure Ulcers 3) Foams antimicrobial foam dressings provide an ideal healing environment by simultaneously managing moisture and bacteria in the dressing. As the foam dressing absorbs exudate, a powerful that safe antiseptic, targets and kills bacteria on contact. Wound type Heavily exudating wound 4) Hydrocolloid works to absorb the exudate from a wound and convert it to a gel that is eithe r stored within the dressing, orpushed through the surface of the dressing away from the wound itself.Wound type can be used very appropriately on dry wounds as any slight moisture produced by the skin creates a gel that in turns helps to keep the skins surface in that area soft and supple, aiding in healing. 5) Hydrogel Wound gels are refined for helping to create or maintain a moist environment Some hydrogels provide absorption, desloughing and debriding capacities to necrotic and fibrotic tissue. Wound type loughy or necrotic wounds What are primary and secondary dressings? Primary are use directly to a wound and may contain some medication.Secondary secure the primary wound dressing in place. They are not secondary in importance, for if the primary wound dressing cannot be kept or applied where intended, then no matter what is placed on the wound susceptibility not work. State two (2) types of leg ulcers giving an explanation of the clinical signs of each one. 1) Venous swo llen ankles filled with fluid that temporarily hold the imprint of your finger when pressed (known as pitting oedema) discolouration and blackening of your skin round the ulcer (known as haemosiderosis) hardened skin around the ulcer, which may make your leg eel hard and resemble the shape of an inverted champagne bottle (known as lipodermatosclerosis), small, smooth areas of white skin, which may have tiny red spots (known as atrophie blanche) 2) Arterial patient will experience an increase in a cramp like distress due to the reduction in arterial blood supply. It can also be presented on leg elevation. If the reduction in blood supply left untreated, it can cause death of tissue in the area being fed by the affected artery. The limb will appear pale and there will be a noticeable lack of hair.When wound you not use compression bandaging as a treatment for a leg ulcer? Arterial ulcers treatment is often urgent. Compression bandages must not be used, as this will reduce the blo od supply even push. Surgery may be needful to clear out the blocked artery (angioplasty). In some cases, the subdivision of blocked artery may require surgical replacement (by-pass surgery). In severe cases, the lower leg may have to be amputated. How do you know if a wound product is working? The wound has signs of progression such as growth of new tissues/ minimising of exudate.At what point does an acute wound become a chronic wound? In healthy individuals with no underlying factors an acute wound should heal within three weeks with remodeling occurring over the next year or so. If a wound does not follow the normal trajectory it may become stuck in one of the stages and the wound becomes chronic. Chronic wounds are thus defined as wounds, which have failed to go along through an orderly and timely process to produce anatomic and functional integrity, or proceeded through the repair process without establishing a sustained anatomic and functional result.So Chronic wounds a re stuck in either prolonged inflammatory stage or proliferative stage. Many clients experience hurting in and around the site of their wound. List facts that need to be included in suffer assessment and provide some examples of things that can be done to reduce a clients pain. In the pain assessment, we should assess the wound and document the pain score that the patient is experiencing. Also, we need to record the comment of the pain (i. e. burning, tingling, stabbing etc. ) and will the pain affect the healing process. Furthermore, we also need to document how we treat the pain.Such as medication or any therapy that has been used. There are things that we can do to reduce a clients pain * Cover the wound to protect it from further injury. * Change the bandage daily, and keep the wound clean to prevent infection. * teach ibuprofen or acetaminophen to ease initial wound pain. If pain lasts for more than a day or two, consult your doctor. * For a stand or ankle wound, stay off your feet as much as possible to ease pain and encourage healing. * Be sure to get plenty of sleep and follow a healthy diet to help your body heal.