Transcript Wound assessment - Canterbury District Health Board

Jeannie Randles RN
Grad cert wound care
PG Cert &PG Dip Primary Health
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documentation
Wound healing process
Chronic wounds
Wound assessment using TIME
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Assess
wound assessment
forms and notes
Re assess
Read previous
documentation
Care plan (up to date
and clear)
Outcomes (up to date
and appropriate)
If its not written it
didn’t happen!!!!
cascade of events
 Haemostasis
 Inflammation
 Proliferation
 Remodelling
Not always in order
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Arrest bleeding
Vasoconstriction
Compression of
injured vessels
Platelet activation
Fibrin production
Clot formation
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Vasodilation
Leukocyte supplant
platelets
White cells
predominant for 1st
three days
Monocytes become
macrophages and
debride the wound
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Fibroblasts migrate from wound margins
Generate cytokines, growth factors, collagen
Capillary loops form(angiogenesis)
Inflammation reduces
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Primary intention – surgical closure, minimises
connective tissue deposition, resulting in rapid
healing
Secondary intention – wounds that are left
open and heal by deposition of connective
tissue resulting in increased scar formation
Tertiary (delayed primary) – delayed closure of
wounds complicated by infection.
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“Chronic wounds are
wounds that fail to
progress through an
orderly and timely
sequence of repair”
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Often stay in
inflammatory stage or
move between stages
http://www.worldwidewounds.com/2004/october/En
och-Part2/Alternative-Enpoints-ToHealing.html
Last Modified: Thursday, 21-Oct-2004
15:19:52 BST
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T is for tissue
Slough
Granulation, healthy or dull/friable
Epithelial islands
Necrotic tissue
Tendon or bone exposed
Describe tissue seen in detail and in %’s
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I is for inflammation
or infection
↑ erythema
↑ exudates
↑ pain
↑ wound size
↑ malodour
Delay in healing
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Tissue becomes friable
↑slough
Undermining
Bridging
pocketing
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Ideal wound healing environment is moist, not
wet and not dry (some exceptions apply)
Describe exudates i.e. amount, colour, odour
Describe effect of exudates i.e. maceration,
desiccation
Frequency of dressing changes and condition
of dressings at changes i.e. saturated or dry
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E is for edges/epethelialisation
Rolled
Epethelialising
Punched out
Sloped
Undermining
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Rolled margins could
suggest a degree of
senescence
Healing stopped
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Wounds are dynamic and need constant re
assessment
Excellent wound care follows excellent wound
assessment
Clear documentation is a crucial component of
wound assessment
Excellent wound assessment involves the
whole of the patient and not just the hole in the
patient