Presentation on theme: "Jeannie Randles RN Grad cert wound care PG Cert &PG Dip Primary Health."— Presentation transcript:
Jeannie Randles RN Grad cert wound care PG Cert &PG Dip Primary Health
documentation Wound healing process Chronic wounds Wound assessment using TIME
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
Arrest bleeding Vasoconstriction Compression of injured vessels Platelet activation Fibrin production Clot formation
Vasodilation Leukocyte supplant platelets White cells predominant for 1 st three days Monocytes become macrophages and debride the wound
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.
“Chronic wounds are wounds that fail to progress through an orderly and timely sequence of repair” Often stay in inflammatory stage or move between stages och-Part2/Alternative-Enpoints-To- Healing.html Last Modified: Thursday, 21-Oct :19:52 BST
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
I is for inflammation or infection ↑ erythema ↑ exudates ↑ pain ↑ wound size ↑ malodour Delay in healing Tissue becomes friable ↑slough Undermining Bridging pocketing
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
E is for edges/epethelialisation Rolled Epethelialising Punched out Sloped Undermining
Rolled margins could suggest a degree of senescence Healing stopped
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