Nursing Care in Hdu

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All Wounds Are Not The Same!

Wound assessment (Subjective)
Remember to ask the client: ćLocation
ćTiming - Cause/When first appeared
ƒáSize ƒáBetter/Worse - What treatments have worked/what hasn¡¦t. ƒáChanges from initial wound
ƒáAssociated Symptoms ¡Vitching, pain, redness.

A full ROS will also highlight any other problems that need to be addressed in order to maximise wound healing.

Wound Assessment (Objective)
Crisp and Taylor (2005) use the following headings when attempting to objectively describe a wound:

Skin Integrity:
ćOpen
ćClosed
ćAcute
ćChronic

Cause:
ćIntentional
ćUnintentional

Severity:
ćSuperficial
ćPenetrating
ćPerforating

Cleanliness:
ćClean
ćClean-Contaminated
ćContaminated
ćInfected
ćColonised
ćAnother way to classify wounds is by the colour, which identifies the healing phase. A wound may be a mixture of colours:

ćBlack - necrotic/dead tissue

ƒáYellow ¡V fibrous exudate

ƒáRed ¡Vgranulation tissue

ćPink -epithelialisation

ODHB (Otago District Health Board) use this classification system to assess wounds, and have adopted a wound assessment tool as part of their co-ordinated care pathways.

(see attached form as an example)

When cleaning the wound, the 2 most common methods involve :

a)irrigation with warmed 0.9% Normal Saline
b)using a gauze soaked with 0.9 % normal saline to wipe the wound. (Remember 1 gauze = 1 wipe!)

What method (a or b) would you use to cleanse wounds #1 to #5?

References

Crisp,J & Taylor, C. (2005). Potter & Perry¡¦s Fundamentals of Nursing. (2nd ed) Elsevier: Australia.
Wound care made incredibly easy(2003). LWW.Philidelphia

ODHB co-ordinated care pathway assessment tool(2003), MIDAS doc 23648...
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