Nursing Care in Hdu
All Wounds Are Not The Same!
Wound assessment (Subjective)
Remember to ask the client:
á Location
á Timing - Cause/When first appeared
á Size
á Better/Worse - What treatments have worked/what hasn¡¦t.
á Changes from initial wound
á Associated 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:
á Open
á Closed
á Acute
á Chronic
Cause:
á Intentional
á Unintentional
Severity:
á Superficial
á Penetrating
á Perforating
Cleanliness:
á Clean
á Clean-Contaminated
á Contaminated
á Infected
á Colonised
á Another way to classify wounds is by the colour, which identifies the healing phase. A wound may be a mixture of colours:
á Black - necrotic/dead tissue
á Yellow ¡V fibrous exudate
á Red ¡Vgranulation tissue
á Pink -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
Wound assessment (Subjective)
Remember to ask the client:
á Location
á Timing - Cause/When first appeared
á Size
á Better/Worse - What treatments have worked/what hasn¡¦t.
á Changes from initial wound
á Associated 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:
á Open
á Closed
á Acute
á Chronic
Cause:
á Intentional
á Unintentional
Severity:
á Superficial
á Penetrating
á Perforating
Cleanliness:
á Clean
á Clean-Contaminated
á Contaminated
á Infected
á Colonised
á Another way to classify wounds is by the colour, which identifies the healing phase. A wound may be a mixture of colours:
á Black - necrotic/dead tissue
á Yellow ¡V fibrous exudate
á Red ¡Vgranulation tissue
á Pink -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
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