Wound Care

 

Factors that Impair wound healing

  1. Malnutrition
  2. Infections
  3. Radiation Therapy
  4. Pre-existing conditions eg diabetes, obesity
  5. age
  6. immunocompromised
  7. dehydration
  8. further mechanical stress eg shear forces
  9. bedridden
  10. prolonged corticosteroid use
  11. impaired O2 eg anemia, COPD

 

Assess for factors of impaired wound healing

  • low serum albumin <35
  • low lymphocyte count
  • 5% weight loss in 1 month
  • intake less than 60% of recommended intake

 

40-50% of diabetics have neuropathy – therefore prevention of wounds – pt teaching

Major Complications of Wound Healing

  1. Evisceration
  2. Dehiscence
  3. Fistulas

 

Braden Scale Assessment Factors

  1. Sensory Perception
  2. Moisture
  3. Activity
  4. Mobility
  5. Nutrition
  6. Friction and Shear

 

Wound Assessment

  1. Location
  2. Size – measurement & photograph
  3. Depth
  4. Presence of Necrotic and Granular tissue
  5. erythmatous
  6. edema
  7. document – care plan write down material used in wound dressing

 

Wound characteristics:

  • red-pink tissue – healing
  • black and brown – eschar – debridement
  • yellow – infections
  • changes in wound
  • dry vs draining wound
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