Note: This guideline is currently under review. Show
Aim Physiology of a wound and wound healing Factors That Inhibit Wound Healing Wound Assessment Wound Management Documentation within the EMR Companion Documents Links Evidence Table References IntroductionThe
assessment and maintenance of skin integrity in the paediatric patient should be fundamental to the provision of nursing care. AimAccurate wound assessment and effective wound management requires an understanding of the physiology of wound healing, combined with knowledge of the actions of the dressing products available. Physiology of a wound and wound healingWound classification- Type of Healing- Skin graft- removal of partial or full thickness segment of epidermis and dermis from its blood supply and transplanting it to another site to speed up healing and reduce the risk of infection. Wound healing is a complex sequence of events that can be broadly divided into two stages:
Factors That Inhibit Wound HealingHolistic assessment of the patient is an
important part of the wound management process. A number of local and general factors can delay or impair wound healing. Local:
General:
Wound AssessmentWhen conducting initial and ongoing wound assessments the following considerations should be
taken into account to allow for appropriate management in conjunction with the treating team:
See Clinical Guideline (Nursing): Nursing Assessment for more detailed nursing assessment information. Considerations for Wound AssessmentType of wound:There is different terminology used to describe specific types of wounds:
such as surgical incision, burn, laceration, ulcer, abrasion. They can be generally classified as either acute or chronic wounds. Tissue loss:The degree of tissue loss may be referred to in broad terms as:
There are classification systems for certain types of wounds such as Burns (Nursing Management of Burn Injuries Clinical Practice Guideline) and Pressure Injuries (Pressure Injury Prevention and Management Clinical Practice Guideline)Wound bed clinical appearance:
Wound measurement:'Assessment and evaluation of wound healing is an ongoing process. All wounds require a two-dimensional assessment of the wound opening and a three-dimensional assessment of any cavity or tracking' (Carville, 2017)
Wound edges:The edges of the wound are assessed for-
Exudate:Is produced by all acute and chronic wounds (to a greater or lesser extent) as part of the natural healing process. It plays an essential part in the healing process in that it:
It is important to assess and document the type, amount, colour and odour of exudate to identify any changes. Excess exudate leads to maceration and degradation of skin while too little can result in the wound bed drying out. It may become more viscous and odorous in infected wounds. Surrounding skin:The surrounding skin should be examined carefully as part of the process of assessment and appropriate action taken to protect it from injury. Presence of infection:Wound infection may be
defined as the presence of bacteria or other organisms, which multiply and lead to the overcoming of host resistance. Infection can disrupt healing and damage tissues (local infection) or produce spreading infection or systemic illness. Infection adversely affects wound healing and may be the cause of wound dehiscence.
Wound healing and clinical infection demonstrate inflammatory responses and it is important to ascertain if increases in pain, heat, oedema and erythema are related to the inflammatory phase of wound healing or infection. Pain:Pain can be an important indicator of abnormality. The pain associated with chronic wounds and wounds that require frequent dressing changes can be underestimated. Wound ManagementGuidelines for wound management:
Acute Wound ManagementWound cleansingThe goal of wound cleansing is to:
Principles of wound cleansing:
Choice of dressingA wound will require different management and treatment at various stages of healing. No dressing is suitable for all wounds; therefore frequent assessment of the wound is required. Wound healing progresses most rapidly in an environment that is clean, moist (but not wet), protected from heat loss, trauma and bacterial invasion.
There are a multitude of dressings available to select from. Effective dressing selection requires both accurate wound assessment
and current knowledge of available dressings (Ayello, Elizabeth A) Wounds healing by Primary IntentionThese wounds require little intervention other than protection and observation for complications.
Wounds healing by delayed primary intentionOccurs when the wound is
contaminated or infection is suspected. These traumatic or surgical wounds require intensive cleaning before healing can occur. Debridement using irrigation may be required.
Absorbent or protective secondary dressings will be required for most wounds- it is important to ensure that the surrounding skin is protected from maceration. A skin barrier wipe can be used. Wounds healing by secondary intentionAcute surgical or traumatic wounds may be allowed to heal by secondary intention- for example a sinus, drained abscess, wound dehiscence, skin tear or superficial laceration. RCH Dressing Selection Resources
Chronic wound managementDetermine the aetiology for inhibition of wound healing. Address or control the factors identified for example: presence of infection, poor nutritional status, appropriate dressing selection, moist wound environment. Dressing selection should be based on the specific wound characteristics and referral to Stomal Therapy should be initiated to promote optimal wound healing. Advanced wound therapies may be required to be utilitised e.g surgical debridement, application of a negative pressure dressing, hyperbaric therapy. Ongoing ManagementDischarge planningParents and carers should be given a plan for the ongoing management of the wound at home. A range of appropriate dressing products can be obtained from the RCH Equipment Distribution Centre. For more complex wound care needs involvement of the inpatient care coordinators may be required to make appropriate referrals to Wallaby or an alternative for ongoing wound management at home. Medical teams managing patients may request specific wound care and follow up to occur at RCH via Specialist Clinics- this may also include Nurse Led Clinics or patients may be referred to their local GP for wound follow up. Documentation within the EMRIt is an expectation that all aspects of wound
care, including assessment, treatment and management plans, implementation and evaluation are documented clearly and comprehensively. Wound care and dressing changes can also be ordered/preplanned utilising the ‘Orders’ activity. EMR Learning Resources and Tip Sheets:
Companion Documents
Links
References
Evidence Table
Please remember to read the disclaimer The development of this clinical guideline
was coordinated by Kirsten Davidson, EMR Lead Nurse Educator. Approved by the Clinical Effectiveness Committee. Current as of March 2019. Which laboratory result would the nurse anticipate when reviewing the cerebrospinal fluid analysis of a client with bacterial meningitis?In people with meningitis, the CSF often shows a low sugar (glucose) level along with an increased white blood cell count and increased protein.
Which assessment findings would provide an indication of increased intracranial pressure?These are the most common symptoms of an ICP:. Headache.. Blurred vision.. Feeling less alert than usual.. Vomiting.. Changes in your behavior.. Weakness or problems with moving or talking.. Lack of energy or sleepiness.. What happens when ICP increases?A sudden increase in the pressure inside a person's skull is a medical emergency. Left untreated, an increase in the intracranial pressure (ICP) may lead to brain injury, seizure, coma, stroke, or death. With prompt treatment, it is possible for people with increased ICP to make a full recovery.
Which components would the nurse assess when using the Glasgow Coma Scale to assess a patient who sustained?The scale assesses patients according to three aspects of responsiveness: eye-opening, motor, and verbal responses. Reporting each of these separately provides a clear, communicable picture of a patient.
|