Wound Management Principles 100% VERIFIED ANSWERS 2024/2025, Exams of Nursing

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Wound Management

Principles 100% VERIFIED

ANSWERS 2024/202 5

Acute Wounds Skin injuries from accidents or surgery healing predictably within 4-12 weeks. Chronic Wounds Wounds with delayed healing, often due to underlying conditions, lasting over 3 months. pH Measurement of acidity, skin pH ranges 4-6, high pH in wounds due to bacteria. Wound Bed Preparation Managing wounds to create a healing environment, involving debridement and exudate control. T.I.M.E Acronym for wound bed preparation phases: Tissue, Infection/Inflammation, Moisture, Edges. Wound Cleansing Using fluids to remove debris, optimize healing, and reduce infection risk. ANTT Aseptic non-touch technique for compromised wound environments. Eusol & Miltons Traditional antiseptics toxic to human cells Chlorhexidine gluconate & cetrimide (Savlon)

Traditional antiseptics with risk of anaphylaxis Chlorhexidine (Hibiclens) Traditional antiseptic with risk of anaphylaxis Hydrogen peroxide Traditional antiseptic causing air embolus Acetic acid (vinegar) Traditional antiseptic that is corrosive Povidone-iodine Traditional antiseptic effective against various microorganisms but deactivated by body fluids Dakin's Solution Alkaline and drying traditional antiseptic inactivated by organic matter PHMB (Polyhexamethylene Biguanide) Broad-spectrum antimicrobial used for wound cleansing, effective against MRSA and VRE Prontosan Brand name for PHMB, effective as a debriding agent and in removing biofilm Gauze, combine, lint Low absorbency dressings that may stick, shed fibers, and create a medium for microbes Non-adherent (e.g., Melolin) Dressing for low exudate superficial wounds that may still stick Alginate (e.g., Kaltostat) Absorbent dressing that does not stick and can be used for packing and promoting hemostasis Foam (e.g., Allevyn)

Dressing that wicks moisture away from the skin, available in sheet or cavity form Tulle gras Dressing with reduced adherence that requires a secondary dressing Semipermeable film (e.g., Opsite) Dressing that keeps the wound moist, suitable for low exudate wounds only Composites (e.g., CombiDerm) Dressings with layers of two or more types, such as hydrocolloid adhesive and central absorbent pad Silicones (e.g., Mepilex) Dressing that minimizes trauma on removal, ideal for skin tears, may combine silicone layer with foam Hydrogel sheets (e.g., Curagel Island) Dressing that softens necrotic tissue, cools, and soothes Amorphous hydrogels (e.g., Solsite gel) Dressing that expands with moisture, maintains hydration, and softens necrotic tissue PHMB solution or impregnated dressings Antimicrobial dressing effective against MRSA and VRE Odour absorbing dressings (e.g., Actisorb) Dressings with activated charcoal to absorb odour, bacteria, and exudate Antiseptic tulle gras (e.g., Bactigras) Dressing for infected wounds, not absorbent Cadexomer iodine (e.g., Iodosorb) Dressing that desloughs and is antimicrobial

Wound honey (e.g., Medihoney) Dressing creating an antimicrobial moist environment Silver dressings (e.g., Acticoat) Dressings with antibacterial, antiviral, and antifungal properties Bandages Roller, tubular, gauze, crepe, elasticated, cohesive Zinc paste bandages For dry and eczematous skin Ostomy or wound appliances For excessive exudate Bioengineered products / skin Future directions Nanotechnology Future directions Moisture Balance Categories: DRY, MINIMAL, MODERATE, HEAVY, INFECTED / SLOUGH Dressing Options PHMB, Hydrogels, Hydrofibre dressing, Calcium alginate, Hydrocolloids, Iodasorb / inadine, Semipermeable, Foam sheet/cavity, honey films, Interactive wet, Extra absorbent dry dressings, Silver foam / alginate, Hydrocolloid /paste / powder & sheet, Calcium alginates, Hypertonic saline, Foams, Wound/ostomy bag, Silicone/foams Points to consider Factors to consider in wound management

Wound Management Plans Include rationale for care, demographic data, wound location, wound type and aetiology, short and long term goals, dressing frequency, cleansing type, primary dressing, secondary dressing, fixation, and other relevant care Negative Pressure Wound Therapy (NPWT) Controlled negative pressure wound therapy to assist wound healing; contraindications include malignancy of the wound, untreated osteomyelitis, unexplored fistulas, known allergies to acrylic adhesives, and direct contact with blood vessels, organs, or nerves Hyperbaric Oxygen Therapy (HBOT) Administration of 100% oxygen at pressure greater than sea level; beneficial for non-healing wounds, soft tissue damage, infections, burns, skin grafts, and crush injuries; considerations include session duration, ear popping, and common side effects Undisturbed wound healing Promotes moist wound healing, reduces tissue trauma, lessens dressing change frequency, allows uninterrupted healing phases, supports ExtraCellular Matrix integrity, reduces biofilm, pain, and allows autolytic debridement Skin tears Wounds caused by shear, friction, or blunt force resulting in skin layer separation; can be partial- thickness or full-thickness TIME CDST Acronym for assessing patients and wounds, bringing in multidisciplinary teams, controlling underlying causes, deciding treatment, and evaluating and reassessing Acknowledgment of Country Recognition of traditional owners of the land where the University sits. Wound Assessment

Evaluation of wounds using appropriate terminology. ANTT Principles and techniques of Aseptic Non-Touch Technique. Moist Wound Healing A method that facilitates wound healing by maintaining a moist environment. Debridement Removal of non-viable tissue from a wound to promote healing. Granulation Formation of new tissue in the healing process of a wound. Epithelialization The process of forming new epithelial cells over a wound surface. Exudate Fluid and cells that are discharged from a wound. Biofilms Bacterial colonies surrounded by protective coatings in wounds. Slough Dead tissue that sheds or falls off from healthy tissue. Necrosis Death of cells or tissues in a localized area due to disease or injury. Eschar A thick, hard crust that forms over a wound. Inflammation

Body's response to injury or infection, characterized by redness, heat, and swelling. Granulating Tissue New tissue with tiny blood vessels that forms on the surface of a wound during healing. Epithelialising Tissue Tissue that covers the surface of a wound during the healing process. Moisture Balance Maintaining optimal moisture levels in the wound bed to support healing. Epithelial Advancement Progress of new epithelial cells moving across the wound surface. Bacterial Wound Swab Procedure to obtain a sample from a wound for bacterial analysis. Wound Care Products Products used to manage wounds based on factors like location, size, and type. Wound Bed Preparation Process of preparing the wound bed by managing tissue and controlling infection. Air Drying Effect of allowing a wound to dry without a dressing, affecting healing and scarring. Wound Healing Goals Objectives of wound management including tissue management and infection control. Moist Wound Healing Benefits Advantages of maintaining a moist environment for wound healing. Hydrogel

Gel that forms from the wound fluid provides a moist wound environment Alginate Absorb exudate, used for exuding yellow wounds Hydrocolloid Provide barrier, control humidity, used for moist red wounds to allow epithelialisation and reduce shear Vascular Granulation Tissue Tissue in the process of forming new blood vessels Epithelialisation The growth of epithelial cells over a wound surface Silicone Dressings Dressings that conform to different anatomical shapes, absorb moderate exudate, and can be used on infected wounds with appropriate antibiotic treatment Overgranulation/Hypergranulation Occurs when tissue grows excessively, compressing the wound Impregnated Gauze Gauze infused with substances like medications or antiseptics Foams Dressings suitable for low to heavily exuding wounds, including granulating and epithelialising wounds Autolytic Debridement Process where the body's own enzymes break down tissue Antimicrobial Dressings

Dressings that contain agents like silver or iodine to combat infection Necrotic Tissue Dead tissue that requires debridement Secondary Dressings Dressings used to secure primary dressings, protect, absorb exudate and odour, and maintain a moist wound environment Critical Thinking Process of analyzing the wound characteristics and selecting appropriate treatments Non-stick pad A dressing to prevent adherence to wound surface Combine pad A dressing combining multiple layers for wound management Tubular bandage A stretchable bandage for securing wound dressings Gauze Material used for wound dressing and absorption Enzyme Aids in wound debridement and healing process Foam cavity dressings Dressings designed for wounds with high exudate Silicone Material used in dressings for wound management

Exudate absorbers Dressings that absorb wound exudate Film Transparent dressing for wound protection National Safety and Quality Healthcare Service Standards Guidelines for healthcare organizations to ensure quality care Pressure injury prevention Measures to prevent pressure injuries in healthcare settings Comprehensive skin inspections Thorough examinations to assess skin condition and prevent injuries Infection prevention and control systems Processes to reduce transmission of infections in healthcare Personal protective equipment Gear worn to minimize exposure to infectious agents Aseptic technique Sterile practices to prevent contamination during procedures TIME acronym Framework for wound bed preparation: Tissue, Infection/Inflammation, Moisture balance, Edge