Readjust the bandage immediately. Show
After a bandage is applied, the nurse must assess, document, and immediately report changes in circulation. The skin of the underlying body parts is distal to the bandage for coolness, pallor, cyanosis, diminished or absent pulse, and tingling or numbness. When applying a bandage it is acceptable to loosen and readjust as needed. Coolness, diminished pulse, and a blue color (cyanosis) indicate there is a circulatory impairment. Therefore the bandage must be readjusted immediately to prevent damage to the arm. Tightening the bandage will further compromise circulation. The arm may be placed in the sling, but the pressure needs to be relieved to reestablish circulation. Passive range-of-motion exercises will not eliminate the pressure that is causing the circulatory impairment. Note: This guideline is currently under review. 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 of the following approaches is correct technique when wound irrigation is performed quizlet?Which approach is correct technique when wound irrigation is performed? Selecting a soft catheter for deep wounds with small openings.
When should a nurse consider culturing a wound?Of the 7 studies, 3 studies suggest that classic signs of infection may not always be present but culturing may be indicated when additional signs such as pain, necrotic tissue, prolonged or delayed healing, and wound bed deterioration occur.
Which nutrients will the nurse expect to be helpful in healing a superficial wound?Nutrition plays a vital role in burn healing, minimising complications of care and meeting the increased metabolic demands associated with paediatric patients with burns. A diet high in protein, calcium, energy and micronutrients (in particular Zinc and Vitamin C) has been shown to be most beneficial for wound healing.
What should the nurse do when removing intermittent sutures quizlet?A cosmetically aesthetic result would not be achieved. What should the nurse do when removing intermittent sutures? a. Snip both sides of the suture before removing.
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