Jeannie Randles RN Grad cert wound care PG Cert &PG Dip Primary Health

 documentation  Wound healing process  Chronic wounds  Wound assessment using TIME

 Assess  wound assessment forms and notes  Re assess  Read previous documentation  Care plan (up to date and clear)  Outcomes (up to date and appropriate)  If its not written it didn’t happen!!!!

 cascade of events  Haemostasis  Inflammation  Proliferation  Remodelling  Not always in order

 Arrest bleeding  Vasoconstriction  Compression of injured vessels  Platelet activation  Fibrin production  Clot formation

 Vasodilation  Leukocyte supplant platelets  White cells predominant for 1 st three days  Monocytes become macrophages and debride the wound

 Fibroblasts migrate from wound margins  Generate cytokines, growth factors, collagen  Capillary loops form(angiogenesis)  Inflammation reduces

 Primary intention – surgical closure, minimises connective tissue deposition, resulting in rapid healing  Secondary intention – wounds that are left open and heal by deposition of connective tissue resulting in increased scar formation  Tertiary (delayed primary) – delayed closure of wounds complicated by infection.

“Chronic wounds are wounds that fail to progress through an orderly and timely sequence of repair” Often stay in inflammatory stage or move between stages och-Part2/Alternative-Enpoints-To- Healing.html Last Modified: Thursday, 21-Oct :19:52 BST

 T is for tissue  Slough  Granulation, healthy or dull/friable  Epithelial islands  Necrotic tissue  Tendon or bone exposed  Describe tissue seen in detail and in %’s

 I is for inflammation or infection  ↑ erythema  ↑ exudates  ↑ pain  ↑ wound size  ↑ malodour  Delay in healing  Tissue becomes friable  ↑slough  Undermining  Bridging  pocketing

 Ideal wound healing environment is moist, not wet and not dry (some exceptions apply)  Describe exudates i.e. amount, colour, odour  Describe effect of exudates i.e. maceration, desiccation  Frequency of dressing changes and condition of dressings at changes i.e. saturated or dry

 E is for edges/epethelialisation  Rolled  Epethelialising  Punched out  Sloped  Undermining

 Rolled margins could suggest a degree of senescence  Healing stopped

 Wounds are dynamic and need constant re assessment  Excellent wound care follows excellent wound assessment  Clear documentation is a crucial component of wound assessment  Excellent wound assessment involves the whole of the patient and not just the hole in the patient