Visit the wound care clinic
1) Today, visit wound care room (Room no 10) at emergency department.
-Met KakYah and two male nurses and two Hos. (they are very nice and treated us well).
-Patient usually came to the clinic (outpatient clinic) EOD to clean and dress the wound.
-The nurses explained concisely to us about the tools needed for dressing and the techniques.
-Observe full cleaning and dressing the wound for DFU (diabetic foot ulcers), venous ulcers, bed sores at sacral, post appendicectomy wound with colostomy.
-Followed a nurse to respective wards to clean and dress the wound mainly bed sore patient.
He taught us how to document the wound inspection.
Documentation of wound inspection
-Met Dr Amalina Nudin at HDU ward.
1) ages (extreme ages)
2)diseases /comorbidities
3) medications (steroids or chemotheraphy)
4) obesity
5) nutrition
6) impaired blood supply
7) lifestyle (smoking / alcohol)
SIZE :
Measuring wound surface area (length, width, depth)
SURROUNDING SKIN:
Assess for sign of maceration, infection, ischemia, crepitus.
T.I.M.E
T : Tissue
= viable (granulation and new epithelial)
=non viable (necrotic and slough tissues)
I : Infection /Inflammation
= signs and symptoms of infection as presence of pus,pain,malodour
M: moisture imbalance
= exudate level dry,minimal or moderate/wet
E: epidermal margin
= advancing
= non advancing
1) Clean with cleansing foam ( berbuih tapi tak perlu dibasuh dengan air just lap)
2) Hydrocyn water for healing faster (Increase O2 to wound)
4) Foam - as bacterial barrier to cover exudate) *usually if use use gauze, must use 64sheets to give maximum function so foam is more better.
5)Aqua cell Ag - Hydrofibre to absorb exudate
6) aloe vera oil - to prevent bed sores, dryness of skin and reduce itchness
7) Bandage
+ Sline : something that cover the wound from healing . During cleaning the wound,must debride the sline till healthy and bleed tissue seen .
8) Blade - to cut the aqua cell Ag into respective size of woun,foam and necrotic patch.
10) Wound ruler - to measure the size of wound length x width
11) sterile water - apply all around the skin surrouding the wound
There are 2 type of debridement which are :
a) mechanical debridement : manually remove during cleaning of wound
b) autolytic debridement apply gel on the wound usually on post operation.
+Bed sores usually happen at bony prominence as sacral, scapula, occipital.
+In bed sores, if necrotic patches present, the wound is unstageable and must remove the necrotic patch with blade first to promote healing at that area.
WOUND ASSESSMENT
1) ages (extreme ages)
2)diseases /comorbidities
3) medications (steroids or chemotheraphy)
4) obesity
5) nutrition
6) impaired blood supply
7) lifestyle (smoking / alcohol)
LOCAL WOUND ASSESSMENT
SIZE :
Measuring wound surface area (length, width, depth)
SURROUNDING SKIN:
Assess for sign of maceration, infection, ischemia, crepitus.
T.I.M.E
T : Tissue
= viable (granulation and new epithelial)
=non viable (necrotic and slough tissues)
I : Infection /Inflammation
= signs and symptoms of infection as presence of pus,pain,malodour
M: moisture imbalance
= exudate level dry,minimal or moderate/wet
E: epidermal margin
= advancing
= non advancing
DRESSING SET
Dressing set 1
Dressing set
Dressing set 1
Dressing set 2
Dressing set 3
1) Clean with cleansing foam ( berbuih tapi tak perlu dibasuh dengan air just lap)
aloe vera cleansing foam
2) Hydrocyn water for healing faster (Increase O2 to wound)
Hydrocyn aqua
About hydrocyn aqua
3) Gel for the epithelization (Increase granulation tissue)
About hydrocyn aqua
Debride gel
4) Foam - as bacterial barrier to cover exudate) *usually if use use gauze, must use 64sheets to give maximum function so foam is more better.
Foam
5)Aqua cell Ag - Hydrofibre to absorb exudate
Aqua cell Aq covering the venous ulcers (grey colour)
+ Sline : something that cover the wound from healing . During cleaning the wound,must debride the sline till healthy and bleed tissue seen .
Bandage
8) Blade - to cut the aqua cell Ag into respective size of woun,foam and necrotic patch.
Blade
9) Hypafix plaster. -
11) sterile water - apply all around the skin surrouding the wound
Sterile water
There are 2 type of debridement which are :
a) mechanical debridement : manually remove during cleaning of wound
b) autolytic debridement apply gel on the wound usually on post operation.
+Bed sores usually happen at bony prominence as sacral, scapula, occipital.
+In bed sores, if necrotic patches present, the wound is unstageable and must remove the necrotic patch with blade first to promote healing at that area.
Bed sores wound
Example of bed sores documentation
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