Wound Care Classification Of Wounds
Wound Care Classification of wounds
First, the definition of the wound: normal skin (tissue) in the external injury factors such as surgery, external force, heat, current, chemical substances, low temperature and the body of internal factors such as local blood supply disorders caused by damage. Second, the purpose of wound care: for the patient to replace the wound accessories, keep the wound clean, prevent and control the infection, promote healing. Third, the wound classification: wound healing time is 2 weeks for the boundaries, acute wounds: surgical incision, skin abrasions, burns, skin area of chronic wound: pressure ulcers, lower extremity vascular ulcers, diabetic foot ulcers, other refractory Fourth, the assessment of: the whole body, the local situation debridement: choose the right way Dressing: a reasonable choice of dressing record: record the above situation re-evaluation: treatment is appropriate, adjust the program five, operational assessment: 1, Assess the patient's condition, mental state, the degree of awareness of the wound, a reasonable operation to understand the causes and duration of wound formation. 2. Evaluate the factors that affect wound healing. 3, observe the wound site, color, area, (length × width × height), with or without sneak, tissue morphology is complete, exudate color, traits and quantity, infection and wound around the skin condition. 4, the local factors affecting the wound healing: wound temperature and humidity, local blood circulation, wound foreign body, wound infection. 5, pre-operation preparation: wound care products: sterile dressing cylinder, tweezers, salt water cotton balls, dry cotton balls, sterile gauze, sterile scissors, curved discs, disposable towels, dressings dressings. Measuring tools.
Six, the operating procedures: 1, hand washing, wearing a mask, check your doctor's orders. 2, check the patient, explain to the patient the purpose of the operation, to obtain cooperation. 3, carrying things to the bed, identification, block the patient, adjust the room temperature to 24-25 ℃. 4, from the outside to the inside of the dressing, the inner accessories with tweezers opened. 5, assess the wound Select the appropriate wound cleaning agent to clean the wound, remove foreign body and necrotic tissue, according to the wound assessment to choose the appropriate wound dressing, properly fixed. 6, to help patients take comfortable supine, bed head raised less than 30 degrees, once again check the patient. 7, to guide patients with bed activities, to strengthen nutrition, sorting objects, hand washing, take masks, records. 7, the choice of dressing principle: the absorption of wound exudate, wound healing to create a good wet environment, with good permeability, allowing the body to exchange, blocking the external environment particles foreign body, and keep the wound temperature, Will not cause mechanical damage again; easy to use, comfortable, economical. 8, health education: inform the patients and their families to keep the wound dressings and the surrounding skin clean and dry; guide the bath, turn over, cough, and activities when the wound protection method.
9, note: 1, weekly observation, measurement, recording and analysis of the wound 2, according to the wound selection of wound cleaning fluid, generally with saline, or no toxic to human tissue disinfectant. 3, if there are many wounds to dressing, should first wash the wound, after the wound infection; clean wound dressing, should be out of the wound from the middle of disinfection, infection wound dressing should be from the wound outside the middle of disinfection, infection wounds Requires bacterial culture and susceptibility testing.