Biofilms: represent a survival mechanism of microorganisms and are therefore ubiquitous in nature.topical antimicrobials and the use of antibiotics to
Systemic infection: Microorganisms spread from the wound through the vascular and or lymphatic systems and involves either a part of the body (spreading) or the whole body (systemic). Healing is impaired and can lead to wound breakdown. When microorganisms and bacteria move into the wound tissue and invokes a host response. Local infection: Invasion by an agent that, under favourable conditions, multiplies and produces effects that are injurious to the patient.The infection is contained but wound healing may be delayed. Colonisation: Microorganisms multiply but do not provoke a host response.It does not provoke a host response so healing is not impaired. Contamination: The presence of microorganisms that are contained and do not multiply.Inflammation is an essential part of wound healing however, infection causes tissue damage and impedes wound healing. Occurs in the proliferative phase when tissue is over grown. Hyper granulating tissue: Appears red, uneven or granular.Necrotic tissue is dead tissue that prevents wound healing. Necrotic tissue: Appears hard, dry and black.Slough is devitalised tissue made of dead cells or debris. Slough tissue: Appears yellow, brown or grey.Occurs when healthy tissue is formed in the remodelling phase that is well vascularised and bleeds easily. Granulating tissue: Appears red and moist.Occurs in the final stage of healing when the wound is covered by healthy epithelium. Epithelial tissue: Appears pink or pearly white and wrinkles when touched.It stands for Tissue, Infection or Inflammation, Moisture balance and Edges of the wound or Epithelial advancement. TIME is a valuable acronym or clinical decision tool to provide systematic assessment and documentation of wounds. Having the knowledge, skills and resources to assess a wound will result in positive outcomes, regardless of product accessibility. Non-surgical wound: an acute or chronic wound which is not secondary to surgical intervention.Surgical wound: a wound which is secondary to surgical intervention e.g.Chronic wound: a wound which fails to progress or progresses slowly through the stages of healing.Acute wound: a wound which occurs suddenly and progresses through the stages of healing as expected.The goal of wound management: to protect new epithelial tissue.Remodelling(24 days- 1 year): epithelial tissue forms in a moist healing environment.The goal of wound management: to promote tissue growth and protect the wound.Proliferation(2-24 days): the wound is rebuilt with connective tissue to promote granulation and repair the wound.The goal of wound management: to clean debris and prevent infection.Signs and symptoms include redness and swelling. Inflammation(0-4 days): neutrophils and macrophages work to remove debris and prevent infection.The goal of wound management: to stop bleeding.Haemostasis(occurs within the first few seconds): blood vessels constrict to stop bleeding and form blood clots.
The goal of wound management is to understand the different stages of wound healing and treat the wound accordingly. Wound healing occurs in four stages, haemostasis, inflammation, proliferation and remodelling, and the appearance of the wound will change as the wound heals. Ongoing multidisciplinary assessment, clinical decision-making, intervention, and documentation must occur to facilitate optimal wound healing. The guideline aims to provide information to assess and manage a wound in paediatric patients. Therefore, wound assessment and management is fundamental to providing nursing care to the paediatric population. Leading causes of increased morbidity and extended hospital stays.
STAPLED WOUND SKIN
The skin is the body’s largest organ and is responsible for protection, sensation, thermoregulation, metabolism, excretion and cosmetic. A wound is a disruption to the integrity of the skin that leaves the body vulnerable to pain and infection.
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