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Nutrition interventions
Encourage better eating habits
Assist with menu planning
Arrange community services when needed
and unable to do so
Activities or inactivity
Wound debris
Infection
All wounds, but especially those that fail to heal, should be inspected for foreign bodies and
x-ray may be required. Cleansing of the wound should be gentle but through. Solution used
should be nontoxic (such as normal saline).
Wound Infection
All wounds are contaminated, but this does not necessary lead to sepsis (Smith, 1983).
Bacteria exists as part of the natural flora the skin, and organisms migrate into the wound
from the surrounding skin.
Type of Wound
a. An acute wound is any surgical wound that heals by primary intention, or any
traumatic or surgical wound that heals by secondary intention, and which proceeds
through an orderly and timely reparative process that result in sustained restoration of
anatomical integrity.
b. A chronic wound occurs when the reparative process does not process through an
orderly and timelly process as anticipated and healing in comlicated and delayed by
intrinsic and extrinsic factors that impact on the person, the wound or the environment
(Lazarus et al, 1994)
Aetiology
T is impact to ascertain the aetiology or cause of wounding in order to guide management and
future preventative strategies. The commones aetiologies will be trauma or surgical
interventations, but infection, disease processes, skin manifestations, ischaemaand facititious
wounding (self-harm) can result in wound.
Type of Healing
a. Primary Intention
When there is minimal tissue loss and the edes of the wound are held in close
apposition by either suture, clips or tape. Minimal scarring result.
b. Delayed Primary Intention
When the wound is infected or contains foreign bodies and requires intensive
cleaning, prior to primary closure 3-5 days later.
c. Secondary Intention
Woundhealing is delayed and occurs by an obvious process of granulation,
contraction and ephitelisation. Scarring results.
d. Skin Graft
Partial or full thickness skin grafts are used to speed up the healing process and
reduce the risk of infection.
e. Flap
Surgical relocation of skin and subcutaneous tissue to the wound from an adjacent or
distant site.
Tissue Loss
Tissue loss can be calculated by two and three dimensionaal measurement or according to a
devised classification system. Two and theee dimensional measurement of the wound will be
used to record linear or volume measurement of tissue loss. Akthough it is difficult to obtain
an accurate linear three dimensional assesment when there is an uneven wound base.
Occasionally, the degree of tissue loss is referred to in the following broad terms.
Assesment classification systems have been devised for certain wound types such as burns,
pressure ulcerss and skin tears.
Assesment of Burns
Burns are usually classified as follows:
Classification of Burn
Superficial
Superficial partial-thickness
Deep partial-thickness
Full thickness
ubdermal
The degree of burn is also referred to and equates t the classification of burn as follows.
Degree of Burn
Calssification of Burn
First
Superficial
Second (suprficial)
Superficial partial-thickness
Second (deep)
Deep partial-thickness
Third
Full-thickness
Fourth
Subdermal
(Wilson, 2000)
Percentage of burn in relation to total body surface area (TBSA) or body surface area (BSA)
is determined according to:
Gambar nine of rules
0.1-
Head
Neck
year
1-4 years
5-9 years
10-14
years
15 years
Adult
19%
17%
13%
11%
9%
7%
2%
2%
2%
2%
2%
2%
Anterior
trunk
13%
13%
13%
13%
13%
13%
Posterior
trunk
13%
13%
13%
13%
13%
13%
Each
buttockq
2.5%
2.5%
2.5%
2.5%
2.5%
2.5%
Genitalia
1%
1%
1%
1%
1%
1%
Lower arm
3%
3%
3%
3%
3%
3%
Hand
2.5%
2.5%
2.5%
2.5%
2.5%
2.5%
Thigh
5.5%
6.5%
8%
8.5%
9%
9.5%
Leg
5%
5%
5.5%
6%
6.5%
7%
Foot
3.5 %
3.5%
3.5%
3.5%
3.5%
3.5%
Stage 2
Partial thickness skin loss involving epidermis and/ or dermis. The ulcer is superficial and
presents clinically as an abration, blister or shallow crater.
gambar
Stage 3
Full thickness skin loss involving damage or necrosis of subcutaneous tissue tthat may extend
down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with
or without undermining of adjacent tissue.
gambar
Stage 4
Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone,
or supporting structures (for example, tendon or joint capsule). Undermining and sinus tracts
may also be associated with Stage 4 pressure ulcers.
gambar
(Nation Pressure Ulcer Advisory Panel (1989).
Standard 7 reseach
Wound healing is dynamic process, and the clinician must anticipate that wound management
practices will change, as new scentific evidence becomes available.