Documentation: Wound Healing by Secondary Intention

• What is the primary focus of the documentation in wound healing by secondary intention?

  Wound characteristics and healing progress
• Why is accurate documentation of wound characteristics essential?

  It aids in effective wound management
• What are key aspects to document regarding a wound?

  Location, size, appearance, and exudate
• What types of tissue may be found in the wound bed?

  Granulation tissue, slough, or necrotic tissue
• What types of exudate can be present in a wound?

  Serous, purulent, or sanguineous
• How does detailed documentation assist in wound healing?

  It tracks healing progress and guides treatment
• What actions are taken during wound care for secondary intention healing?

  • Irrigate wound with sterile 0.9% NaCl
  • Pack with 5 pieces of 2x2 gauze moistened with sterile 0.9% NaCl
  • Dress with 2 pieces of 4x4 gauze and an abdominal pad
  • Secure with paper tape
• What is the saline solution used for wound irrigation?

  Sterile 0.9% NaCl
• How many pieces of 2x2 gauze are used to pack the wound?

  Five pieces
• What type of gauze is used for dressing the wound?

  Two pieces of 4x4 gauze
• What is used to secure the dressing on the wound?

  Paper tape
• What does the term "tunneling" refer to in wound assessment?

  Extension of the wound into deeper tissues
• What does "undermining" indicate in a wound?

  Wound edges are not attached to the underlying tissue
• What signs of infection should be documented in wound assessment?

  Redness, heat, odour, and temperature
• What is the significance of measuring the wound's length, width, and depth?

  To assess the size and healing progress
• What does "periwound" refer to in wound care documentation?

  The skin surrounding the wound area
• How does the appearance of the wound bed affect treatment decisions?

  It indicates the type of tissue present and healing status