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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.
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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.
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Therefore, wound assessment and management is fundamental to providing nursing care to the paediatric population. Leading causes of increased morbidity and extended hospital stays. The skin is the body’s largest organ and is responsible for protection, sensation, thermoregulation, metabolism, excretion and cosmetic. Understanding and addressing these aspects ensures a comprehensive approach to fracture care.A wound is a disruption to the integrity of the skin that leaves the body vulnerable to pain and infection. Observable signs are rapid heart rate and breathing, low blood pressure, and pale, clammy skin.Įach of these diagnoses demands a tailored nursing intervention, focusing not just on physical recovery but also on the overall well-being of the patient. Symptoms include dizziness, lightheadedness, and weakness. Risk for Hypovolemic Shock: Especially in cases of significant fractures, blood loss can lead to hypovolemic shock.Clinically, signs like prolonged capillary refill, decreased sensation, and potential paralysis are critical markers. Patients may report pain, numbness, or tingling. Risk for Compartment Syndrome : This serious complication involves increased pressure within a muscle compartment.Nurses monitor for signs like open wounds, drainage, redness, swelling, and warmth around the fracture site. Risk for Infection: Particularly in open fractures, where the skin is breached, there’s a heightened risk of infection.Objectively, nurses might observe weakened muscle strength, balance issues, or altered gait. Patients often express difficulty moving, fatigue, or a decreased range of motion.
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