Wound assessment using TIME 2013 Jeannie Randles RN Grad cert wound care PG Cert &PG Dip Primary Health
outline • documentation • Wound healing process • Chronic wounds • Wound assessment using TIME
Documentation !!! • Assess • wound assessment forms and notes • Re assess • Read previous documentation • Care plan (up to date and clear) • Outcomes (up to date and appropriate) • If its not written it didn’t happen!!!!
Wound healing process • cascade of events • Haemostasis • Inflammation • Proliferation • Remodelling • Not always in order
haemostasis Arrest bleeding Vasoconstriction Compression of injured vessels Platelet activation Fibrin production Clot formation
Inflammation • Vasodilation • Leukocyte supplant platelets • White cells predominant for 1st three days • Monocytes become macrophages and debride the wound
proliferation • Fibroblasts migrate from wound margins • Generate cytokines, growth factors, collagen • Capillary loops form(angiogenesis) • Inflammation reduces
Types of wound healing • Primary intention – surgical closure, minimises connective tissue deposition, resulting in rapid healing • Secondary intention – wounds that are left open and heal by deposition of connective tissue resulting in increased scar formation • Tertiary (delayed primary) – delayed closure of wounds complicated by infection.
Chronic wounds • “Chronic wounds are wounds that fail to progress through an orderly and timely sequence of repair” • Often stay in inflammatory stage or move between stages http://www.worldwidewounds.com/2004/october/Enoch-Part2/Alternative-Enpoints-To-Healing.html Last Modified: Thursday, 21-Oct-2004 15:19:52 BST
TIME • T is for tissue • Slough • Granulation, healthy or dull/friable • Epithelial islands • Necrotic tissue • Tendon or bone exposed • Describe tissue seen in detail and in %’s
Inflammation/infection • I is for inflammation or infection • ↑ erythema • ↑ exudates • ↑ pain • ↑ wound size • ↑ malodour • Delay in healing • Tissue becomes friable • ↑slough • Undermining • Bridging • pocketing
Moisture balance • Ideal wound healing environment is moist, not wet and not dry (some exceptions apply) • Describe exudates i.e. amount, colour, odour • Describe effect of exudates i.e. maceration, desiccation • Frequency of dressing changes and condition of dressings at changes i.e. saturated or dry
Edges/epethelialisation • E is for edges/epethelialisation • Rolled • Epethelialising • Punched out • Sloped • Undermining
Rolled wound margin • Rolled margins could suggest a degree of senescence • Healing stopped
Conclusion • Wounds are dynamic and need constant re assessment • Excellent wound care follows excellent wound assessment • Clear documentation is a crucial component of wound assessment • Excellent wound assessment involves the whole of the patient and not just the hole in the patient