What 2 guidelines should you use for cleansing a wound?

The National Institute for Health and Care Excellence recommends that sterile normal saline is used for cleansing surgical wounds during the first 48 hours after surgery (NICE, 2013)….Cleansing surgical wounds

• Kept completely dry;
• Cleansed using tap water only;
• Cleansed using a combination of tap water and shower gel.

Which criteria does the Braden Scale evaluate?

The Braden Scale for Predicting Pressure Sore Risk was developed to foster early identification of patients at risk for forming pressure sores. The scale is composed of six subscales that reflect sensory perception, skin moisture, activity, mobility, friction and shear, and nutritional status.

Which technique is highly recommended for wound cleaning?

The practice of wound cleansing Low-pressure irrigation, often with a syringe, and using normal saline, is the currently favoured method of cleansing and it is the evidence to support this practice that must be evaluated.

What is a contraindication for wound cleansing?

wounds with undermining, sinuses, or tunnels. Contraindications for wound cleansing. • Wounds which require a dry, stable environment, such as wounds covered with stable, hard, dry. eschar or dry gangrene.

What 5 areas does the Braden Scale assess?

These are: sensory perception, moisture, activity, mobility, friction, and shear. Each item is scored between 1 and 4,with each score accompanied by a descriptor.

When do you use the Braden Scale?

The Braden Scale for Predicting Pressure Sore Risk is a universally accepted tool to help staff in nursing homes and hospitals identify individuals who may be at risk for developing bed sores (also called decubitus ulcers, pressure sores or pressures ulcers).

What is the correct sequence for wound healing?

The complicated mechanism of wound healing occurs in four phases: hemostasis, inflammation, proliferation, and remodeling.

How do you clean a wound before suturing?

Skin preparation and wound toilet

1. Disinfect the skin around the wound with antiseptic, but do not put antiseptic inside the wound.
2. Also consider debridement of ragged, non-viable skin edges.
3. If necessary you can trim hair; however, avoid shaving.

When should you not irrigate a wound?

Irrigation may not be necessary for certain highly vascular areas such as the scalp. [5] Wounds with fistulas or sinuses with unknown depth should undergo careful evaluation before irrigation is performed to avoid forcing bacteria and debris containing fluids further into the wound or other body spaces.