[Music] what are the seven steps of effective wound management why is each step important and what happens during each one knowing the answers will help you develop and support the most effective treatment plan to promote healing let's take a closer look at the role of each step and how it's typically performed by a clinician such as a certified wound care nurse wound assessment is the first and foundation step of proper wound management the goal is to identify and address all issues that may impact and potentially delay healing this will help guide the development of the most effective treatment plan in keeping with the health care providers established wound care guidelines to perform this step inspect and evaluate the wound based on several characteristics start by identifying the location length width and depth of the wound then check for undermining which is a rolled over lip around the wound also check for tunneling which occurs when the wound burrows under the skin next look at the exudate for drainage color odor amount and consistency and examine the tissue appearance for color and moisture level is it wet or dry another important characteristic is the parry wound which is the area surrounding the wound itself is the parry wound intact or macerated which means shriveled skin caused by prolonged moisture then examine the wound for infection in bioburden which is the state between normal and infected tissue is the wound red a condition called erythema is there swelling known as edema is the wound warm does it have an odor or does the patient have a fever lastly what is the patient's level of pain by assessing all of these wound characteristics you'll be in a better position to develop and implement the most effective treatment plan and move on to the next step cleansing the wound cleanse and irrigate the wound per its assessment cleansing and irrigating the wound creates the optimum environment for healing in two ways first it removes loose debris exudate pus and free-floating bacteria and second it supports the wound assessment by making the wound easier to see and evaluate to cleanse the wound swab it with dampened gauze or a similar product and irrigate to remove deeper debris step three is to protect the peri wound from wound drainage that can cause maceration and skin stripping protecting the peri wound skin is also essential because it helps prevent the wound from increasing in size but this can be a challenge because peri when skin can appear normal as a result protecting it can be overlooked and damage can occur to protect the peri wound clean it with a normal saline solution then apply a non alcohol based skin prep solution next fill any depth in the wound by packing all open spaces with the appropriate filling material this step is important because it helps prevent pockets of abscess from forming as well as promotes healing wounds that require filling include tunneling wounds undermined wounds and stage three and four pressure injuries fill them based on the wound assessment the wounds contours and the clinicians discretion choose from gauze foams fibers alginates and shells for infected wounds add an antimicrobial agent after filling the wound apply a protective dressing to cover the wound the goal is to maintain a clean moist wound bed which promotes granulation healing and closure properly covering the wound also helps prevent infection while the wound is healing and until healthy skin can resume its infection preventing roll if the protective dressing doesn't secure itself apply a secondary dressing this step helps promote healing by protecting the wound from pathogens securing the dressing also secures medical devices and aids in patient mobility select the most effective secondary dressing based on provider policy and procedures examples include gauze conforming stretch bandages tape transparent film and composite dressing these products attach to cover or pad the protective dressing and help ensure it stays in place the final step is to evaluate the wounds healing progress when you change dressings is it healing regressing or is there no change knowing this is important because it can help you determine if the treatment plan is succeeding or if another approach is required as soon as possible to promote healing to evaluate the wound ask yourself are there any new signs of infection such as a change in color or odor are the protective and secondary dressings staying in place and if applicable is the drainage control working to help promote healing know the seven steps of effective wound management assess cleanse protect fill cover secure and evaluate to learn more visit Cardinal health calm [Music]