HLTENN006 Apply principles of wound management in the clinical environment

Assessment Details
Qualification Code: Title HLT54115 – Diploma of Nursing
Assessment Type Assessment 1 Underpinning Knowledge/Questions
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HLTENN006 Apply principles of wound management in
the clinical environment
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RESULTS (Please Circle) SATISFACTORY NOT SATISFACTORY
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Australian Harbour International College, 114-120 Castlereagh Street, Sydney NSW 2000, Australia
|RTO NO: 41338 | CRICOS Provider Code: 03449J
Filename: HLTENN006 Apply principles of wound
management in the clinical environment
Version 1.0/
November 2017
Review Date:
November 2019
Page 2 of 21

Assessment 1 Underpinning knowledge questions
Instruction to Students:
 Answer the questions below in the spaces text box provided.
 Ensure all references are documented under each individual question.
 Answers are to be typed or for written submissions, use black or blue ink and
ensure your name is attached to the responses.
Case Scenario 1
Mahalia is a 70-year-old woman who has presented via ambulance to Hornsby
Hospital with breathing difficulties, blood pressure (90/50), temperature 38.2
and oedema in her lower limbs and hands. Mahalia has non-blanchable
redness of intact area on her sacrum approximately 5cm diameter in size. On
her lower leg she has a full thickness skin loss 2 cm ulcer which has a small
amount of discharge.
Mahalia has a previous medical history of 25years of heavy cigarette smoking
but states she gave up smoking 3 months ago, however you notice that she
has yellow tinged fingers on her right hand.
Mahalia appears malnourished, has poorly managed chronic heart condition as
she does not like going to the doctors. Mahalia appears frail, unkempt and at
times disorientated.
The decision is made by the medical team to fly Mahalia to North Shore
Australian Harbour International College, 114-120 Castlereagh Street, Sydney NSW 2000, Australia
|RTO NO: 41338 | CRICOS Provider Code: 03449J
Filename: HLTENN006 Apply principles of wound
management in the clinical environment
Version 1.0/
November 2017
Review Date:
November 2019
Page 3 of 21

Hospital for further investigations and treatment.
Using the case scenario provided provide responses to the following questions.
1. What physical assessment and wound assessments would you undertake for
Mahalia? (Min 150 words)
The patient is a 70 years old woman, Mohalia who has been admitted to the
hospital for low blood pressure of 90/50, lower body temperature and oedema
in the legs. She is also having non-blanchable redness of the area which is
intact with the sacrum and also approximately about 5 cm of diameter of size.
She is also having an ulcer of 2 cm on the lower leg and which discharges are
coming out. The medical history is showing that she has been taking cigarette
since 25 years but at the same time also she has left smoking since the last
three months and because of smoking, the condition of her heart is also not
good. To assess the oedema, the thumb should be placed on the oedema
region and the recovery time is noted and the ankle circumference must be
measured. In the small leg ulcer, at first the discharges should be cleaned and
then it can be treated by gradually compression therapy (Finlayson, Wu & Edwards,
2015).
2. What was the most likely cause for the development of Mahalia’s wounds? (Min
50 words)
The diseases from which the patient is suffering are interrelated. The patient is
not able to maintain the failures of heart effectively and the congested heart
failure is one of the important cause of oedema. Both the wounds- redness of
the intact area of the sacrum and the leg ulcer have occurred as she has been
Australian Harbour International College, 114-120 Castlereagh Street, Sydney NSW 2000, Australia
|RTO NO: 41338 | CRICOS Provider Code: 03449J
Filename: HLTENN006 Apply principles of wound
management in the clinical environment
Version 1.0/
November 2017
Review Date:
November 2019
Page 4 of 21

suffering from oedema (Kapp & Miller, 2015).
3. What comfort needs and timeframes for pain medication prior to wound care
would you need to consider for Mahalia? (Min of 50 words)
The patient is suffering from high infection of non-blanchable redness of the
intact area of the sacrum and also from severe pain of ulcer in the lower
portion of leg. Firstly she needs to take rest and not get involved in different
household works. The second thing is she must not walk as if she walks both
her sacral wounds and the ulcer of her leg will get inflamed much more. Before
the wound care much time must not be spend for medication.
4. What factors may affect Mahalia’s wound to heal now an in the future? (Min 50
words)
In order to heal the wounds now and in future, the patient need to get rid of
oedema which is a little bit difficult as she is suffering from heart disease since
a long time and also she has been smoking since25 years. If she does not get
cured from the heart disease, it will seriously become difficult in future to get
cured from the wounds (Marston et al., 2017)
5. What wound product selection would be the most appropriate for Mahalia’s
wounds? (Min of 100 words)
As the patient is suffering from ulcer in the leg, she needs alginate
Australian Harbour International College, 114-120 Castlereagh Street, Sydney NSW 2000, Australia
|RTO NO: 41338 | CRICOS Provider Code: 03449J
Filename: HLTENN006 Apply principles of wound
management in the clinical environment
Version 1.0/
November 2017
Review Date:
November 2019
Page 5 of 21

dressings. Alginate dressings are used in the moderate level to high amount
of drainage of wounds to manage the excess of fluids, painful wounds,
pressure ulcers and also the second or third degree burns. The alginate
dressings are prepared from sea weeds, harvested all around the world. The
alginate dressings can absorb 15 to 20 times their weight in the exudate.
They are manufactured from ropes, ribbons and flat sheets. In the redness
of the sacral region only ointments can be applied (Ahmadian et al., 2016) .
6. Compare the difference in nursing wound care management for Mahalia’s
wounds today and the care that would have been provided in the mid-1800s by
Florence Nightingale. (Min 100 words)
The wound care policy followed by Florence Nightingale was different from
the wound care policy. The wound care policy followed in the ancient times
were mostly homely based. The treatment were delivered in the private
homes. At that time the infection control mechanism policies were not the
matter of much concern but in the present case, the alginate dressings are
used to prevent the spread of the infection apart from curing the wounds.
Nightingale also emphasized on the effective communication by the family
members of the patient, however now a days effective communication is no
doubt important and apart from that the in acute conditions the patients are
kept on hospitals (Diaz et al., 2016).
Australian Harbour International College, 114-120 Castlereagh Street, Sydney NSW 2000, Australia
|RTO NO: 41338 | CRICOS Provider Code: 03449J
Filename: HLTENN006 Apply principles of wound
management in the clinical environment
Version 1.0/
November 2017
Review Date:
November 2019
Page 6 of 21