Case Study: Wound Assessment and Evidence-Based Wound Management Plan

Case Study

Introduction
This paper will discuss the case study of the 72 years old woman, who is admitted to the
ward, after she experienced a fall in her bathroom that resulted in knee injury. Fall has
resulted in a big open wound on her right lower leg. Her wound was sutured by her general
practitioner and was prescribed to take antibiotic medication for the next 72 hours. However,
later she was recommended by the doctors to shift to the hospital for wound management.
Wound management is considered as the combination of the various effective and holistic
measures and interventions that are taken for wound healing. Therefore, this paper will
discuss the case study in detail and will provide an analysis or the comprehensive assessment
of the wound.
The process of wound assessment is an important component of wound management that
place emphasis on applying the appropriate nursing skills and knowledge and developing a
diagnostic hypothesis. Wound Assessment of the patient may include various aspects to be
covered, such as vital sings, patient history, nutritional and fluid balance and activity
tolerance, as these factors can impede wound healing. Patient also has the history of type 2
diabetes and osteoarthritis, which increases the risk of falls and fall related injuries among the
older people.
Therefore, this paper will focus on conducting a comprehensive wound assessment to identify
the process of wound healing and severity of the injury on the basis of evidenced based
knowledge. This paper will also discuss the consequences of the chronic disease on patient’s
physical and cognitive condition that may associated with the factors that result in fall and
fall related injury. The evidence-based knowledge will be applied for developing wound
management strategies for the patients and will also develop a fall prevention interventions in
order to prevent the risk of falls in future.

Wound Assessment
Wound assessment is the process of assessing the individual, who have experienced wound,
assessment of the risks associated with wound and assessment of the healing environment
(Bryant, & Nix, 2015). Therefore, wound assessment carried out in the case was the
individual assessment. Individual was assessing for the reason of presentation.
The wound has been left to heal by primary intention as the wound was immediately sutured
after the injury. The picture of the wound informs that it is a chronic wound that has ben
closed with many stiches. However, the wound healing process has been delayed and pitting
edema can be seen on the wound site (Domingo et al, 2016). Lacerations can be seen and
indicates a significant damage to the blood vessels and size of the wound is very big as it
covers the complete area of the lower leg. Patient has suffered the traumatic wound that
increases the chances of contamination due to the presence of microorganism and dirt. The
surgical wound skin has also become discoloured that indicates the presence of the dead
tissues and also indicates the risk of infection (Shanmugam et al, 2015).
It was identified that wound have been caused due to the fall. Patient medical history
informed that patient has undergone hip replacement and knee replacement surgeries and
have been suffering from osteoarthritis and type 2 diabetes. All the information obtained from
the patient were well documented and recorded. Nutritional status of the patient was also
assessed, as the ineffective nutritional status of the patient can delay the process of wound
healing and can also result in affecting the quality of life (Molnar, Vlad, & Gumus, 2016).
Assessment procedure also requires to assess the patient history towards any kind of allergies
and reactions. This history is important to be known in order to plan the medication and
interventions according to the needs of the patient (Coleman et al, 2017).

Pain assessment is also an important part of wound assessment. Pain assessment is necessary
because the moderate to severe pain can delay the process of wound healing (Greatrex‐White,
& Moxey, 2015). Also, ineffective assessment of the pain can result in causing discomfort for
the patient and can also increase the risk of deterioration. Patient suffers from severe pain and
rated it as 8 on the pain scale. Severe wound pain can also be related to trauma or the
presence of infection of wound site (Greatrex‐White, & Moxey, 2015). Pain assessment is
also necessary because the persistent pain can affect the physical and mental functioning of
the patient and can increase morbidities (Rawal, 2016).
The process of wound assessment also includes the assessment of the vital signs. Therefore, a
systematic ABCDE physical assessment was done to identify the vital signs. It was found that
patient had a clear airway and is able to speak effectively. Airway is clear and the patient is
speaking effectively. Assessment of the airway is significant to identify the risk of
deterioration, as in the case of deterioration patient may need pharmacological and oxygen
therapies. Airway assessment is also important for understanding the impact of trauma
(Stewart et al, 2015). Breathing rate of the patient was assessed that informed that rate of
breathing is 16 breath per minutes and the movement of the chest is normal as well as entry
of air in both lungs was equal. Circulation assessment of the patient informed that patient had
normal heart rate of 90 beats per minute and regular; BP 85/40. However, the diagnosis
results of ECg informed about the presence of IHD.
Another important part of the vital sign assessment is to assess the sings of disability.
Disability can be associated with presence of confusion, cognitive impairment and problems
with decision making, or problems associated with functioning (Smith, & Bowden, 2017).
However, in the case, patient was found to have normal cognitive function. However, the
information obtained from the patient informed that she requires assistive device for walking.
Exposure assessment of the patient informed about the very large wound on the right lower