HLT54115 Diploma of Nursing

HLT54115 Diploma of Nursing
HLTENN006 Apply principles of wound management in the clinical
environment
Written Assessment Student Copy
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Instructions to Students
Welcome to the written assessment. To successfully complete the assessment
requirements, you need to follow the following instructions.
Step 1
Read the study guide and the related resources.
Step 2
Read this assessment to gain an understanding of what you need to do to complete
the unit. Talk to your trainer or supervisor and ask for help if you need to.
Step 3
Complete all questions in this assessment. Please write clearly in pen (not pencil).
You may attach printed answers if you prefer. Do not remove any pages from this
assessment.
Step 4
Complete the cover sheet and attach to this assessment. We recommend you make
and keep a copy of your assessments.
Step 5
Submit for assessment.
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Pressure ulcers
A pressure ulcer (bedsore, decubitus ulcer) is an area of localised damage to the
skin and underlying tissue caused by pressure, shear or friction, Friction and
moisture are the most important factors in the development of superficial skin
breakdown. Pressure and shearing forces have a greater effect on subcutaneous
and muscle tissues. Ulcers can be deep, even with minimal skin breakdown, and
may not be evident until days after injury.214 They commonly form over bony
prominences such as the heels, the malleoli and the sacrum. Pressure ulcers
significantly reduce quality of life and increase care costs, as well as the length of
hospital stay. Prevalence in Australian aged care homes is between 3.4 and 5.4%.
Most pressure ulcers are preventable adverse events.
Prevention
Risk assessment involves examination of the skin, nutritional and general medical
assessment to identify risk factors, and use of a risk assessment tool. Major risk
factors are immobility, sensory loss, impaired cognitive state, urinary and faecal
incontinence, age over 65 years, chronic illness, poor nutritional status, impaired
oxygen delivery to tissues, raised skin temperature, skin dryness and the presence
of pressure, shear or friction forces.
The most commonly used risk assessment tools are the Norton Scale, the Braden
Score, and the Waterlow Risk Assessment.
The Norton Scale is designed to identify the need for preventive pressure care in
older hospital patients/clients and aged care home residents. Each of the five items
is scored from 1 to 4, with a maximum total score of 20. Scores of 14 or less rate the
resident as 'at risk' of developing pressure sores, the lower the score, the greater the
risk. Validity and reliability range from poor to good.
The Norton Scale
Physical
condition
Mental
condition
Activity Mobility Incontinence
Good 4 Alert 4 Ambulant 4 Full 4 Not 4
Fair 3 Apathetic 3 Walk help 3 Slightly limited
3
Occasional 3
Poor 2 Confused 2 Chair bound 2 Very limited 2 Usually/urine 2
Very bad 1 Stupor 1 Bed 1 Immobile 1 Doubly 1
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Preventive strategies to reduce risk factors can be incorporated into care plans for
residents identified as ‘at risk'. Consider
- daily inspection of all pressure points
- protection of skin - routine inspection, moisturisers for dry skin, protect from
moisture (treat incontinence), avoid harsh cleansers
- pressure relieving interventions and devices - pressure relieving positions,
turning schedules, repositioning intervals, reducing contact between bony
prominences and support surfaces, lifting devices and aids, low pressure
support surface for 'at risk' residents, dynamic support surface for high risk
residents
- optimise nutrition and hydration - adequate protein and caloric intake, zinc,
vitamins.
Assessment and management
The ulcer should be assessed and documented daily, based on the depth of tissue
destruction. Stages of pressure ulcer are defined as
Stage 1 - observable pressure related alteration(s) of intact skin whose indicators,
as compared to the adjacent or opposite areas of the body, may include changes in
one or more of the following: skin temperature (warmth or coolness), tissue
consistency (firm or boggy feel) and/or sensation (pain/itching). The ulcer appears as
a defined area of persistent redness if skin is lightly pigmented. In darker skin tones,
the ulcer may appear with persistent red, blue and purple hues
Stage 2 - partial thickness skin loss involving epidermis and/or dermis. The pressure
ulcer is superficial and presents clinically as an abrasion, blister or shallow crater
Stage 3 - full thickness skin loss involving damage or necrosis of subcutaneous
tissue that may extend down to, but not through, underlying fascia. The ulcer
presents clinically as a deep crater with or without undermining of the adjacent tissue
Stage 4 - full thickness skin loss with extensive destruction, tissue necrosis or
damage to muscle, bone or supporting structures (eg. tendon or joint capsule).
Undermining and sinus tracts may also be associated with stage 4 pressure ulcers.
Wound cultures are not indicated unless there is evidence of surrounding cellulitis or
bacteremia. X-rays or bone scans may be indicated to diagnose osteomyelitis in
deep non healing ulcers.229
The differential diagnosis for pressure ulcers includes venous stasis and arterial
ulcers, cancers, traumatic ulcers, neuropathic and infective ulcers, vasculitides and
other skin conditions.
Characteristics by ulcer type for arterial, diabetic, pressure and venous ulcers.
Arterial Diabetic Pressure Venous
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Location Tips of toes or
between toes,
on pressure
points of foot
(eg. heel or
lateral foot), or
in areas of
trauma
Plantar surface
of foot,
especially over
metatarsal
heads, toes,
and heel
Over bony
prominences
(eg. trochanter,
coccyx, ankle)
Gaiter area,
particularly
medial
malleolus
Size and
shape
Small craters
with well
defined
borders
Even wound
margins with
callus
Variable length,
width, depth
depending on
stage (see
staging
system)
Edges may be
irregular with
depth limited to
dermis or
shallow
subcutaneous
tissue
Wound bed Pale or necrotic Granular tissue
unless PAD
present
Varies from
brighter red,
shallow crater
to deeper
crater with
slough and
necrotice
tissue;
tunnelling and
undermining
Ruddy red,
yellow slough
may be present
; undermining
or tunnelling
common
Exudate Minimal
amount due to
poor blood flow
Variable
amount; serous
unless infection
present
Prulent,
becoming
serous as
healing
progressous;
foul odour with
infection
Copious,
serous unless
infection
present
Surrounding
skin
Halo of
erythema or
slight
fluctuance
indicitive of
infection
Normal May be distinct,
diffuse, rolled
under;
erythema,
oedema,
induration if
infected
May appear
macerated,
cruster, or
scaling
Pain Cramping or
constant deep
aching
None, because
of neuropathy
Painful, unless
sensory
function
impaired
Variable, may
be severe,
aching, or
bursing in
character
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Treatment principles are to relieve pressure, promote ulcer healing, reduce risk
factors and optimise general health. Pressure ulcers should heal or show signs of
healing within 2-4 weeks. Provide adequate pain control, treat cellulitis, alleviate
pressure and minimise oedema. Wound cleansing, product selection, and
debridement of nonviable tissue (eschar, slough) depend on the stage of the ulcer.
Numerous dressing protocols are available (see guidelines for details)
- Stage 1 - protect and cover with transparent films, barrier creams, skin
sealants
- Stage 2 - hydrate, insulate and absorb consider transparent films, occlusive
wafers, hydrogels, foams
- Stage 3 - cleanse, prevent infection and promote granulation consider
calcium alginate, hypertonic saline, cavity foams, silver dressings, vacuum
assisted closure
- Stage 4 - as for stage 3 plus pack dead space.
Part A
Assessment Item: Literature Review
The following websites may assist with this assessment
http://www.woundsinternational.com/media/issues/115/files/content_79.pdf
http://www.awma.com.au/journal/past_issues.php
http://www.racgp.org.au/your-practice/guidelines/silverbook/common-clinical-
conditions/pressure-ulcers/
For this assignment please choose three professional quality articles on the
prevention and treatment of pressure areas. Refereed articles and/or guidelines from
the Australian Government and State Health Departments are also acceptable. The
articles or guidelines must be no more than five years old.
Information from Wikipedia or Google is NOT acceptable.
Please print the articles and submit them with your assignment.
The purpose of a literature review is to compare the research and opinions of
different authors and to draw your own conclusions. This is part of learning to read
critically and not just accept what someone else has written.
Once you have found your three articles read them and answer the following
questions:
1. What are the authors’ qualifications?
2. How many references did they use?
3. Do they generally agree on how to prevent pressure areas? If not how do
they differ?
4. What evidence do they use to support their claims?
5. Do they recommend a particular assessment tool such as the Waterlow or
Braden scales?
6. Do the articles discuss the importance of client and family participation?
7. Do the articles discuss the importance of a holistic, primary health and
interdisciplinary approach to wound care?
8. Do the articles discuss strategies to minimise cross-infection.
9. Do the articles use the nursing process to assess, diagnose, plan, implement
and evaluate wound care?
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10. Do the articles discuss wound management strategies for complex and
challenging wounds?
11. Do the articles discuss the impacts of wounds on the client and families or
carers?
12. Do the articles discuss a cost effective framework for wound care
13. Do the articles provide recommendations or suggestions for individualised
plan of care for the person with a complex or challenging wound?
By drawing on the evidence from all three articles list
 Six different risk factors, using a holistic model, that increase the chance of
developing a pressure area giving the reasons for each.
 What are the most common areas, and why, for a pressure area to develop
in aged care residents.
 The best ways to prevent pressure ulcers forming under the headings of :
 Risk assessment
 Wound care
 Pressure reduction / repositioning
 Education including clients, families and carers
Overall word count should be 1,000 words.
Answer:
Literature Review on Journal 1
The authors McInnes et al. (2015) have completed their doctorate from the London
School of Hygiene and Tropical Medicine. The references that they used are
approximately 50 that mostly included published data by diverse authors. The
authors generally agreed on how to prevent pressure areas as they largely reflected
on systematic objectives that illustrated the effectiveness of diverse pressure-
relieving surfaces. The evidence mostly included the importance to carry out the
review that illustrated about health care professionals and the way they tried to
diminish the critical pressure. The studies that reflected on the types of interventions
have also been regarded as an evidence in the journal. The article states about
Waterlow scales that shows that patients without exiting a pressure are put under
high risk. The article do not discuss about client and family participants to wound
care. The article reflects on the methods that shows how to deal with cross-infection
in immobile patients. It does not use the nursing procedure however, it illustrates
about the nursing methods thus involving nursing participants. The article discusses
about prevention strategies as well as search strategies that has helped to recognize
randomised trials in ulcer. The effects on intervention have been illustrated in the
article that discusses the impact of wounds on the family members. It discusses
about cost effective framework for wound care from the viewpoint of the UK NHS
and Personal Social Service. The article provides implications about practice as well
as for research. It has been recommended to initiate valid as well as reliable
detecting methods that will act as predictive of pressure ulcer development.
Literature Review on Journal 1
The authors Clark et al. (2014) have completed their research from the college of
nursing. Some of them have been a part of the Wound Healing Practice
Development Unit whereas; some are part of the wound care team. The total
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number of references that are used in the article is 31. The article agrees on the
prevention pressure areas as it has introduced three studies that has examined the
role of prophylactic dressings. This has aimed to protect the nose from coming in
contact with medical devices. The evidences that has been used to support the claim
includes a table that reflects on the comparison that are made between ten studies
between the pressure uclears. The article provides an overview about the outliers of
the Braden scale. The article does not illustrate about client participants however, it
has included data on participants while illustrating about data extraction as well as
summarizing about major quality indicators. The article provides a holistic approach
to wound care that has helped to accomplish modification of applied mechanical
loads. The article lacks the strategies that help to reduce the overall cross-infection.
The nursing procedure has been discussed that illustrates about prophylactic usage
of dressing. This has provided an introduction of dressing that is known to raise the
security of vulnerable anatomical sites. The article discusses about wound
management strategies that illustrates that it will help to change the local wound. It
also discusses about the impacts of wounds on the client and families that states
that ulcer prevention reduces pressure. The article provides an overview about costs
of pressure care areas thus reflecting on the average marginal cost of making use of
prophylactic dressings. The article provides recommendations for individualised care
plan stating that there is limited evidence that are of high quality thus linking
dressings to enhanced pressure prevention of ulcer. The article recommends that
there is a requirement to carry out comparative clinical studies. These studies reflect
on the diverse dressing types to examine the vitro performance between dressings.
Literature Review on Journal 3
The authors Gilligan et al. (2017) have completed their studies based on how to treat
pressure ulcers. This has helped them to treat ulcer patients more rapidly with the
help of medicinal honey. They have been trained to deal with real-world data that are
collected by the outpatient department care setting in a hospital. The total number of
references that have been used are 44 that includes both books and journals. The
objective of the article has been to make a comparison of enzymatic debridement
using by making use of clostridial collagenase ointment (CCO) with autolytic
debridement. This has been a part of using medicinal honey in the hospital
outpatient setting for providing treatment to pressure ulcers. The evidences that has
been used includes the results that has been collected from approximately five
hundred seventeen CCO treated patients. It has clearly reflected on the total visits
that are made by CCO patients. The article has also introduced an innovation part
that illustrates about PU patients. The article does not provide any recommendation
as such however; it clearly states that it is imperative to provide goals of the patients
to initiate a clinical decision. The article does not include either Waterlow or Barden
scale. The article states that pressure ulcers lead to substantial clinical economic
challenges that affect both the clients as well as their families. It provides a holistic
approach stating that has illustrated about showing recognized electronic health
records from the year 2007– 2013. The strategy that has been reflected in the article
is a multimodal care strategy that acts as an imperative part of the management.
This includes nutritional assessment, mobilization as well as body positioning. It
does not reflect on any nursing procedure however, it provides an overview about
healing procedure. The article illustrates about the substantial cost as well as
prevalence of high costs that differs considerably with the help of clinical setting. The
article recommends that medical history of a patient should not be restricted to their
visits or a particular provider.
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References
Clark, M., Black, J., Alves, P., Brindle, C.T., Call, E., Dealey, C. and Santamaria, N.,
2014. Systematic review of the use of prophylactic dressings in the prevention of
pressure ulcers. International Wound Journal, 11(5), pp.460-471.
Gilligan, A.M., Waycaster, C.R., Bizier, R., Chu, B.C., Carter, M.J. and Fife, C.E.,
2017. Comparative effectiveness of clostridial collagenase ointment to medicinal
honey for treatment of pressure ulcers. Advances in wound care, 6(4), pp.125-134.
McInnes, E., Jammali‐Blasi, A., Bell‐Syer, S.E., Dumville, J.C., Middleton, V. and
Cullum, N., 2015. Support surfaces for pressure ulcer prevention. Cochrane
Database of Systematic Reviews, 8(9), pp. 89-110.
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Part B
Clinical Competency Demonstration of the ability to effectively and safely manage a
simple wound for a single client/patient.
The management of a client/patient requiring wound care will be conducted in the
nursing home under supervision of a Registered Nurse. You will be allocated a time
to complete this assessment. Before undertaking this assessment you will be
provided with formative assessment in the nursing laboratory. You must be deemed
competent in the nursing laboratory before you are able to undertake this
assessment on a resident.
Planning Comments
1. Identifies specific indications for
contact / communication / action with
the client/patient (i.e. are there any
specific orders?).
2. Verifies the validity of any written
orders to provide appropriate wound
management.
3. Reviews the client/patient
documentation / history / information
/ medication chart /
communication(s) from members of
the multidisciplinary team and
considers the evidence.
4. Effectively and in a timely manner
washes hands.
5. Gathers the necessary equipment
- Clean and sterile gloves, apron,
goggles (PPE)
- Sterile scissors and/or
clip/staple/stitch remover, sharps
container
- Dressing pack, required dressing
materials
- Appropriate solutions if necessary
- Other:
Specify______________________
___________________________
_
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Implementation
6. Evidence of therapeutic interactions;
e.g. gives client/patient a clear
explanation regarding the
management of the wound
7. Undertakes assessment of the
situation identifying that it is
appropriate to manage the wound
‘this way’ in the circumstances e.g.
that it is required/considers any
medication (analgesia) or any vital
sign or other assessments required.
8. Maintains dignity, provides privacy,
pain relief and other comfort
measures – displays problem
solving abilities
9. Assists the client/patient to an
appropriate position as necessary
10. Put on PPE as required and washes
hands
11. Ensure client/patient is comfortable
and prepared
12. Put on clean disposable gloves and
remove the tape/bandage or ties
13. With gloved hand remove dressing
one layer at a time, taking care not
to disturb drains or tubes. Keep
soiled surface out of client/patients
eye line. If the dressing is ‘stuck’,
explain to the client/patient that you
will moisten the dressing so that it
comes free without any discomfort.
14. Observe any drainage e.g. amount /
character / consistency / colour /
odour
15. Remove PPE and Washes hands
16. If necessary cleans the wound
utilising appropriate solution(s) and
dresses the wound using appropriate
choice of dressing and fixation
17. Repositions client/patient and
maintains privacy dignity, ensures
comfort as far as possible
throughout and at that point
18. Concludes the interaction with the
client/patient by considerately
concluding the therapeutic
relationship
19. Cleans/tidies area; disposes of any
waste appropriately and as soon as
is practicable; removes gloves and
other PPE (as necessary).
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Recording and documenting
20. Reporting and Recording of relevant
information:
- Nursing Care
- Medication Chart
- Other if appropriate:
(e.g. particular assessment chart (wound)
and/or anticoagulant therapy chart) Specify
i.e. plan
Reflection
21. Demonstrates ability to reflect on the
activity and to link theory to practice
- Relates to decisions made
- Evidence utilised and
- Implications for planning of patient
care.
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The following website may assist with this assessment
http://www.citewrite.qut.edu.au/write/reflectivewriting.jsp
Reflection by Student: (Use Gibbs Reflective cycle or another model of reflection and
discuss how you would approach your practice differently or more effectively. Please
indicate the model you have used).
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Assessor Feedback
Student: _______________________________ Date: _______________
Assessor: ______________________________ Date: _______________
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