Wound Care: Introduction to Wound Care Answer Template

This article provides an answer template for Introduction to Wound Care. It covers an overview of wound healing, patient/wound assessment, types of wounds, and wound classification. The article also includes case studies and clinical decision-making frameworks for two patients. The patients' medical history, wound assessment, and treatment goals are discussed in detail.

Caboolture / Kilcoy Hospitals and Woodford Corrections Health Service
Acute Care Transition
Support Program
Introduction to Wound
Care Answer Template

Statement of Copyright
© THE STATE OF QUEENSLAND (QUEENSLAND HEALTH) 2019
Statement of Indemnity
Version Control
Authors
Developed by: Kylie Hillier, Nurse Educator Caboolture Hospital
Beth McCauley, Acting Nurse Educator, Royal Brisbane and Women’s
Hospital
Additional support and editing: Kerrie Coleman, Nurse Practitioner, Skin Integrity Services, Royal Brisbane
and Women’s Hospital
Acute Care Transition Support Program Editorial Group

Unit 1 – Overview of Wound Healing
Modes of Wound Healing
Activity 1
1.1. Discuss and document the different types of wounds that would be
classified as healing by primary intention, delayed primary intention
and secondary intention.
1.2. Select two patients in your care that suit the following requirements:
 Patient One: Requires a dressing to a wound that is healing by primary
intention.
Patient 1 : patient 1 is male and 52 years old and he is suffering from the
hypertension from last few year. He has a surgical wound on right hand which
becomes now a ulcer.
 Patient Two: Requires a dressing to a wound that is healing by
delayed primary intention or secondary intention.
Patient 2 is male and he is 60 years old. He is also suffering from
diabetes since last several years. He has backbone surgical wound on
his back due to road accident which takes long time to cure.
1.3. Complete Appendix 1, Section One for each patient: Identify and
justify the phase of wound healing that applies to your patient’s wound.
1.4. Complete Appendix 1, Section Two for each patient: Identify and
justify the mode of healing that applies to your patient’s wound.
If access to your allocated patients is limited, or they have been discharged after your
initial assessment, you may draw from past experience or the literature to inform your
case study.
1.1Type answers here
There are two kinds of wounds and are classified on the basis of nature of the wound. The two
kinds of wounds are mentioned below-
 Acute wound – it is a type of surgical wound which heals by primary intention. The
traumatic wound heals by secondary intention also comes under acute wounds. It is
caused by trauma and causes damage in tissue. The causes of acute wounds include
heat, electricity, friction, chemical exposure, projectiles and blunt force. Acute wounds do
not need any kind of surgery it can be managed by normal healing and this normal healing
causes closure of wound.
 Chronic wound – it is developed when the healing processes don not cause recovery. It
is defined as the wound that is not recovered by the normal healing process. It get stuck in
the inflammation phase. It is caused by poor blood circulation or due to weak immune
system. It develops due to disruption in the normal wound healing cycle. A chronic wound
may be infectious, ischemic, surgical and radiation poisoning.

1.3 and 1.4 Type answers here
PATIENT: 1

PATIENT: 2
 Include
subjective/objective data
SECTION ONE
Identify and justify the
phase of wound healing
that applies to your
patient’s wound. List anyInflammation □ Justify your assessment: In case of patient 2 Requires a dressing to
a wound that is healing by delayed primary intention or secondary
intention. Patient feel pain and marked redness as well just after the
injury .
Reconstruction
and Regeneration
□ Reconstruction and regeneration process is a healing process in formation
of new tissue occurs but in case of my patient this process is too slow.
Maturation □ In patient 2, at maturation stage the wound was completely closed as the
collagen in the skin is remolded. The collagen are responsible for the
reconstruction of the skin and the skin becomes uneven and thick.
SECTION TWO
Identify and justify the mode
of healing that applies to
Primary Intention □ Justify your assessment:
Delayed Primary
Intention
□
Secondary
intention
□ Patient's wound left open. The wound is left for healing process. The wound
is allowed for healing, filling and closing up naturally. The patient was
treated with regular dressing to the area of injury and after six weeks she
got recovered.

Unit 2 – Patient/Wound Assessment
Introduction
Activity 2
2.1 Complete Appendix 1 – Section Three for each patient: Discuss with
your patient their reason for admission and aetiology of their wound.
Document your findings.
2.2 Complete Appendix 1 – Section Four for each patient: List the specific factors
that may affect the tissue integrity and wound healing of each patient.
PATIENT: 1
 Include
subjective/objective data
Patient 1 is a 52 years old male .
Who is suffering with
hypertension and also suffering
from the the surgical wound on
his back. Since his wound now
become a ulcer so he required a
good treatment and for this
SECTION THREE
Discuss the reason for
admission with each
patient and the aetiology ofWounds are commonly occurred
due to injury. In case of patient 1
the injury was cause by a minor
accident in which his right hand
gets some cut and scar which
Requires a dressing to a wound
that is healing by primary
intention. in case of patient 2 the
back bone injury caused due to
road accident.
SECTION FOUR
List the specific factors
that may affect the tissue
integrity and wound
Factors: Justification:
Age of the patient My patient was fifty two years old. The older age people have delayed
wound healing where as in young ones healing process takes place rapidly.
In older age people the inflammation response gets decreased.

Type of wound In patient 1 wound was caused due to road accident and it heals rapidly
because it the minor surgery on his right hand . Types of wound also affect
the speed of recovery. Larger and severe wound takes time for healing
where as wounds caused by small cut or injury heal faster. Circular wound
heals slowest and linear wounds heal faster.
Infection Skin breaks causes bacteria enter into the skin specially at the site of the
injury. My patient's injury was completely covered so the chances of
bacterial infection is negligible.
Chronic diseases My patient was also suffering from diabetes so the healing process got
delayed .
Poor nutrition patient was not taking the diet properly and this made healing delayed.
PATIENT: 2
 Include
subjective/objective data
SECTION THREE
Discuss the reason for
admission with each
patient and the aetiology ofIn case of patient 2 the back injury
caused due to road accident by
motorcycle. Due to road accident
the surgical wound is deeper and
severe and it is left open to heal
by itself.
SECTION FOUR
List the specific factors
that may affect the tissue
integrity and wound
Factors: Justification:

Age factor Patient 2 was younger and healing becomes easier in younger ones as the
inflammation response is faster.
Poor nutrition As my patient was eating oily and sugary food so wound developed pus and
started paining.
Type of wound As the patient met with road accident the injury was severe and so the
healing may take time.
Infection In case of patient 2 the wound left to heal by itself so there is possibility of
bacterial infection
Chronic disease As patient was healthy there was nothing to worry
Activity 3 3.1 Review the Wound Management Procedure and Wound Management/Assessment
Tool/Pathway for your facility. Discuss the procedure and the tool with your
Preceptor/CN/CF/NE/CNC/NUM. Does your facility have a dedicated wound
management/skin integrity team? If so, review and document their role within the
organisation.
3.1 Complete Appendix 2 for each patient: Undertake a review of each patient and
their medical history and complete the Clinical Decision Making Framework.
PATIENT: 1
Objective Data
Vital Signs: Patient’s Observations
Heart Rate 120 beats per minute
Respiratory Rate 19 breaths per minute
Blood Pressure 90/80 mmHg
Temperature 35 degree Celsius
Oxygen Saturations 92.00%
Relevant
Laboratory/D
Test Results

WBC test: patient WBC count- 3500
normal WBC count- 4500 to
Cholesterol test: patient HDL level- 140
mg/dL
Sugar level: patient glucose level- 130 mg/dL
normal glucose level- 100 mg/dL
Subjective Data Patient one is suffering from hypertension
and a accidental wound on his right hand.
Pain Assessment Pain score of patient 1 is 4 /10 on pain scale.
He feel pain in only surrounding to the
wound and no itching around his wound.
Wound Assessment There are minor cut on patient right hand
from which a liquid exudates ooze out.
Patient/Relative/Carer Reports Patient 1 is suffering from hypertension.
Any additional relevant assessment
data
No
PATIENT: 2
Objective Data
Vital Signs: Patient’s
Observations
Normal Parameters
for patients age
Heart Rate 95 beats per minute 100 beats per minute
Respiratory Rate 18 breaths per minute 20 breaths per minute
Blood Pressure 110/70 mmHg 120/80 mmHg
Temperature 35 degree Celsius 37 degree Celsius
Oxygen Saturations 95.00% 95.00% 95.00%
Relevant Laboratory/Diagnostic Tests
Test Results Normal Parameters
for patients age
WBC test: patient WBC count- 4200
normal WBC count- 4500 to 11000
Cholesterol test: patient HDL level- 132mg/dL
normal HDL level – less than 130 mg/dL

Sugar level: patient glucose level- 95mg/dL
normal glucose level- 100 mg/dL
Subjective Data
Pain Assessment Pain score of the patient 2
is 8/10 which is a severe
type of pain .
Wound Assessment There was a surgical
wound on his back which
is now become ulcer. And
yellow liquid ooze out
from his wound.
Patient/Relative/
Carer Reports
He is diabetic.
Any additional
relevant assessment
data
no
3.2 Identify and document the treatment and management goals for your patients from the
assessment data that you have collected in the Clinical Decision Making Framework. Justify
your treatment and management goals.
ANS:-For patient 1 and patient 2, the treatment and management goal is healing of wound
and reducing the pain. Since patient is suffering from the highly infected wound due to this he
face the problem of high fever, low blood pressure, high heart rate rhythm, and low
respiratory rate. Patient is also suffering from the pain (lim 2020). Since patient is suffering
from the high fever therefore he needs some anti-pyratic medicine to reduce their body
temperature. They should also give to some anti analgesic drugs which reduce the pain of
patient and provide some antibiotics which reduce the bacterial growth in the wound of patient
and help to heal the wound of patient (Gil, 2020).
Types of Wounds
Activity 4

4.1 Based on your reading, complete the Wound Classification table. If the Wound
Management/Assessment Tool/Pathway at your facility has different/more
descriptive sections, then please include them.
Table 1 - Wound Classification
Clinical Appearance Description
Granulation A granulation tissue which is healthy is pink or red in color, which is
a good indicator of healing. Unhealthy granulation is dusky red, dark,
bleeds easily and may indicates the presence of wound infection.
Epithelialisation It is the final phase of proliferation stage of wound healing, or
epithelial cells resurface or injury.
Slough It refers to white or yellow material in the wound bed. It is generally
wet but may be dry. Consist dead cells which accumulate in the
wound exudation.
Necrosis There are different types of necrotic tissue which is present in the
form of eschar and slough. Slough is characterized as being tan,
green, yellow or brown colour which may be loose, moist and stringy
in appearance. Eschar presents as thick, dry leathery tissue which is
Hypergranulation Excess granulation is also known as proud flesh or hypergranulation.
The wound tissue will evident above the normal bed of wound. It is
generally friable and bleeds.

Exudate Type
Serous Any semisolid fluid which has oozed out of a damaged tissue or its
capillaries, it is very specifically because it is characterized by high
protein and the white blood cells. It is secreted through the inflamed
Haemoserous It is the type of drainage of watery, pink colored fluid, drainage of a
thin composed of serum and blood. This kind of ooze of any wounds
Sanguineous Sanguineous exudate is the indication of trauma to blood vessels. A
bleeding which is fresh, seen in full thickness wound and in ddep
partial wound.
Purulent It is a opaque and thick exudate which is tan , green,yellow or brown
in color.
Haemopurulent It is Thin, watery and cloudy and yellow in color.
Wound Edge Description
Normal Indicate wound completely heal.
Colour Pink edges indicates growth of new tissue
Raised Indicate hyper-granulation.
Rolled Indicate hyper-granulation.
Contraction Coming together indicate healing process
Sensation Increased pain or absence of sensation lead further treatment.
Surrounding Skin Description
Erythema It indicates healing process occur. Redness process.

Oedematous Tissue with excess of interstitial fluid.
Macerated Soften the tissue indicates healing process.
Cellulitis It is common , serious ,potential bacterial skin infectious wounds.
Fragile/Thin Porous tissue which becomes permeable for exudates
Dry/Scaly Indicates wound healing process occur.
Dermatitis/Eczema It is broken tissue wound treated by the topical steroid.
Induration Abnormal hardening of tissue which is caused due to the
consolidation of the edema.
Skin Tears
Activity 5 5.1 Locate the STAR tool in your work area. Using the tool, categories the
following skin tears and describe their features.
thi
Category 1a
This is category 1a type skin tear where the edges of
wound can be realigned to the normal anatomical
position without undue stretching and the skin flap color
is not pale dusky or darkened.

Category 1b A skin tear where the edges can be realigned to
the normal anatomical position without undue
stretching and the skin or flap color is pale and
dusky or darkened.
Category 2b A skin tear where the edges can not be realigned
to the normal anatomical position and skin or flap
color is not pale dusky or darkened.
Category 2b A Skin tear where the edges can not be aligned to
the normal position and the skin flap color is pale,
dusky or darkened.
(Carville, 2017; Curtain University of Technology, 2010)
Skin Tear Management
Activity 6
6.1 Complete Table 3 and discuss how you wound manage the factors relating to skin tears.

Requirement Management Strategy
Haemostasis Blood pressure maintenance by the help of diuretics and anti
diuretics
Temperature regulation by anti pyretic drugs
Wound Cleaning Remove the dressing gently
reduce the contamination by washing the wound through antiseptic
liquid.
Preservation of the skin
flap if viable
Reduce contamination by anti septic
attached through the living tissue
Pain Management For reducing the pain gives some analgesic drugs.
Promote moist wound
healing
Uses of patches
by the use of moisturizer.
Dressing Use anti bacterial
use disinfectant
use sterile aqua protective dressing.

Prevent from further
injury
Use of some injury protective equipment like during motorcycle riding
helmet, knee flap cover, and so on.
Use antiseptic and anti microbial agent.
Documentation Note all the medical history.
Note patient medical requirement and tests.

Pressure Injuries
Activity 7
7.1 Using the pressure injury staging system at your health care facility, categorise the pressure
injuries in Table 4 and describe their features.
7.2 Identify and justify at least five (5) prevention strategies that you can implement to prevent your
patients from acquiring a pressure injury. Document your answer.
Table 4 - Pressure Injury Staging
Stage Description
Stage 1 Intact skin in a local area of non-blanch able
redness that is erythema. Changes in
sensation and temperature (Newbern, 2018).
Stage 2 Loss of skin with exposed dermis with partial
thickness. Rapture serum blister occur.
Deeper tissue and fat not visible (Tehan, & et.
al., 2020).
Stage 3 Loss of skin with full thickness. Eschar or
slough may be visible.
Stage 4 Full thickness tissue and skin loss. Eschar
and slough may be visible.

Stage 5 Deeper tissue injury. Revealing a dark
wound bed or blood-filler blister.
Normal dark
wound
Indicate only superficial dark skin.
Sore Lip sore it is blister. Or sore in mouth.
7.2
Prevention strategies may include:
prevention strategy may include to use anti microbial agent or take use topical antiseptic agent for
the wound. There are several strategies through which wound may be prevented as like:
 avoiding the hot water, sharp objects fire and hazards (Price, & et. al., 2021)(.
 Checking the body sores at regular interval.
 Losing the body weight if any overweight.
 Managing the health conditions.
 Being as active as much as possible.
 Eating the healthy diet.
 Quitting the smoking (Hess, 2020).
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Incontinence Associated Dermatitis
Activity 8
8.1 Read the document Incontinence-Associated Dermatitis: Moving
Prevention Forward (search for the reading using the search bar):
http://www.woundsinternational.com/media/other-
resources/_/1154/files/iad_web.pdf. Identify the key concepts relating to
recognising, preventing and managing IAD. Critically discuss how the
management strategies in the above reading relate, or differ, to those used in
your health care facility.
____________________________________________________________________________________
_____IAD that is incontinence-associate dermatitis is a kind of irritant contact dermatitis which is
associated with physical and chemical irritation of the barrier of skin, which subsequent skin damage and
provoking inflammation. Recognition of IAD is done through the assessment of skin, in which includes
clinical observation of signs and symptoms of IAD by visually examination of the area of skin which are
being unmasked to feces and urine. It is suggested to evaluate the skin of those all patients on daily basis
who is suffering from the lack of self control on fecal and urinary excretion. By the help of a barrier after all
incontinence episode can assist to terminate IAD (MOORE, & BAXTER, 2021). A complete pressure injury
termination program like together with a distinctive delivered skin protection to incontinence care and
decrease the occasion of buttock or sacral pressure injuries via 89%. The management of IAD should
necessarily concentrate on cleansing of skin and remove the debris, microorganism and irritant. Use skin
moisturizer to augment or repair the barriers of skin, enhancing or retaining the content of water,
decreasing the water loss through trans-epidermal route and improve or restore the lipid structure inter-
cellular. The insufficiency of corresponding between cost effectiveness of products and procedures and
study about efficacy complex standardization of IAD management. The management strategies used in
the above discussion is totally related to those which is usually related to the healthcare system because
in health care system health carer also applied skin moisturizer to prevent the pressure injuries, water
retention and enhancing the capacity of water. They use barrier to remove the IAD (Oropallo, & et. al.,
2022).
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Unit 3 – Wound Management
Infection Control
Activity 9
9.1 Visit the Hand Hygiene Australia website https://www.hha.org.au/hand- hygiene/5-moments-
for-hand-hygiene. Complete the 5 Moments for Hand Hygiene in Figure 1 and identify when
you would need to complete each moment when attending to your patients’ wound care
needs.
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_ANS:- Moment:1- Before touching a patient.
Moment:2- Before starting the procedures.
Moment:3- After a procedures or body fluid exposure risk.
Moment:4- After touching a patient.
Moment:5- After touching the surroundings of a patient.
Moment 1 should be done to protect the patient from the harmful germs in the hands of healthcare worker.
it should be done at the time of touching a patient in different way like shaking hands, provide health
interventions, any medical device touching which is connected to the patient like IDC, IV pump and so on.
Any personal care activities like dressing, bathing, brushing, and personal aid. At the time of taking pulse,
applying an oxygen mask, measuring blood pressure, oral medications, feeding a patient, brushing teeth
and so on.
Moment 2: once the hand hygiene has been done than nothing should be touched in the parent's
environment before starting the procedure. It has been done to protect the patient from the infection occur
through the pathogen. It should be done at the time of vein's puncture, arterial blood gas, IV flush, PEG
feeds, IV medications, eye drop instillation, suppository insertion, vaginal pessary, wound dressing,
surgical procedures and so on (Thomas, & Sreenivasan, 2022).
Moment 3: it should be done immediately after the body fluid exposure risk or a procedure. It has been
done to protect the healthcare giver or the surroundings of health care from the contamination with
different types of pathogen. It should be done after contact with a used urinary bottle, contact with
pathology samples, cleaning spills of urine, feces or vomit from patient surroundings, contact with blood
saliva, semen, wax, breast milk, tears, mucous, and so on.
Moment 4: It should be done after touching a patient. Hand sensitization should be done before leaving
the patient zone. Because it provide assist to protect the healthcare provider and the surroundings of
healthcare from the contamination of potential pathogens.
Moment5: It should be done after touching the surrounding of patient however patient has not been
touched by the carer . Always do hand hygiene before leaving the patient's room. It has been done to
prevent the contamination for health worker or their surroundings.
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9.2 Visit the ANTT website http://antt.org/ANTT_Site/what_is_ANTT.html and locate the ANTT
Clinical Practice Framework (available via the What is ANTT? Tab). Identify if your facility
has a procedure relating to hand hygiene and ANTT. If so, please read it. Review the
framework and discuss the application of the framework to your practice in wound care
management with your Preceptor/CN/CF/NE/CNC/NUM. Document your findings
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______ANS: In the practice of wound care management, healthcare firm desiring to ensure safe aseptic
practice regularly, therefore they use the frame work named ' the 4 C's' that is clarity, concern, compliance
and competence. ANTT use to interchangeable paradigm and conflicting, of sterile,aseptic,non touch and
clean technique or more other term for patient safety. The ANTT framework is intended and design for all
the invasive procedures which occur in clinic and medical device maintenance. The main goal of practice
of wound care management is to make healing process faster and free from microorganism (Goorani, & et.
al., 2019).
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Diagnosing Infection
Activity 10
10.1 Complete the table below and identify five (5) signs of wound infection that
may be found in acute or chronic wounds. Identify the subjective and objective
signs and symptoms that you would expect to find.
Table 5 - Signs of Wound Infection
Sign Description
Fever It is very common sign and symptoms for wound. If the fever goes to 101
degree Fahrenheit or above and it persist throughout the long time period
then it indicates the possible wound infection. The high fever works as
indicator for wound infection and need to be treated at the earlier stage.Inflammati
on
Swelling is the normal sign of beginning stage of wound healing. Swelling
should be decrease continuously on the healing of wound. If it swelling is
persistent the it is the sign of further wound infection. Inflammation is a quick
response of the body just after the injury.Redness Due to natural inflammatory process of healing, site of wound appear slightly
red. If red is deeper and for long time then it indicates worsen and expanding
condition of wound. Redness marked on the site of injury is also a sudden
reaction of the body just after the injuryHeating Surrounding area of wound generally seems warmer than other normal area.
When body reacts against the pathogens then the surrounding are of
wounds become warmer.
Pain If any wound is occur then due to damage of tissue patient feel pain around
the wounds. Pain occurs in the area of wound due to the secretion of an
Autocoid from the invective are named as Prostaglandin.

Wound Debridement
Activity 11
11.1 Identify the scope of practice in relation to RNs and RMs performing tissue
debridement in your facility. Does your facility implement other methods of debridement
that are not listed in the table below? If so, identify these. Document your findings.
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______I
________ANS:- Debridement is an important part for wound healing or wound management. Every
practitioner have to aware to the available range of option. Debridement is the process of removal of
non-viable tissue from the wound bed for enhancing the wound healing process. Since chronic
wounds are suffering from lots of bacteria so they create barrier to healing process of wound. The
availability of nutrient, oxygen make ideal environment for growth of aerobic or anaerobic bacteria.
There are several Method of debridement in the facility which is Autolytic, hydosurgical, mechanical,
sharp, surgical, ultrasonic and so on. In the facility debridement should be done by the professional
nurses, doctors, and the health carer. No, facility does not implement other methods of debridement.
All the methods of debridement which is used in facility are given in the table (Kielo, & et. al., 2019).
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Table 6 - Methods of Debridement
Type &
Description
Advantages Considerations Relative
Contraindications

Surgical
Debridement
 It is very
fast .
 It required
highly
skilled
health
worker.
 It is
applicable
for the
infected
 Manage biofilm
 remove non-viable
tissue.
 Contradicted in
diabetic patient.
Conservative Sharp
Wound
Debridement
 No blood
loss.
 By sterile
instrumen
t.
 Removal of non viable
tissue.
 Scissors to create clean
wound bed.
 Patient with an
intact eschar an no
any clinical
evidence for
infection.
Enzymatic
Debridement
 It is very
easy to
perform.
 It is highly
selective.
 Application of biological
enzyme.
 Selective attacks non-
viable tissue.
 Not use in heavily
infected wounds.
Autolytic
Debridement
 Easy to
perform.
 it is
natural.
 It is
painless.
 It works
as
antimicro
bial
agent.
 Use body own enzyme.
 Enzyme liquefy the non
viable tissue.
 Contradicted in
poor perfusion and
stable, intact
eschar and dry.
 Sometime it leaves
strain on skin
Mechanical
Debridement
 Easy to
perform.
 Faster
than
autolytic
and
enzymatic
.
 Remove both
devitalized tissue, and
debris tissue.
It is contradicted in older
age people.

Other: NO No No No

Biofilm
Activity 12
12.1 Read the document Biofilms Made Easy (search for the reading using the
search bar):
http://www.woundsinternational.com/media/issues/288/files/content_8851.pdf.
Document the key concepts relating to biofilms and wound management.
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___biofilm is a thin layer of bacteria and other microorganism that cover different surfaces. Any
microorganism stick to the surface of skin and if skin is moist it starts to reproduce causes bacterial
infection. Three steps involved in the formation of biofilm includes attachment, maturation and
dispersion. The microorganism adhere to the surface and it get adhere by a glue like substance.
Preventing reconstitution with anti-biofilm agents, selective biocides and antibiotics. Biofilm causes low
grade inflammatory response and thus works as a barrier while wound healing. Biofilm is made up of
complex strains of microbes, algae, fungi and bacteria. Sharp debridement is used for removing
biofilms. Wounds where acute debridement does not work, mono filament debridement pads are used.
Removal of biofilm includes administration of well penetrating and appropriate antibiotics. PHMB is
used as antimicrobial agent while dressings against biofilms microorganisms to prevent reconstruction
of bactericidal agent. Other antimicrobial agents used are acetic acid, honey, silver and iodine.
Commonly, removal of colonized or surgical excision of infected tissue is the way to treat biofilms. The
outcome and management of patient is affected by the potential of biofilm microorganism to withstand
antibiotics. Biofilm gives a negative impact on wound healing as it contributes to bacterial infection and
inflammation and thus wound healing is delayed. The biofilm allows bacteria to respond to other
bacteria and then it causes delayed wound healing. In wound care management, it is becoming a
priority to manage the biofilm in chronic wounds (Watanabe, & et. al., 2021, November).
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Moisture Balance and Exudate
Activity 13
13.1 Refer back to Wound Classification Table (Activity 4). Review your
previous answers. Has your previous assessment included all
components of the integrated exudate assessment? If not, identify how
your assessment now differs. Justify your reasoning for these differences.
Document your answer.
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____Granulation-A granulation tissue which is healthy is pink or red in color, which is a good indicator
of healing. Unhealthy granulation is dusky red, dark, bleeds easily and may indicates the presence of
wound infection.
Epithelialisation -It is the final phase of proliferation stage of wound healing, or epithelial cells
resurface or injury.
Slough- It refers to white or yellow material in the wound bed. It is generally wet but may be dry.
Consist dead cells which accumulate in the wound exudation.
Necrosis- There are different types of necrotic tissue which is present in the form of es char and
slough. Slough is characterized as being tan, green, yellow or brown color which may be loose, moist
and stringy in appearance. Escher presents as thick, dry leathery tissue which is usually tan.
Hyper granulation- Excess granulation is also known as proud flesh or hyper granulation. The wound
tissue will evident above the normal bed of wound. It is generally friable and bleeds.
I reviwed the classification of wounds and mentioned above. I found my previous assessment
included all components of the integrated exudation
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Periwound Management
Activity 14
14.1 Review the periwound protection products that your facility
uses. Identify the most commonly used product and list the
advantages and disadvantages.
Product

1) Doliosis D50
wound aid
drops
2) med pride
hydro colloid
dressing
3) aqua protective
dressing
4) sterile gamjee
roll
It protects skin and
prevent further
microbial infection in
skin.
It forms protective layer
on skin and inhibits the
entry of microbes in
skin.
It entraps moisture and
gives speedy recovery.
It isolates the wound.
Microbial infection is
prevented and healing
process gets easier. It
helps to deal with biofilm
management and
prevent the rapid growth
of microorganisms.
Adherents used in such
products leaves strain on
skin and can give
discomfort to the patient.
The dressing can cause
skin inflammation and
itching. In some cases the
dressing may cause
infection too if left open.
Pain Management
Activity 15
15.1 Review the medication charts of your two selected patients
from Appendix One and complete Appendix Three. Discuss
two analgesic medications per patient.
PATIENT: 1
Wound Type Acute □ Chronic □
Pain Scale 1-10/10: Pain Description:
Medication 1: Class: Mechanism of
Action:
Dose, Route, Time &
Frequency:
Side Effects: Nursing Implications:
Paracetamol Antipyratic
and
analgesic
Inhibits
prostagflandins
synthesis.
morning and evening. Drowsiness,
sedative
Give the patient after some
meal because it can upset
the stomach. Check patient
allergy state.
Justify why is this analgesia is suitable for your patient based on their wound:
patient 1 is suffering from the wound in which there is no tissue loss because it is treated by the primary intention of
wound care therefore, he is treated through the stretching process. Since patient's 1 wound showing some
inflammation and pain due tho the release of prostaglandin so, by the help of paracetamol synthesis of
prostaglandin can be inhibited and provide some relieve from the the inflammation and pain.
Medication 2: Class: Mechanism of
Action:
Dose, Route, Time &
Frequency:
Side Effects: Nursing Implications:

Ibuprofen NSAIDs It is non-
selective
inhibitor of
cyclooxygenase
that is cox
enzyme, which is
400mg, oral route,
every four to six hour,
thrice a day.
Feeling dizzy,
headaches,
indigestion, being
sick,constipation.
The patient's liver and renal
assessment should be done
before taking this
medication.
Justify why is this analgesia is suitable for your patient based on their wound:
patient 1 is suffering from the wound in which there is no tissue loss because it is treated by the primary intention of
wound care therefore, he is treated through the stretching process. Since patient's 1 wound showing some
inflammation and pain due tho the release of prostaglandin so, by the help of ibuprofen, synthesis of prostaglandin
can be inhibited by blocking of COX enzyme and provide some relieve from the the inflammation and pain.
PATIENT: 2
Wound Type Acute □ Chronic □
Pain Scale 1-10/10: Pain Description:
Medication 1: Class: Mechanism of
Action:
Dose, Route, Time &
Frequency:
Side Effects: Nursing Implications:
paracetamol
acetamino
phen.
Acetaminophen
block the actions
of that enzyme
which sens the
signals or
chemicals named
as
prostaglandins
500 mg, twice a day,
oral route, morning and
evening.
Drowsiness and
sedative action.
Temporary use only, should
not be given more than 6-7
days regularly.
Justify why is this analgesia is suitable for your patient based on their wound:
acetaminophen blocks the CNS signals and provide the relief from pain for more time period therefore this drug is
suitable for the patient 2 because patient 2 is suffering from a tissue loss wound and feel more pain than the patient
1.
Medication 2: Class: Mechanism of
Action:
Dose, Route, Time &
Frequency:
Side Effects: Nursing Implications:

Ibuprofen NSAIDs Inhibitors of
COX enzyme. It is
a non selective
inhibitor of this
enzyme
Oral, 300-500mg,
twice a day, in morning
or evening.
Constipation,
diarrhea, dizziness
drowsiness and so
on.
Be aware that patient
which may risked of GI
bleeding and risk of CV
event.
Justify why is this analgesia is suitable for your patient based on their wound:
patient 2 is suffering from that wound which has been treated with the late intervention means he is suffering from
tissue loss wound which takes lots of time for treating and feel pain for longer duration therefor patient 2 have to
take ibuprofen which inhibit the COX2 enzymes. And inhibits the production of prostaglandins which is responsible
for the signaling the pain to the central nervous system.
Unit 4 – Wound Dressings Evaluating a Wound Dressing
Activity 16 16.1 Complete Appendix Four. Identify and discuss the listed dressings.
Natural and Synthetic Fibre Dry Dressing
Description It is two types 1- gauze -based dressing and paste bandages like as
zinc paste bandages dressing.
Indication Burns, wounds healing by secondary intention.
Benefits Decreases adhesion to wound. It is moist environment aids healing.
Precautions/
Contraindications
Allergy
Products available
at my facility
Jelonet, sofra-tulle
(Carville, 2017)
Non-Adherent Dry or Film Coated Dressing

Description :- it is non-adherent plastic film which is dry thin perforated absorbenty pad.
Indication:- it is suitable for wound with moderate exudates.
Benefits:- it is low wound adherence. It may absorb the light exudates.
Precautions/:- do not use for dry wound.
Contraindications:- dry wound because it may cause tissue dehydration.
Products available at my facility:- melolin, tricose, and melolite

Island Dressing
Description Consist of a non-woven sterile adhesive backing with an adsorbent
wound pad which gives a bacterial proof and water resistant.
Indication It is primary and secondary dressing.
Benefits It is effective water barrier which gives permission for showering and
bathing.
Precautions/
Contraindications
Patient with a hypersensitivity for the components of product or product
itself.
Products available
at my facility
Veeba thousand island dressing.
(Carville, 2017)
Super Absorbent Non-Adherent Dry Dressing
Description It is multi layer wound covers which is non adherent.
Indication Wound with less exudate.
Benefits Useful in flat wounds, sinuses, cavity and undermining wounds.
Precautions/
Contraindications
Dry wounds.
Products available
at my facility
Aquacel, versiva.
Tulle Gras Dressings
Description It id gauze impregnated with paraffin.
Indication Wounds healing by secondary intention and burns.

Benefits Reduces adhesion with wound.
Precautions/
Contraindications
allergy
Products available
at my facility
Sofra-tulle

Semi-Permeable Film Dressing
Description It is semi-permeable thin transparent
polyurethanefilm. Which thin and transparent.
Indication Superficial wounds.
Benefits Moisture evaporation occur. Reduce pain.
Provide barrier to external environment.
Precautions/ Highly exudatives wounds.
Contraindications Highly exudatives wounds.
Products available at my facility OpSite, Tegaderm.

Hydrocolloid Dressing
Description It is polyurethane film coated with adhesive.
Indication Small burns, abrasions.
Benefits Retains moisture, painless removal.
Precautions/
Contraindications
Dry wound infection.
Products available
at my facility
Duoderm.
Hydrogel Dressing
Description It is semi-occlusive and made up of complex hydrophillic polymer.
Indication Deep wound, minor burns, dermal ulcer and skin tears.
Benefits Keep sloughing or necrotic wounds clean or promote removal of pathogen.
Precautions/
Contraindications
Wound with heavy drainage, fragile peri- wound skin, infected wound.
Products available
at my facility
Synerheal collagen.

Alginate Dressing
Description It is natural calcium alginate dressing.
Indication Highly exudatives wounds or moderate wounds. It need for homeostasis.
Benefits It can forms gel on wound and create moist environment.
Precautions/
Contraindications
Hard eschar or dry wound.
Products available
at my facility
Kaltostat.
Polyurethane Foam Dressing
Description In this adhessive layer incorporated.
Indication Wound with moderate to mild exudate.
Benefits Protective ,moist and highly exudate.
Precautions/
Contraindications
Dry wound infection
Products available
at my facility
Polymem.

Negative Pressure Wound Therapy
Activity 17
17.1 Document the action, indications, benefits and considerations of
negative pressure wound therapy. Identify three (3) products used in your
facility.
ANS:- negative pressure wound therapy is a method in which occur drawing out infection and fluid from
the wound to help it for heal. There is the application of negative pressure therapy which is indicated for
chronic and acute wounds, and so it is to promote the diabetic foot wounds healing process, traumatic
wounds, pressure wounds, flaps and grafts partial thickness burns and dehisced surgical wounds.
Negative pressure wound therapy can be used for any size of wound like deep wound. Negative
pressure wound therapy which is used in the treatment of diabetic foot ulcer, is not indicated in infected
and ischemic wounds. Benefits for negative pressure wound therapy is Earlier hospital discharge, less
need for surgery, fewer wound dressing changes. It promote the healing of diabetic foots wound.
Product used in the facility is The PICO , polyurethane, polyvinyl alcohol foam (Gupta, & Pahuja, 2021,
October).
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Documentation
Activity 18
18.1 Locate your facility’s Wound Management/Assessment Tool/Pathway and
discuss the documentation requirements with your
Preceptor/CN/CF/NE/CNC/NUM
ANS:
_________ for assessment of the wound in the facilities there are following consideration should be
follow:

 like type of wound
 aetiology of wound
 kind of wounds.
 Clinical appearance of wound
 measurement and dimensions of wound.
 Wound edge and so on.
Management of wound means the guidelines for wound management, which are following:
1. promote multidisciplinary approach.
2. Initial patient wounds assessment
3. determine the goal of care.
4. Respect the fragile wound environment.
5. Follow the principle of managing wound.
Documentation: record patient history, name , given treatment and so on.
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18.2 Complete the Wound Management/Assessment Tool/Pathway for each of your patient’s
wounds and attach to this module. For the purpose of this exercise, de-identify the patient
on the tool to be submitted.
18.3 Develop a discharge plan for each of your patients based on your assessment data
collected throughout the module and attach it to this module. Consider: Interdisciplinary
involvement, dressing frequency and type, pain relief, who will attend to the dressing, patient
mobility and nutrition, compliance etc.
ans:- Discharging of the patient is process of giving relief from the acute hospitals which is
characterized through the range of patient needs and circumstances. In the process of discharging a
discharge plan is making for the patient in which no of things are included like the time period or
frequency of dressing. How much mobility should be necessary for the patient. Amount and type of
nutrition required for the patient pain relief medication and so on. Following instruction should be given
before descharging the patient like
1- take the antibiotic or analgesic drugs regularly for 5 days as the doctor suggested.
2- change the dressing of wound after 3 weeks regularly.
3- do not eat unhealthy diet which cause itching in the wound.
4- visit the hospital to wound condition monitoring after 7 days till the wound does not become fully
cure.
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Activity 19
19.1 Write a reflection on how completing this module will/will not change your
nursing practice and identify any knowledge gaps. Seek the support from your
Preceptor/CN/CF/NE/CNC/NUM to identify professional development activities
to support your knowledge regarding diabetes management and include these
in your Performance and Development Plan (PDP).
ANS:- By completing this module I would definitely gain some more important aspect for the treatment
of wound. After completion of this module now I knew about the types of wound care and kind of
wound. I have gained more knowledge about the types of dressing and also learned the way of
dressing. I learned that if a patient is diabetic then there is lot of chances that they take higher amount
of time for healing their wound rather than normal person. Finally I learned about the types of
exudates , skin edge and how to operate the wound assessment process and techniques.
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References
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diagnose or exclude surgical site infection. Journal of wound care, 27(3), 128-135.
Jaiganesh, A., Poornima, N., & Jebasharon, J. (2021). Automated Wound Assessment System for Foot Ulcer
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lim joo jin, r. u. t. h. (2020). wound assessment and decision-making process of nurses encountering
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