Principles of Wound Management in Clinical Environment
Added on 2023-06-10
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Test PrepDisease and DisordersNutrition and WellnessHealthcare and Research
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Apply principles of wound management in
the clinical environment
123 TMP E – Assessment Template – Written v1.3 Page 1 of 24
the clinical environment
123 TMP E – Assessment Template – Written v1.3 Page 1 of 24
Case Study Scenario 1 – Burn Injury:
Carol Mitchell, aged 64 was admitted to the burns unit after sustaining burns to the front and back of her left
lower leg and foot. Carol had been cooking in her kitchen, when she accidently knocked a saucepan full of hot
oil over herself. Carol’s husband drove her to the nearest medical centre where Carol’s burn was treated and
then she was transported by ambulance to the hospital for further assessment.
15595171 / Bork / shutterstock.com
In the emergency room, Carol was conscious and in evident distress. Her admission notes were: areas of
variable depth of injury over her posterior lower leg and foot only; dark pink discoloration with sluggish capillary
refill, blistering is evident; an area on her inner left ankle has an area of blotchy red/white with sluggish to
absent capillary refill, patient is complaining of pain on her lower leg, but states that her ankle is somewhat
pain free.
After consultation with the Burns team, the burns are to be surgically debrided and a small skin graft will be
applied to her inner ankle injury.
123 TMP E – Assessment Template – Written v1.3 Page 2 of 24
Carol Mitchell, aged 64 was admitted to the burns unit after sustaining burns to the front and back of her left
lower leg and foot. Carol had been cooking in her kitchen, when she accidently knocked a saucepan full of hot
oil over herself. Carol’s husband drove her to the nearest medical centre where Carol’s burn was treated and
then she was transported by ambulance to the hospital for further assessment.
15595171 / Bork / shutterstock.com
In the emergency room, Carol was conscious and in evident distress. Her admission notes were: areas of
variable depth of injury over her posterior lower leg and foot only; dark pink discoloration with sluggish capillary
refill, blistering is evident; an area on her inner left ankle has an area of blotchy red/white with sluggish to
absent capillary refill, patient is complaining of pain on her lower leg, but states that her ankle is somewhat
pain free.
After consultation with the Burns team, the burns are to be surgically debrided and a small skin graft will be
applied to her inner ankle injury.
123 TMP E – Assessment Template – Written v1.3 Page 2 of 24
Case Study 1 - Short answer questions: word count and referencing stated where
required
Read each question carefully and ensure you answer each part.
1. The wound healing process commences when any damage to the skin
has occurred. Once the skin is impaired and a wound is created the
healing process begins. This is a dynamic and complex process. It consists
of four stages
Match the stage with the physiological and biochemical processes
haemostasis – stage 1
inflammation phase – stage 2
proliferation or reconstruction phase – stage 3
maturation phase – stage 4.
Stage Physiological and Biochemical Processes
proliferation or reconstruction
phase – stage 3 During this phase tissue is temporarily replaced and the area is cleaned up b
macrophages which digest the dead bacteria and debris. New blood capillaries ar
developed and granulation tissue (mainly collagen) is laid down. As granulation tissu
continues to be laid the epithelium thickens to 4 to 5 layers forming the epidermis. Th
wound contracts and becomes smaller. This stage can take from 2 to 24 days
inflammation phase – stage 2 Process of the wound being closed by clotting. Starts when blood leaks out of th
body. The first step is when blood vessels constrict to restrict the blood flow. Nex
platelets stick together in order to seal the break in the wall of the blood vessel. Finall
coagulation occurs and reinforces the platelet plug with threads of fibrin which are lik
a molecular binding agent, this stage happens very quickly
homeostasis – stage 1 Vasodilation of surrounding tissues occurs due to the release of histamine and othe
vasoactive chemicals. This increases blood flow to the surrounding areas which lead
erythema, swelling, heat and pain. White blood cells descend into the area as
defense response. This phase lasts approximately three days
maturation phase – stage 4 The wound and surrounding tissue is gradually remodeled and the collagen cells lai
down are strengthened. This stage can last from 24 days to approximately one yea
During this stage the wound is still at risk and should be protected.
123 TMP E – Assessment Template – Written v1.3 Page 3 of 24
required
Read each question carefully and ensure you answer each part.
1. The wound healing process commences when any damage to the skin
has occurred. Once the skin is impaired and a wound is created the
healing process begins. This is a dynamic and complex process. It consists
of four stages
Match the stage with the physiological and biochemical processes
haemostasis – stage 1
inflammation phase – stage 2
proliferation or reconstruction phase – stage 3
maturation phase – stage 4.
Stage Physiological and Biochemical Processes
proliferation or reconstruction
phase – stage 3 During this phase tissue is temporarily replaced and the area is cleaned up b
macrophages which digest the dead bacteria and debris. New blood capillaries ar
developed and granulation tissue (mainly collagen) is laid down. As granulation tissu
continues to be laid the epithelium thickens to 4 to 5 layers forming the epidermis. Th
wound contracts and becomes smaller. This stage can take from 2 to 24 days
inflammation phase – stage 2 Process of the wound being closed by clotting. Starts when blood leaks out of th
body. The first step is when blood vessels constrict to restrict the blood flow. Nex
platelets stick together in order to seal the break in the wall of the blood vessel. Finall
coagulation occurs and reinforces the platelet plug with threads of fibrin which are lik
a molecular binding agent, this stage happens very quickly
homeostasis – stage 1 Vasodilation of surrounding tissues occurs due to the release of histamine and othe
vasoactive chemicals. This increases blood flow to the surrounding areas which lead
erythema, swelling, heat and pain. White blood cells descend into the area as
defense response. This phase lasts approximately three days
maturation phase – stage 4 The wound and surrounding tissue is gradually remodeled and the collagen cells lai
down are strengthened. This stage can last from 24 days to approximately one yea
During this stage the wound is still at risk and should be protected.
123 TMP E – Assessment Template – Written v1.3 Page 3 of 24
2a. Skin Assessment – outline the steps of the skin assessment for Carol’s burn that would be
carried out immediately on admission to the emergency department.
The burn assessment in Carol's burn case can include the assessment of airways, breathing,
circulation, disability, exposure as well as the requirement for the resuscitation of the fluids. In the
emergency department, the care nurses must visualize Carol's burn that can be sustained while the
victim accidentally knocked a saucepan which is full of hot oil over herself. As per the rule of nine, the
surface area of the body can be categorized into an anatomical area which can represent the 9%, or
multiple of 9% of overall body surface. However, the 9% each of the head and each of the upper limb,
about 18% for each lower limb, front of trunk as well as the back of trunk. The care nurse may consider
the depth of burn. As the burn wounds are generally dynamic and need a re-assessment within the first
24 to 72 hours because the depth can enhance as a result of an inadequate care treatments or a
supper-added contamination.
https://patient.info/doctor/burns-assessment-and-management
2b. Part of the assessment (here is a clue for the above question) is burn size. Using the burn
chart (below), tick the correct estimate of the size of Carol’s burn using the information in
the scenario
◻ Burn percentage 20% approx.
◻ Burn percentage 9% approx.
◻ Burn percentage 27% approx.
◻ Burn percentage 0.7% approx.
224297740 / stihii / shutterstock.com
2c. When a patient suffers a burn injury it is important to classify the wound.
Provide a description for each of the classifications in the table below.
Classification Description
123 TMP E – Assessment Template – Written v1.3 Page 4 of 24
carried out immediately on admission to the emergency department.
The burn assessment in Carol's burn case can include the assessment of airways, breathing,
circulation, disability, exposure as well as the requirement for the resuscitation of the fluids. In the
emergency department, the care nurses must visualize Carol's burn that can be sustained while the
victim accidentally knocked a saucepan which is full of hot oil over herself. As per the rule of nine, the
surface area of the body can be categorized into an anatomical area which can represent the 9%, or
multiple of 9% of overall body surface. However, the 9% each of the head and each of the upper limb,
about 18% for each lower limb, front of trunk as well as the back of trunk. The care nurse may consider
the depth of burn. As the burn wounds are generally dynamic and need a re-assessment within the first
24 to 72 hours because the depth can enhance as a result of an inadequate care treatments or a
supper-added contamination.
https://patient.info/doctor/burns-assessment-and-management
2b. Part of the assessment (here is a clue for the above question) is burn size. Using the burn
chart (below), tick the correct estimate of the size of Carol’s burn using the information in
the scenario
◻ Burn percentage 20% approx.
◻ Burn percentage 9% approx.
◻ Burn percentage 27% approx.
◻ Burn percentage 0.7% approx.
224297740 / stihii / shutterstock.com
2c. When a patient suffers a burn injury it is important to classify the wound.
Provide a description for each of the classifications in the table below.
Classification Description
123 TMP E – Assessment Template – Written v1.3 Page 4 of 24
Superficial The superficial burn wound can involve only the epidermal layers of the skin.
these generally do not blister but are very painful, red, blanch with pressure,
and dry as well. in this, the slight alterations within the air current moving past
to the exposed superficial burn can cause a patient to experience a
excruciating pain.
Partial thickness The partial thickness is generally the second degree burn which can include
the epidermis as well as a part of the dermis layer of the skin. the site of the
burn can appear blistered, red as well as can be swollen and painful as well.
the burn can cause a mild pain and slight discomfort, specifically when
something like a cloth rubbing against the burned area.
Full thickness In the full thickness burns, the skin of a patient either be black, white, brown,
leathery in appearance and many more. in this, in the burn it can frequently
form an eschar around the wound. since the nerve endings are generally
damaged along with the dermis, and these such types of wound are quite
painless (Full Thickness Burns are a Life- Threatening Injury that require
medical attention, 2018).
State which one would most likely apply to Carol’s area of her burn around her inner left
ankle and give a rationale for your choice.
From the above scenario of Carol’s area of burn, it is identified that her injury can involve a full
thickness type of burn wound. it is because the nerve endings are mainly responsible for the sensations
that are damaged. From her case scenario, it is analyzed that the third degree burn can damage the
epidermis and dermis of a patient.
2d. When undertaking a wound assessment, the main purpose is to optimize the healing
process and to produce a baseline status against which the healing process can be
measured
Outline four (4) aspects you may consider when conducting a holistic wound assessment.
Provide a reason for each of your choices.
In this, a holistic wound assessment can include the medical history of a patient, consisting the current
and past medical conditions, it can also include the psychological, social as well as the spiritual history,
their wound care environment as well as can assess to the specialized well-being care services. the
wound healing process can include the four phases which are as mentioned below:
Hemostasis Stage: It is generally an easy pathway to identify that the body has started the hemostasis
stage is that the blood will begin to clot. if a patient can experience a break within the skin as well as are
begin to bleed, then their blood vessels will work to constrict the flow of blood. the platelets then
generally stick collaboratively to seal the break within the skin.
Inflammatory Stage: This particular stage can occur right when the skin can break. when a person gets
injured, then their blood vessels begin to leak, and swelling can occur. In this, the swelling as well as
inflammation can aid to control the bleed as well as can prevent the infections. the white blood cells
known as Neutrophils that can enter the wound to remove the bacteria and debris as well.
Proliferative Stage: It is mainly the third stage, when the wound can rebuild itself as well as the new
skin can rise the new tissue oxygen and nutrients as well. in this, the cells known as fibroblast can work
to effectively heal the wound by gripping the edges of the wound as well as pull them combined.
Maturation Stage: It is the stage also known as remodeling stage is when the collagen within the skin is
regenerated as well as the wound can completely close. in context with earlier stage, the collagen which
can rebuild the skin is generally uneven and thick as well. within the maturation stage, the collagen fibre
can begin to align more efficiently with each other as well as can lie more close combined to cross-link
(Wound Care Stage, 2021).
123 TMP E – Assessment Template – Written v1.3 Page 5 of 24
these generally do not blister but are very painful, red, blanch with pressure,
and dry as well. in this, the slight alterations within the air current moving past
to the exposed superficial burn can cause a patient to experience a
excruciating pain.
Partial thickness The partial thickness is generally the second degree burn which can include
the epidermis as well as a part of the dermis layer of the skin. the site of the
burn can appear blistered, red as well as can be swollen and painful as well.
the burn can cause a mild pain and slight discomfort, specifically when
something like a cloth rubbing against the burned area.
Full thickness In the full thickness burns, the skin of a patient either be black, white, brown,
leathery in appearance and many more. in this, in the burn it can frequently
form an eschar around the wound. since the nerve endings are generally
damaged along with the dermis, and these such types of wound are quite
painless (Full Thickness Burns are a Life- Threatening Injury that require
medical attention, 2018).
State which one would most likely apply to Carol’s area of her burn around her inner left
ankle and give a rationale for your choice.
From the above scenario of Carol’s area of burn, it is identified that her injury can involve a full
thickness type of burn wound. it is because the nerve endings are mainly responsible for the sensations
that are damaged. From her case scenario, it is analyzed that the third degree burn can damage the
epidermis and dermis of a patient.
2d. When undertaking a wound assessment, the main purpose is to optimize the healing
process and to produce a baseline status against which the healing process can be
measured
Outline four (4) aspects you may consider when conducting a holistic wound assessment.
Provide a reason for each of your choices.
In this, a holistic wound assessment can include the medical history of a patient, consisting the current
and past medical conditions, it can also include the psychological, social as well as the spiritual history,
their wound care environment as well as can assess to the specialized well-being care services. the
wound healing process can include the four phases which are as mentioned below:
Hemostasis Stage: It is generally an easy pathway to identify that the body has started the hemostasis
stage is that the blood will begin to clot. if a patient can experience a break within the skin as well as are
begin to bleed, then their blood vessels will work to constrict the flow of blood. the platelets then
generally stick collaboratively to seal the break within the skin.
Inflammatory Stage: This particular stage can occur right when the skin can break. when a person gets
injured, then their blood vessels begin to leak, and swelling can occur. In this, the swelling as well as
inflammation can aid to control the bleed as well as can prevent the infections. the white blood cells
known as Neutrophils that can enter the wound to remove the bacteria and debris as well.
Proliferative Stage: It is mainly the third stage, when the wound can rebuild itself as well as the new
skin can rise the new tissue oxygen and nutrients as well. in this, the cells known as fibroblast can work
to effectively heal the wound by gripping the edges of the wound as well as pull them combined.
Maturation Stage: It is the stage also known as remodeling stage is when the collagen within the skin is
regenerated as well as the wound can completely close. in context with earlier stage, the collagen which
can rebuild the skin is generally uneven and thick as well. within the maturation stage, the collagen fibre
can begin to align more efficiently with each other as well as can lie more close combined to cross-link
(Wound Care Stage, 2021).
123 TMP E – Assessment Template – Written v1.3 Page 5 of 24
3a. As stated in the case study, Carol is complaining of pain
Which of the following strategies may be utilised to provide comfort to Carol? (There is
more than one)
◻ Provide pain relief
◻ Provide distraction therapy
◻ Elevate Carol’s foot above heart level (not much recommded in burn cases)
◻ Ensure bed comfort
◻ Assess stress / anxiety levels and look at reducing these
◻ Inform Carol that pain is a normal aspect of a burn and there is not much that can be done to
reduce all pain
3b. Describe an appropriate pain assessment tool and then explain why it is important to
reduce pain levels in patient with wounds?
The pain assessment tool is generally a multidimensional observational assessment of the vulnerable
patients who can experience the pain. The pain measurement tools are the instruments which are
specifically designed to measure the pain of a person. The tools have been used for the pain
assessment at the healthcare organization and generally been chosen on the reliability, validity and
usability as well as are mainly recognized by the pain specialist to be clinically effective while assessing
the acute pain. It is considered as an essential component as it can enable the management of pain to
be effectively titrated as well as tailored to the needs of the patient, more specifically during the
management of wound procedures (Pain assessment and measurement, 2019).
4. It was noted in the case study for Carol that she required “surgical debridement” to her
burns. Explain what surgical wound debridement is and why is it done?
The debridement is mainly a procedure for treating a wound within the skin. It can involve the thoroughly
cleaning of the wound as well as removing all the hyperkeratotic such as the thickened callus or skin
part, contaminated as well as non-viable tissue, the foreign debris as well as the residual material from
the dressings. It is generally a main step in the entire protocol for effectively treating the diabetic foot
ulcers that is generally occurs among 20% of the diabetic patients as well as can precede about 85% of
all the diabetes-associated lower leg amputations. Such that in the above case scenario of Carol, she
needs surgical debridement to her burn towards the hyperkeratotic, infected as well as the non-viable
tissues can be surgically removed by using a scalpel as well. It is done because it can effectively
reduces the developing risk of infection or contamination as well as can give comfort in the minor burns
as well.
5. Describe how the skin heals with the assistance of a skin graft.
In this, a graft is generally a skin that is surgically placed over a deeply burned region or to cover an
opening of the wounds. The skin grafting technique can enable the healthcare providers to stretch the
skin on the wide region. It can aid the region heal after the procedure. The care providers can place the
healthy skin over the damaged skin. They generally secure the skin in place with the stitches or staples
and put a dressing over the region. In addition to this, when the surface area of the burn in body is
broad, the sheet grafts are generally saved for the neck, face and hands, as well as making the most
clear parts of the human body can appears less scarred. Furthermore, when a burn is minute and there
is some of the donor skin available, a sheet graft may be used to cover the whole burned region. It can
aid the region to heal after surgery.
6. When assessing a patient’s wound discuss 2 common problems / complications you may
encounter.
The two possible common issues or complications that can be encountered while assessing the
patient's wound such as:
123 TMP E – Assessment Template – Written v1.3 Page 6 of 24
Which of the following strategies may be utilised to provide comfort to Carol? (There is
more than one)
◻ Provide pain relief
◻ Provide distraction therapy
◻ Elevate Carol’s foot above heart level (not much recommded in burn cases)
◻ Ensure bed comfort
◻ Assess stress / anxiety levels and look at reducing these
◻ Inform Carol that pain is a normal aspect of a burn and there is not much that can be done to
reduce all pain
3b. Describe an appropriate pain assessment tool and then explain why it is important to
reduce pain levels in patient with wounds?
The pain assessment tool is generally a multidimensional observational assessment of the vulnerable
patients who can experience the pain. The pain measurement tools are the instruments which are
specifically designed to measure the pain of a person. The tools have been used for the pain
assessment at the healthcare organization and generally been chosen on the reliability, validity and
usability as well as are mainly recognized by the pain specialist to be clinically effective while assessing
the acute pain. It is considered as an essential component as it can enable the management of pain to
be effectively titrated as well as tailored to the needs of the patient, more specifically during the
management of wound procedures (Pain assessment and measurement, 2019).
4. It was noted in the case study for Carol that she required “surgical debridement” to her
burns. Explain what surgical wound debridement is and why is it done?
The debridement is mainly a procedure for treating a wound within the skin. It can involve the thoroughly
cleaning of the wound as well as removing all the hyperkeratotic such as the thickened callus or skin
part, contaminated as well as non-viable tissue, the foreign debris as well as the residual material from
the dressings. It is generally a main step in the entire protocol for effectively treating the diabetic foot
ulcers that is generally occurs among 20% of the diabetic patients as well as can precede about 85% of
all the diabetes-associated lower leg amputations. Such that in the above case scenario of Carol, she
needs surgical debridement to her burn towards the hyperkeratotic, infected as well as the non-viable
tissues can be surgically removed by using a scalpel as well. It is done because it can effectively
reduces the developing risk of infection or contamination as well as can give comfort in the minor burns
as well.
5. Describe how the skin heals with the assistance of a skin graft.
In this, a graft is generally a skin that is surgically placed over a deeply burned region or to cover an
opening of the wounds. The skin grafting technique can enable the healthcare providers to stretch the
skin on the wide region. It can aid the region heal after the procedure. The care providers can place the
healthy skin over the damaged skin. They generally secure the skin in place with the stitches or staples
and put a dressing over the region. In addition to this, when the surface area of the burn in body is
broad, the sheet grafts are generally saved for the neck, face and hands, as well as making the most
clear parts of the human body can appears less scarred. Furthermore, when a burn is minute and there
is some of the donor skin available, a sheet graft may be used to cover the whole burned region. It can
aid the region to heal after surgery.
6. When assessing a patient’s wound discuss 2 common problems / complications you may
encounter.
The two possible common issues or complications that can be encountered while assessing the
patient's wound such as:
123 TMP E – Assessment Template – Written v1.3 Page 6 of 24
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