Diploma Nursing HLTENN006 Learning Journal: Wound Care Analysis

This document is a learning journal assignment for the Diploma of Nursing (HLT54115) unit HLTENN006, focusing on wound management in a clinical environment. It includes various activities such as summarizing the chain of infection, explaining the importance of hand hygiene, describing dif...Read More

Assessment Cover Sheet
Qualification: Diploma Nursing HLT54115
Unit of Competency: HLTENNOO6
Assessment Task: Learning Journal
Assessment Date/Submission date: 17/11/2018 Journal 4(1,2,3,6,7)
General Instructions:
 Complete all tasks detailed in the followingpages
 Fill in this assessment cover sheet and submit with your completed assessment task
 Sign thedeclaration
 Submit the completed tasks within the duedate
STUDENT ORGINALITY DECLARATION: Please tick to indicate that you understand the
following statements: I declare that:
 The attached assessment is my own work, except where I have cited the
originalsources.
For the purposes of assessment, I give the assessor of this assessment permission to:
 Reproduce my work and provide a copy to another member of staff,and
 Validate the assessment for its authenticity which may include communicating a
Student Name: Bindu Kharel
Student ID: 804453555
Student Signature:
Date: 19/11/2018
Assessment Outcome:
For UOC being assessed by multiple assessment activities, each activity will
be reported as Satisfactory or Not Satisfactory
 [Satisfactory] [NotSatisfactory] 
Resubmission(RS)For UOC being assessed for the final result it will be reported as AC
(Competent) or NC (Not yet competent)
 [Competent-AC]  [NotYetCompetent-NC] 
Resubmission(RS)Assessor
Name/
Signature:
Date:
Assignment extension request
A request must be made in writing to the head teacher prior to the assignment due date of submission with
reasonable explanations concerning delay. If granted the late submission is limited to a maximum of one (1)
week from the original submission date. No assignment will be accepted after the seven (7) day period. Non-
submission of the assignment on the due date will result in failure of that unit.

HLTENN006 V4 March 2017
Bindu
You will need to resubmit this assignmentz9questin 1 & 3) by 21 January. I would recommend that you go
to Foundation studies before resubmitting.
This was your second attempt. You will need to email Ros to reapply for this Unit.
Any questions please do not hesitate to contact me. I am on leave until January the21 January.
Thanks Bindu.
Joanne Clarke

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LearningJournal
HLTENN006 Apply principles of wound management in the clinical environment
Contents
Journal Activity 1: Chainofinfection...............................................................................................3
Journal Activity 2:Handhygiene......................................................................................................4
Journal Activity 3: Typesofwounds.................................................................................................5
Journal Activity 4: Wound assessmentcasestudy............................................................................6
Journal Activity 5: Woundassessmenttools.....................................................................................9
Journal Activity 6: Advantages and disadvantages ofassessmenttools.........................................10
Journal Activity7:Drains................................................................................................................11
Journal Activity 8: Typesofdressings............................................................................................12
Journal Activity 9: Principles of complexwoundmanagement......................................................13
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Journal Activity 1: Chain of infection
Using relevant resources, research the ‘Chain of Infection’. Summarise your readings using the
headings in the table below.
Main Points Development of an infection occurs in a cycle that depends on the
presence of all the following elements:
Infectious agent
(Pathogen)
Infectious agents refers to the pathogen or germ that is responsible for
causing the disease. Viruses, fungi, bacteria and parasites may act as an
infectious agents. Although some pathogens are associated with the
wellbeing of the body. They causes diseases only when, they leave their
actual place and transmit to the other place of our body. Infectious agents
are any microorganisms that can cause a disease such as virus, bacteria,
parasites etc. Ability to grow, enter tissue, cause disease are some of the
Reservoir
Reservoir refers to the habitat in which the infectious agents normally
live, grow and multiply. Reservoir may include animals, environment
and the human. However, it is not fixed that, always the pathogen will
transmit to the host from the reservoir. The small pox virus has the
human reservoir. Disease can be transmitted from animal to human as
well, Disease like Ebola can be transmitted to human from the animal.
Soil, water are the example of environmental reservoir (CDC,
2019).Reservoir is the place where microorganisms resides, thrives and
Portal of ExitMode of
escape
The term refers to the path in which the pathogen leaves its host. For
example, influenza virus’s portal of exit is the respiratory tract.Mode of
escape is the place where the microorganisms leaves the reservoir, such
as the respiratory tract (nose, mouth), intestinal tract(rectum via stool),
urinary tract, blood and other body fluids. (RCN.2016)
Mode of
transmission
The pathogen may transmit to its host from the reservoir by many ways.
They mainly transmit via direct and indirect ways. The pathogen may
transmit via direct contact and it is the direct mode of transmission. In an
indirect mode, the virus can be transmitted through air, vehicle and
vector (CDC, 2019).Mode of transmission is the means by which an
Portal Mode of
entry
Portal of entry is the manner in which a pathogen enters into the host’s
body. E.g- Skin is the portal of entry for hookworm.Mode of entry are
those opening where an infectious host enters the host’s body such as
mucus membrane, open wounds, or tubes inserted in body cavities like
urinary catheters or feeding tubes.(RCN.2016)
Susceptible host
Susceptible host is that particular host who has lesser immunity or some
genetic alteration and as a result they may safe to a particular pathogen or
may more vulnerable to the pathogen. Sickle cell anemia people are
partially protected from malaria (CDC, 2019).Susceptible host is a person
who is at risk for developing an infection from the disease. Factors
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Journal Activity 2: Hand hygiene
Explain the importance of hand hygiene in relation to best practice in wound management.
Hand hygiene is viewed as one of the most important components of infection control activities. In
the wake of the growing burden of health care associated infections , the increasing severity of
illness and complexity of treatment, superimposed by multi-drug resistant pathogen infections,
health care practitioners are reversing back to the basics of wound management by simple measures
like hand hygiene. There is also a scientific evidence that if hand hygiene is properly implemented,
hand hygiene alone can significantly reduce the risk of cross-transmission of infection in healthcare.
Preventing and managing infection in wound care can often be challenging. In particular, chronic
wounds are almost inevitably going to acquire a collection of various bacteria, likely to include
staphylococcus aureus and pseudomonas, along with a mixture of gram-positive and gram-
negative bacteria. The most fundamental element to any infection control policy is effective hand
washing, both before and after dealing with any patient or client. Patients are generally unwell,
recovering from an operation or may have decreased immunity leaving them at increased risk of
infection from germs. Our main motive is to prevent patients from infection . One of the easiest and
most effective ways to reduce infection is for all staff, patients and visitors to practice good hand
hygiene. Proper hand hygiene is the single most important, simplest, and least expensive means of
reducing the prevalence of HAIs and the spread of antimicrobial resistance. Several studies have
demonstrated that adherence to hand hygiene practices has significantly reduced the rates of
acquisition of pathogens on hands and has ultimately reduced the rates of HAIs in a hospital.
Improper hygiene doesn’t just leave us with a greater risk of contracting infections. Hand hygiene,
has great impact on patient's pre and post-surgical process. Hence it can be considered as one of the
best technique in relation to the wound management. (Indian journal of medical research.Nov,2011)
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Journal Activity 3: Types of wounds
Using any relevant textbook, write a short paragraph about each of the following wound types.
Surgical incision
It is the process that is executed during the operation procedure and the incision is due to the cut of
skin and soft tissues.
Traumatic injury
This injury is mainly happened due to life threatening events and it needs immediate medical
treatment as it is associated with the life of the patient (Shier, Butler & Lewis, 2015).
Ulcers
Ulcers is a sore on a mucous membrane or on the skin. It may appear inside or outside of the body.
Long time immobility can also cause ulcers in the skin.
Burns
Burns are associated with the severe skin damage due to hit, cold, electricity and chemical
exposure (Shier, Butler & Lewis, 2015).
Avulsion
It is the partial or complete tearing of the tissue and skin. It is mainly occurred due to violent
accidents, explosions.
Abrasions
It occurs when the skin is scraped by a hard or rough surface. Road rash can be an example (Shier,
Butler & Lewis, 2015).
Amputations
Amputations refers to the surgical removal of any part of the body that is mainly leg or arm of the
body. Amputations can be done due to infection or gangrene of the limb (NHS, 2019)
Graft and Donor site
It is a general surgical procedure in which a skin is removed from the site called donor site and it is
placed in injured area of body. Upper Thigh may be a donor site (Tasmanian Health services,
2019).
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References
CDC. (2019). Principles of Epidemiology | Lesson 1 - Section 10. Retrieved from
https://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson1/section10.html
NHS (2019). Amputation. nhs.uk. Available at: https://www.nhs.uk/conditions/amputation/
[Accessed 25 Jan. 2019].
Shier, D., Butler, J., & Lewis, R. (2015). Hole's essentials of human anatomy & physiology. New
York: McGraw-Hill Education.
Surgical incisions
A surgical incision is a cut made through the skin and soft tissue to facilitate an operation or
procedure. Multiple incisions could be made for an operation. Generally, a surgical incision is
made as small and unobtrusive as possible to facilitate safe and timely operating conditions.
(Wounds Australia.2018)
Traumatic injuries
A physical injuries of sudden onset and severity which require immediate medical attention is
known as traumatic injury. The insult may cause systemic shock called “shock trauma”, and may
require immediate resuscitation and interventions to save life and limb. (Wounds Australia.2018)
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Ulcers
Ulcers are sores that are slow to heal or keep returning. They can take many form and appear inside
or outside of the body. ABreak in the tissue lining of the stomach is called stomach or gastric ulcer.
Most stomach ulcers are caused by infection with the Helicobacter pylori bacterium or anti-
inflammatory medication, not stress or poor diet as once thought. (Wounds Australia.2018)
Burns
Burn is a type of injury to skin, or other tissues, caused by heat, cold, electricity, chemicals,
friction, or radiation. Most burns are due to heat from hot liquids, solids, or fire. (Wounds
Australia.2018)
Avulsion
Avulsion is an injury in which a body structure is forcibly detached from its normal point of
insertion by either trauma or surgery. (Wounds Australia.2018)
Abrasions/skin tears
An abrasion is a wound caused by superficial damage to the skin, no deeper than the epidermis. It is
less severe than a laceration, and bleeding, if present, is minimal. Mild abrasion , also known as
grazes or scrapes, do not scar or bleed, but deep abrasions may lead to the formation of sca.
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(Wounds Australia.2018)
Amputations
An amputation usually refers to the removal of the whole or part of an arm/hand or a leg/foot.
Amputation an occur after an injury (traumatic amputation) or deliberately at surgery. In vascular
surgery amputation are only rarely performed on the arms. (Wounds Australia.2018)
Graft and donor sites
A skin graft is a section of epidermis and dermis which has been completely separated from its
blood supply in one part of the body, the donor site, before being transplanted to another area of the
body, its recipient side. (Wounds Australia.2018)
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Journal Activity 4: Wound assessment case study
Sarah Victor had a hysterectomy 12 days ago. Sarah has been readmitted with a major wound
dehiscence and has completed a course of antibiotics. There are no current signs and symptoms of
systemic infection although there is still a moderate amount of malodorous exudate and Sarah states
that she is experiencing increased pain and discomfort.
Patient Details
Name: Sarah Victor
Address: 66 Ellsworth Avenue UMINA NSW
Sex: Female D.O.B: 10.5.55
Age: 53 years
Marital status Married
Country of birth: Australia
Admitted: Emergency dept
Social history: Alcohol : social only
Smoker 20 daily
Medical history: 1995 - cholecystectomy
- chronic bronchitis
Current medications: Becotide PRN
Ht: 155 cm
Wt: 85 kilograms
Vital signs: Temp 36.5, P 96, BP 130/80.
Allergies: Nil
This is an important activity that will require you to use all the information you are learning to
help care for Sarah. You will be answering questions based on the information provided in the
online resource and further independent research. Some of the questions will be best left until
you complete the specific topic areas. A proposed allocation of marks for this activity is
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included.
Using the information provided in the case study and further independent research
complete the following tasks. (Word limit 1500)
1. Using the wound assessment chart following, complete an assessment of Sarah’swound.
Sarah’s wound is showing some level of granulation along with minor amounts of
epithelialization. it is clear from the picture that the wound is on the way of getting better
as it is showing no sign of infection with visual appearance of red healthy tissue on the
wound bed. The edges of the wound also appear to be healthy with growth of healthy tissue
as advancing pink epithelium is growing to generate a new healthy skin.In the picture we
can also see Sarah’s wound is producing moderate amount of exudatesgetting. The wound
appears to be dry which can be a disadvantage to the restoration process as the wound must
be in a moist environment to promote rapid healing. Sarah is also complaining of increased
pain and discomfort.(Wound Australia.2017)
At a first glance, Mrs. Victor’s wound shows moderate amount of healing and it is in the
stage of regeneration. The wound of Mrs. Victor’s wound is 11 cm in length and 4 cm in
width approximately. The wound depth is at maximum at the top end where the depth is
approximately 1 cm deep. In visual appearance, Mrs. Victor’s wound showing the presence
of granulation with minor amount of epithelization. From the visual appearance of the
wound, it is clear that the wound has not infected yet systematically and healthy red tissue
can be seen in the wound bed with some fat tissues underneath. However, from the
patient’s information, it is evident that the wound does produce some malodorous exudates
and it signifies the presence of necrotic tissues and early bacterial infection. Discomfort
and pain also points towards that deduction. No maceration has been noticed around the
surrounding skin of the wound and healthy pink soft tissues is visible which is indicative of
healing (Wound Australia 2017).
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2. Write a description of Sarah’s wound using correct wound managementterminology.
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In order to minimize cross infection, prevent spread of disease and to reduce further
complications, there are various strategies Mrs. Sarah need to follow.
o By using proper aseptic technique as per the dressing standard Mrs. Sarah’s wound
must be cleaned and dressing must be change daily or PRN.
o The wound area should keep free from any strain or pressure.
o Five moments of hand hygiene must be performed every time, before and after any
activity, there is an activity related with the surgical wound and its dressing.
o Mrs. Sarah should take complete rest and keep in contact with the medical team
regarding the surgical wound.(Caresearch.2017)
3. Describe the strategies that could be used to minimize cross infection, prevent the
spreadof disease and reduce further complications.
Since Sarah’s surgery has result in a big wound so that it will be very tough and
challenging for Mrs. Sarah to manage the pain and its associated problem during the
retrieval and curing process. In case ,if the pain endures to persist It will be even more
difficult and challenging for Sarah as the pain can hamper her ability to do her activities of
daily livings, It can reduce Sarah’s general movement. Sarah’s incapability to move can
increase the additional risk of developing pressure injury specially on her buttocks, heel,
sacrum. Additionally, the strong odor of wound can cause some level of nervousness and
distress to Sarah and her Family, friend and relatives as they might make a judgement of
Sarah’s health condition or they may think the odor as some signs of infection. As we all
know that smoking and drinking alcohols are never beneficial to our health and it can
increase the risk of inflammation and it may results the wound healing duration more
longer so that, if Mrs. Sarah have those habits she should overcome that challenge by
quitting the smoking or drinking alcohol at least until her wound get completely cured.
Sarah should always stay in touch with her clinical team and update them if she notices any
changes in her wound condition. For example, pain level, amount of exudates, odor, wound
size etc. (Agency for clinical innovation.2018)
Mrs. Victor has a large, open wound due to the recent surgery of her and managing large and
open wound is a bit tricky as it can be infected very quickly and complicate the healing process
further. The patient has discomfort and pain in her wound area as well as the presence of
malodorous exudates. This signifies the presence of necrotic tissues and initial bacterial infection.
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First of all, the patient has to continue the dose of antibiotic provided after the surgery. Then sample
should be taken from the wound site to determine the type bacterial infection, so that the GP can
provide appropriate antibiotic. Particular attention must be given to determine whether the infection
is from MRSA or community acquired MRSA. Appropriate measure should be taken if it this kind
of infection. The patient has discomfort and pain in her wound area; hence she has to control her
daily activities to put less pressure on the wound for faster healing. Personal hygiene like washing
hands with soap have to maintained to reduce the chance of infection and particularly hand should
be washed with soap before handling the wound. Apart from that, Mrs. Victor is a heavy smoker and
smoking delays the healing process. Therefore, she has to stop smoking during the healing period for
faster healing (Agency for clinical innovation, 2018).
4. Using a holistic approach, discuss the impact the wound may have on Sarah’slife.
A comprehensive holistic patient assessment is performed, followed by a detailed wound
assessment. The patient assessment should be multidimensional, fully acknowledging the
patient's wider social, psychological and lifestyle factors that may affect wound healing, to
ensure realistic and appropriate care planning. Careful holistic patient assessment involves:
History
The patient's medical and medication history are important because wound healing may be impaired
by concomitant conditions such as diabetes, chronic obstructive pulmonary disease and vascular
problems.(Wounds Autralia.2018)
Pain
Wound pain is a complex multidimensional phenomenon which has a variety of causes including
infection and deterioration of the wound itself, inappropriate treatment or anticipatory pain. It is
influenced by a multitude of factors including psychological and social factors.(Wounds
Autralia.2018)
Nutrition
Sufficient nutritional and fluid intake is essential for healthy growth and repair of body tissue. Accurate
assessment of nutritional status and a balanced diet that meets individual requirements is vital for healing.
(Wounds Autralia.2018)
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Mobility
A patient's mobility status and any difficulties around how this affects the wound and their wellbeing must
be considered. Many people that enjoyed active lives before their wound can experience reduced mobility
and social interaction. (Wounds Autralia.2018)
Wound size
The normal wound healing process involves wounds filling with granulation tissue which decreases the
wound depth and volume, with new epithelium decreasing the wound surface area and changing the wound
shape and size.(Wounds Autralia.2018)
Wound bed
Local wound assessment provides valuable information on wound aetiology, stage of wound healing,
healing progress and tissue viability. Careful examination of the wound bed requires recognition of the
various types of both viable and non-viable tissue that can be present in wounds.(Wounds Autralia.2018)
Infection
There is widespread clinical awareness of the bacterial continuum within wounds which involves
recognizing contamination, colonisation and infection, as well as the influence of biofilm.
Product selection
Skillful wound product selection is an important outcome of on-going holistic wound assessment
and is inextricably linked to time and optimum wound bed preparation.(Wounds Autralia.2018)
Possible Impacts of wound on Sarah
 Anxiety about potential job loss, finances and overall health outcome.
 Depression over a reduced quality of life and loss of independence.
 Embarrassment about potential wound odor, visible wound drainage etc.
 Shame or feeling like a burden on family members and caregivers.
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 Grief about loss of bodily function and an altered body image.
 Isolation from friends and family due to decreased mobility, depending upon location and impact of
wound. Feelings of worthlessness may become overwhelming when multiple emotions are
experienced.
(Wounds Autralia.2018)
5. Describe the physiological processes of woundhealing.
The physiological stages of wound healing proceed in an organized way and follow four
processes that can be listed as follows:
Haemostasis
Haemostasis is the process of the wound being closed by clotting. Haemostasis starts when
blood leaks out of the body. The first step of haemostasis is when blood vessels constrict to
restrict the blood flow. Next, platelets stick together in order to seal the break in the wall of
the blood vessel. Finally, coagulation occurs and reinforces the platelet plug with threads of
fibrin which are like a molecular binding agent.(Kestrel health information.2017)
Inflammatory
Inflammation is the second stage of wound healing and begins right after the injury when the
injured blood vessels leak transudate (made of water, salt, and protein) causing localized swelling.
(Kestrel health information.2017)
Proliferative
The proliferative phase of wound healing is when the wound is rebuilt with new tissue made up of
collagen and extracellular matrix. In the proliferative phase, the wound contracts as new tissues
are built.(Kestrel health information.2017)
Maturation
Maturation Also called the remodelling stage of wound healing, the maturation phase is when
collagen is remodelled from type III to type I and the wound fully closes. The cells that had been
used to repair the wound but which are no longer needed are removed by apoptosis, or
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programmed cell death.(Kestrel health information.2017)
6. In collaboration with the health care team, develop an individual wound
management plan. Refer to databases and websites you have used to inform
yourdecision.
Your answer should include a description and rationale for the following:
 cleansingtechnique
 wound managementproducts
Wound cleansing techniques:The goal of wound cleansing is to eliminate visible debris and
devitalised tissue, remove dressing residue and also remove excessive or dry exudates. Irrigation
is the chosen method for cleansing open wounds. This may be carried out utilising a syringe in
order to produce gentle pressure in order to loosen debris. Gauze swabs and cotton wool should
be used with caution as can cause mechanical damage to new tissue and the shedding of fibres
from gauze swabs/cotton wool delays healing.Wound care standard should always follow during
the wound cleansing time such as,
 Use Aseptic Technique procedure
 Wound cleansing should not be undertaken to remove 'normal' exudate
 Cleansing should be performed in a way that minimises trauma to the wound
 Wounds are best cleansed with sterile isotonic saline or water
 The less we disturb a wound during dressing changes the lower the interference to healing
 Fluids should be warmed to 37°C to support cellular activity
 Skin and wound cleansers should have a neutral pH and be non-toxic
 Avoid alkaline soap on intact skin as the skin pH is altered, resistance to bacteria decreases
 Avoid delipidating agents as alcohol or acetone as tissue is degraded
 Antiseptics are not routinely recommended for cleansing and should only be used sparingly
for infected wounds.
(Wound Australia.2018)
Wound management product:
A wound will require different management and treatment at various stages of healing. No dressing
is suitable for all wounds, therefore frequent assessment of the wound is required. As a health care
professional we should make Considerations when choosing wound care products,
 Maintain a moist environment at the wound/dressing interface
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 Be able to control (remove) excess exudates. A moist wound environment is good, a wet
environment is not beneficial
 Not stick to the wound, shed fibres or cause trauma to the wound or surrounding tissue on
removal
 Protect the wound from the outside environment - bacterial barrier
 Good adhesion to skin
 Sterile
 Aid debridement if there is necrotic or sloughy tissue in the wound (caution with ischaemic
lesions)
 Keep the wound close to normal body temperature
 Conformable to body parts and doesn't interfere with body function
(Royal children hospital Melbourne.2017)
 Non-flammable and non-toxic
For example, if the wound is dry then the wound product such as Hydrocolloid, Flims semi
permeable or Non adherent dressing can be use. Similarly for the minimal exudate Hydrogel,
silicon absorbent can be use. For the moderate exudate, wound products such as calcium
alginate, hydro fibre, foam can be use. And if the wound has a heavy exudate then we can
use absorbent dressing or ostomy bag to promote the wound healing. To promote the
effective wound healing health care team should always inspect the wound properly rather
than rely only on the wound chart from the previous shift.(Royal children hospital
Melbourne.2017)S
7. Describe how you would evaluate the effectiveness of your wound assessmentstrategy.
There are numerousaspects such as pain level of wound, wound health status, wound
appearance and its surrounding skin, wound size etc. that will determine how effectively
the wound is healing. To measure the healing process it is very important to continuously
examine the wound and document it as per visual observations of wound length, width and
dept as well as secretion from the wound. Different types of wound heal at different rate
and required different types and different level of treatment and care. This strategy should
be the base for wound care and treatment. Following appropriate technique with up to date
information is crucial for any wound care to be effective. Hence in order for the wound
assessment to be effective and advantageous to the patient it is vital that the assessment
procedure ensure that the above mentioned fact and information is carefully followed and
checked and if there are any short coming within the procedure or care plan then the
assessment process must identify it during the assessment and right action must be taken to
correct the weakening.(Ausmed.2018)
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8. Discuss how using principles of primary health care can lessen the impact of the
management of the wound on the client and theirfamily.
The focus in primary health care has been changing from acute care to the prevention and
management of chronic disease. This has required changes to the organization of primary health care
practices and the involvement of a greater number of team members for the betterment of the patient
and their family. Every patient with a wound has the right to expect clinically effective standards of
care; therefore, clinicians need to provide an accurate diagnosis, clear treatment goals, rationale of
dressing choice and therapy. If the patient is presenting with multiple wounds, each wound must be
assessed individually and documented accordingly. Primary health care providers such as GPs and
practice nurses have a particularly important role in the identifying, assessing at risk patients and
offering brief interventions and long term follow up. However this is often insufficient and more
intensive education and support are required from a range of providers and services including
community based programs. Prevention requires the organization of care within the practice as well
as across different organizations. Facilitating this is an important role for Medicare Locals and needs
to be incorporated into their population health planning. There is also a need for them to forge
partnerships with state health services, local government and nongovernment organizations to
achieve their goals. The transition towards a more equitable and accessible primary health care
system is a key plank of health reform.
(Wounds Australia.2018)
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Journal Activity 5: Wound assessment tools
Using relevant textbooks or the internet, research various wound assessment tools.
Find TWO assessment tools and write a short paragraph about each.
Wound assessment
1.Pressure ulcer scale of healing (PUSH)
The Pressure Ulcer Scale for Healing (PUSH) tool is a fast and accurate tool used to measure the
status of pressure wounds over time. The tool was designed by National pressure ulcer advisory
panel (NPUAP) and has been validated many times over. As per the recommendation of NPUAP
this tool should be used on a regular basis, at least weekly or whenever the patient or wound status
changes. The PUSH tool measures three parameters that are considered most indicative of healing:
 Wound size (greatest length x greatest width = wound surface area)
 Exudate amount (estimate as light, moderate or heavy after removal of the dressing)
 Tissue type (closed/resurfaced, epithelial tissue, granulation tissue, slough, necrotic
tissue/eschar)(Ostomy Wound management. 2009)
2. Bates-Jensen wound assessment tool (BWAT)
Bates-Jensen Wound Assessment Tool which was lately known as the Pressure Sore Status tool.
The Pressure Sore Status tool (PSST) was developed by Barbara Bates-Jensen which is
a standardized tool designed for easy assessment, meaningful communication between healthcare
clinicians regarding pressure ulcer and accurate tracking of wounds. In order to use the tool, nurses
must have a working knowledge of wound vocabulary and wound-assessment skills. ( Journal of
Wound Ostomy & Continence Nursing. (2018).
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Journal Activity 6: Advantages and disadvantages of assessment tools Describe the
advantages and disadvantages of these tools
Assessment tool: Pressure ulcer scale of healing (PUSH)
Advantages Disadvantages
 It reduces the risk of liabilities as the
caretakers are alerted so that they can
react quickly and efficiently if the wound
isn’t improving or getting worse.
 Reliable, easy to learn and also more
accurate than the traditional ones
 It saves time. (Ostomy wound
management.2009)
 The results derived are totally dependent
on investigations which may be
inconsistent
 All the scores need to be compared to
provide an indication of healing, but if the
score are not accurate then there is no
result of better healing.
(Ostomy wound management.2009)
Assessment tool: . Bates-Jensen wound assessment tool (BWAT)
Advantages Disadvantages
 13 different areas are assessed because of
which it helps to determine the wound
condition more precisely.
 Standardized pressure ulcer care protocols
and proves that it can be used effectively in a
clinical setting. . ( Journal of Wound Ostomy
& Continence Nursing. 2018).
 It is very time consuming to observe and
noting down things is a lengthy process.
 Epithelization is needed to be determined by
the percent of wound that is covered .
( Journal of Wound Ostomy & Continence
Nursing. (2018).

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Journal Activity 7: Drains
Identify four different types of drains, their use and specific nursing care.
Drain type 1: : Hollow Plastic Tube OR Sump Drain
Use and specific care:
It is deep drain which is usually sutured in position and attached to closed circuit low grade suction and
usually used following major abdominal surgery. There is possibility of large amount of drainage. Once
suction is removed, it acts as a gravity drain. (wound source.2017)
Drain type 2: Gravity OR Superficial Wound Drain
Use and specific care:
This drain promotes healing by draining superficial fluid from around surgical incision and is usually
located towards the lower end of suture line and just to the side. It drains into “Coloplast” bag or directly
into an absorbent dressing and are sometimes shortened prior to removal. Some of the examples are
corrugated, portex or red rubber drain. (wound source.2017)
Drain type 3: T-Tube
Use and specific care:
A special tube is placed in the common bile duct to allow the drainage of bile into a closed drainage bag.
Open/ traditional cholecystectomy is used to allow heal and prevent bile backing up into the liver due to
post-operative edema of the common bile duct. (wound source.2017)
Drain type 4: Portable vacuum suction drain
Use and specific care:
Perforated plastic catheter is attached to specialized vacuum unit which provides gentle suction . It is used to
drain haemoserous fluid that may collect superficially under a suture line. System may require in the
intermittent re-establishment of the vacuum. This type of drain is not shortened prior to removal . Some o f
the examples of this type of drain are Redivac, Hemavac, Portavac. (wound source.2017)
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Journal Activity 8: Types of dressings
Using an appropriate nursing text, the internet and any product information research each of the
following types of dressings:
1. Film membranes
Film dressings are composed of a thin polyurethane membrane coated with a layer of acrylic adhesive.
Whilst being extremely flexible and allowing visualization of the wound without disturbance, they hold no
properties to absorb wound exudate. (Wiley online library.2009)
2. Foams (Hydrophilic, polyurethane dressings)
Foams are soft, open-cell hydrophilic , non-adherent dressings that have single or multiple layers. The
surface of the dressing is hydrophilic and is placed against the wound to allow exudate to pass through. It
protects and cushions wounds. Small pores decrease the chance of tissue migration into the foamdressing. A
gentle adhesive allows for a secure fit to help protect and cushion the wound site.. (Wiley online library.2009)
3. Foam cavity dressings
Foam dressings are highly absorbent and are available in a range of different shapes, sizes and
compositions. Cavity is indicated for the extended management of full thickness cavity wounds healing
by secondary intention, including pressure sores, pilonidal sinuses, and surgical excisions/incisions to
physically prevent premature wound closure and/or absorb excessive exudates.. (Wiley online
library.2009)
4. Hydrogels
Hydrogels dressings are those type of dressing which provides hydration to wound. It is one of the
good source for providing moisture to a dry lesion. These dressings act fast to help cool down a wound,
as well as provide temporary relief from pain for up to six hours. Hydrogels have high water content i.e.
up to 80% for amorphous gels, 90% for sheet gels. These products have the unique ability to provide
additional moisture to the wound. .(Independence Australia.2018)
5. Hydrocolloids
Exudate combines with the polymers and forms a gel to cover the wound bed and stimulates granulation
when hydrocolloids are applied to a wound and promotes formation of granulation tissue and provides
pain relief by keeping nerve endings moist Suitable for de-sloughing and for light to medium exudate.
It also helps in skin protection on areas of shearing and friction. For example: comfeel. . (Wiley online
library.2009)
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6. Alginates
Alginates are soft, highly absorptive dressings that conform to the wound. It is easy to remove and
won’t damage new, healthy tissue. They are used on wounds with moderate to heavy drainage. It is
highly absorbent interactive dressings which is suitable for venous leg ulcers, pressure ulcers,
fungating wounds, infected wounds. (wounds Australia.2018)
7. Combinations
Combination is usually used for large bleeding wounds after initial bleeding control by direct
pressure dressing. It has a high absorbency feature which is capable of handling heavy
drainage, promote healing and keep the wound dry and also contains high absorbent cotton
allow liquid to diffuse throughout the combine pad.
8. Miscellaneous
Miscellaneous dressing is a combination of different dressings which are used to protect
patients with different dressing needs. For example : inadine, cadeoxime, Povidone Iodine
which is dressing with a chemical complex made up of iodine that fight against bacteria in a
wound. Another miscellaneous dressing is silver which is a antimicrobial and also fights
against bacteria and kills bacteria as it absorbs in the dressing.
. (Wiley online library.2009)
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Journal Activity 9: Principles of complex wound management
Choose two of the wounds that we have looked at in this topic (Activity 3), give a detailed
description and outline the principles of management:
Burn
When the skin comes in contact with something hot, it may be damaged, with death of cells in the skin, this is
called Burn. The severity of the injury depends on the intensity of the heat and the length of time that it is in
contact with either heat or certain chemicals. Most burns are thermal with the largest proportion being scalds,
particularly in the pediatric population. Thermal burns also include contact, flame, and flash injuries.
Chemical and electrical injuries can cause deeply destructive damage to underlying muscle and bone with life
threatening systemic effects under a deceptively small area of involved skin. Burns are classified by the depth
of injury, which helps determine the appropriate treatment which are classified as 1st, 2nd, 3rd,4th degree burn.
The principles of managing burns are similar in children and those for adults, but burn depth assessment is
often more difficult in children due to their thinner skin. Children also require burns resuscitation fluid at a
lesser total body surface area percentage than adults (10% in children as opposed to 20% in adults).
Awareness about hypothermia during initial cooling, especially in young children. For the initial management
of burns first aid is required and immediate, effective analgesia should be provided. Airway and breathing,
circulation, burns depth should be assessed and estimation of surface area should be done as well. Things
such as time of burn, extent - Burn diagramdepth, first aid and tetanus status.(PMC.2017)
Abrasion
An abrasion is a wound caused by superficial damage to the skin, no deeper than the epidermis. It is less
severe than a laceration, and bleeding, if present, is minimal. Mild abrasions, also known as grazes or scrapes,
do not scar or bleed, but deep abrasions may lead to the formation of scar tissue. A more traumatic abrasion
that removes all layers of skin is called an avulsion. Abrasion injuries most commonly occur when exposed
skin comes into moving contact with a rough surface, causing a grinding or rubbing away of the upper layers
of the epidermis. There are three types of abrasion 1st, 2nd and 3rd abrasion.
Key principles of management of skin tear/abrasion includes clean the wound, approximate the skin flap,
apply dressing, review and reassess the wound, use of appropriate dressing, prevent further trauma,
maintaining skin integrity. Infection may be managed using topical antimicrobials or systemic antibiotics to
help prevent the onset of serious complications such as cellulites or generalized sepsis. The main aims of
management are to preserve the skin flap and protect the surrounding tissue, reapproximate the edges of the
wound without undue stretching, and reduce the risk of infection and further injury. (Wound Australia.2018)

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References:
Agency for clinical innovation. (2018). Wound management | Agency for Clinical Innovation. Retrieved
from https://www.aci.health.nsw.gov.au/networks/spinal-cord-injury/pi-toolkit/management/
cleanse-the-wound
Ausmed. (2018, February 21). Wound Care – Introduction, HEIDI Assessment, Tissue Types. Retrieved
from https://www.ausmed.com/articles/wound-care-assessment/
Independence Australia. (2018). Wound Dressings - Wound Care. Retrieved from
https://store.independenceaustralia.com/wound-care/wound-dressings.html
Indian Journal of medical research. (2011, November). Hand hygiene: Back to the basics of infection
control. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3249958/
Journal of Wound Ostomy & Continence Nursing. (2018). Bates-Jensen Wound Assessment Tool:
Pictorial Guide. Retrieved from
https://journals.lww.com/jwocnonline/Abstract/2010/05000/Bates_Jensen_Wound_Assessment_
Tool__Pictorial.5.aspx
Kestrel health information. (2017, March 17). The Four Stages of Wound Healing. Retrieved from
https://www.woundsource.com/blog/four-stages-wound-healing
Ostomy Wound management. (2009). A prospective study evaluating the Pressure Ulcer Scale for
Healing (PUSH Tool) to assess stage II, stage III, and stage IV pressure ulcers. Retrieved from
https://www.researchgate.net/profile/Ulkue_Guenes/publication/26242488_A_prospective_study
_evaluating_the_Pressure_Ulcer_Scale_for_Healing_PUSH_Tool_to_assess_stage_II_stage_III_
and_stage_IV_pressure_ulcers/links/0c96053aa75dc229380
PMC. (2017). ABC of burns: Management of burn injuries of various depths. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC478230/
Royal college of nursing. (2016). Chain of infection | RCN. Retrieved from https://rcni.com/hosted-
content/rcn/first-steps/chain-of-infection

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Wiley online library. (2009). A review on wound dressings with an emphasis on electrospun
nanofibrous polymeric bandages - Zahedi - 2010 - Polymers for Advanced Technologies
- Wiley Online Library. Retrieved from
https://onlinelibrary.wiley.com/doi/full/10.1002/pat.1625
Wound Australia. (2018). Impact of chronic wounds on you and those close to you - Wound Awareness
Week. Retrieved from https://www.woundaware.com.au/impact-of-chronic-wounds-on-you-and-
those-close-to-you/
Wound source. (2017, November 16). Identifying the Different Types of Wound Drainage.
Retrieved from https://www.woundsource.com/blog/identifying-different-types-wound-
drainage
Wounds Australia. (2018). What is a wound? Types of Wounds. Retrieved from
http://www.woundaware.com.au/what-is-a-wound/

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