HLTENN006 Diploma of Nursing: Apply Wound Management Principles

This assignment comprises a knowledge test on the principles of wound management within a nursing context. It includes definitions of key terms such as asepsis, aseptic technique, and various types of wounds (venous, arterial, mixed, discharging, malignant, neuropathic, infected, burns, fistulas, sinuses, and skin grafts). The assignment also covers factors contributing to pressure ulcer development, phases of healing, intrinsic and extrinsic factors inhibiting healing, and key considerations for wound assessment. Furthermore, it discusses the physical and psychological impacts of wounds on clients, carers, and families, and explores holistic care in the community setting for individuals with complex wounds, including referral options and the importance of nutrition and wound care techniques. Finally, it identifies potential complications of wound healing and references the National Safety and Quality Health Service Standards.

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Nursing
Student’s Name
Student’s Number
University
Module Code
Module Name
Date

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HLT54115 Diploma of Nursing
HLTENN006 Apply principles of wound management in the clinical environment
Knowledge Test Student Copy
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Instructions to students
You are required to be assessed as competent in all questions on this knowledge Test. If you
do not achieve competence in all questions, please see your trainer for additional assistance
before making another attempt at the knowledge test.
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The following websites may assist with this assessment
http://www.awma.com.au/home
http://www.smith-nephew.com/australia/about-us/what-we-do/advanced-wound-
management/
http://www.smith-nephew.com/australia/about-us/what-we-do/advanced-wound-
management/
http://www.health.wa.gov.au/woundswest/education/
Question 1
Define the term asepsis.
_________________________________________________________________________thi
s is the absence of all infection or infectious organisms. Asepsis comprises of all mechanisms
aimed at minimizing the risk of infection by bacteria, virus or fungus
Question 2
Define the term aseptic technique
_this is the utilization of practices and mechanisms to prevent infection from pathogens
(Rowley, et al., 2010)
Question 3
Part A
What is the definition of a wound?
__ A wound is an injury to the body which involves breaking or laceration of a membrane
and sometimes to the body tissues (Shah, 2011).
Part B
What is the definition of a venous wound?
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A venous wound is a wound on the ankle or leg that is as a result of damaged or abnormal
veins caused by insufficient return of blood back to the heart (Greer et al., 2013).
Part C
What is the definition of an arterial ulcer?
These are injuries on the lower extremities which are caused by poor perfusion leading to the
damage of the arteries (Greer et al., 2013).
Part D
What is the definition of a mixed ulcer?
A mixed ulcer is an injury caused by a combination of both arterial and venous diseases due
to chronic venous insufficiency (Mosti, Iabichella, and Partsch, 2012)
Part E
What is a discharging wound?
A discharging wound is one in which the body produces a liquid in response to the tissues
damaged (Spiliotis et al., 2009).
Part F
What is a malignant wound?
malignant wound is that caused when cancerous cells attack the epithelium, permeate the
blood vessels and the epidermis leading to a loss of vascularity, lack of skin nourishment and
hence death of the skin (Grocott, Gethin, and Probst, 2013).
Part G
What is a neuropathic ulceration wound?
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A neuropathic ulceration wound is that which is caused by peripheral neuropathy in which
there is loss in the sensitivity leading to monotonous stress, unrecognised injuries and
painless ulcers developing on the limb’s pressure points (Gardner et al., 2013).
Part H
What is an infected wound?
An infected wound is a localized skin excavation or defect of the soft tissue beneath in which
infectious organisms have penetrated into viable tissue near the wound (Sarabahi, 2012).
Part I
What is a burn?
A burn is a type of injury to any skin layer as a result of extreme heat, cold or friction
(Rowan et al., 2015)
Part J
What are fistulas and sinuses?
A fistula is an irregular channel between two anatomic channels that originate from an
internal cavity or organ to the body surface. Whereas a sinus is an irregular pathway which
begins or ends in a single opening (Schecter et al., 2009).
Part K
What is a skin graft?
A skin graft is a transplanted tissue of the skin (Shimizu and Kishi, 2012).
Part L
What is a visceral graft?
A visceral graft is a transplant of one of the visceral organs such as the stomach, small
intestines, pancreas etc
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Part M
Skin infections account for a significant portion of dermatologic diseases, often resulting in,
or as a consequence of a disruption in the skin's integrity. List three fungal and three viral
skin infections.
Fungal skin infections include athlete’s foot, ringworm, and jock itch
Viral skin infections include oral ulcers, herpes simplex, and herpes zoster
Question 4
What factors contribute to pressure ulcer development? Name 4
Chronic disease such as diabetes mellitus
Cognitive deficit
Shear force
Poor nutrition
(Primiano et al., 2011)
Question 5
List the four (4) phases of healing?
_hemostasis phase
Defensive phase
Proliferative phase
Maturation phase
(Pakyari et al., 2013)
_________________________________________________________________________
Question 6
Name four intrinsic and four extrinsic factors that inhibit healing.
Intrinsic factors
Age
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Suppressed immune system
Diabetes mellitus
Skin with reduce sensation
Extrinsic factors
Stress
Smoking
Poor nutrition
Medication
(Wild et al., 2010)
Question 7
Match the following terms:
a) Primary Intention 1. Closure 3 to 5 days later
b) Delayed Primary Intention 2. Wound is healing by the different
phases of healing
c) Secondary Intention 3. Wound edges are held sutures, clips
Question 8
Part A
List 12 key factors that need to be considered when assessing a wound?
i. The location of the wound
ii. Extent of tissue involvement
iii. Type of wound
iv. Type and percentage of tissue in wound base
v. Size of the wound
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vi. Edge of the wound
vii. Wound bed
viii. Depth of the wound
ix. Wound exudate
x. Presence of odour
xi. The peri-wound area
xii. Pain
(Sibbald et al., 2011)
Part B
Discuss the physical and psychological impacts of wounds on clients, carers and families
The physical effects of wound include pain, infections and the inability to perform routine
duties. Chronic wound can be very painful. Such pain can minimize ones mobility and
activity level, more so when there is intense pain during movement. Morbidity as a result of
wounds can lead to potential complications. Physical pain also affects the family and carers
who have to spend time and resources for healing. Infections can worsen the state of the
wound and even take an extensive time to heal as the body is aimed at fighting the infection
instead of healing. If not treated in time, wound infections can spread to other body organs
and can lead to amputation of the infected organ in extreme situations. Wounds can also
cause impairment in the daily activities such as showering and going to work. This
significantly affects the family who have to devote more time and resources to the patient.
The psychological issues caused by wound infection affects the patient in several ways. A
chronic wound may produce an odour or continued discharge which can be embarrassing and
stressful to the individual. As a result the infected person can withdraw from the family and
social events, and such isolation is likely to cause loneliness and low self-esteem. Studies
have also indicated that people with chronic wound infections are more prone to mental
health disorders in addition to anxiety and depression caused by social isolation, alterations in
body images and poor quality life. The carers and family are also affected by the odour which
makes them uncomfortable since they cannot do away with the patient. The carers and close
family members are also at risk of infection when taking care of the wounded individual. An
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aspect that might cause them to shy away from providing the necessary care and attention
(Gorecki et al., 2009).
Part C
The following website may assist with this question
http://www.awma.com.au/publications/2011_standards_for_wound_management_v2.pdf
Primary Health Care aims to promote health, prevent disease and injury and reduce health
inequalities within the Australian and global populations. The focus is moved away from
treatment and cure of disease within secondary and tertiary health settings such as hospitals
and refocused towards removing the cause of disease and injury from the community and
individual. Strategies are based on individual and local community participation in
identification of strengths and health issues and health priorities.
Central to Primary Health Care is empowerment of individuals and communities in health
promotion and disease prevention. How would you provide holistic care in the community
setting for a person with a complex wound?
You are working in the community setting and your evaluation of a wound is that it is not
healing and is infected. Who could you refer the client or the client’s family to? How would
you explain to the family the importance of nutrition, wound care techniques and infection
control?
The provision of holistic care in the community for the individual with complex wound will
involve the consideration of a number of factors. The first step is to ascertain the history of
the patient with regard to medication because the healing of the complex wound might be
slowed by illnesses such as diabetes (Ousey and Cook, 2011). The next step is to carry out
pain assessment with a specific focus on dressing changes. Central to wound infection is pain
assessment because uncontrolled pain can lead to morbidity and psychological stress which
can further impede the healing process.
The nutritional status of the patient will also be assessed because a balanced diet and enough
intake of fluid is significant for healing. In case there is evidence of poor nutrition, the patient
can then be referred to a dietician for additional examination and intervention. The wound
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size will also be measured to determine the level of healing (Halim, Khoo, and Saad, 2012).
Since, it is a community setting basic measures such as the use of a tape measure, tracing or
digital photography can be used to assess the progress of the wound and documented.
The wound bed assessment will also be carried out to provide important information on
wound aetiology, process and progression of healing. The healing progress will also be
ascertained by examining the wound color and peri wound area of the wound bed (Ousey and
Cook, 2011). This can be facilitated by the use of colour charts to demonstrate the clinical
appearance of wounds. Wound exudate will also be observed to help in determining the
condition of the wound bed.
Referring the patient will depend on the factor inhibiting wound healing process. If the
patient has chronic illnesses that inhibit wound healing such as diabetes, then in would refer
him/her to medical professional for in-depth evaluation to ascertain the best intervention such
as therapeutic intervention.
If the cause is found to be poor nutrition, then I will refer the patient to a dietician. if the
patient behaviours such as smoking and drinking is found to be the cause, then I will refer
him to a medical counsellor.
Poor nutrition leads to insufficient nutrients for the body to foster wound healing. Wound
infections increase the protein and caloric needs of the patient. Insufficient calories due to
poor nutrition causes the body to synthesize proteins for energy, which further drains the
body of its healing capacity.
Wound care techniques are important because they prevent further infection and facilitate
wound healing process. This can be done by just looking at the odor, drainage, and color of
the wound to ascertain its healing progress. This is important because if the wound is not
addressed at initial stages, it can worsen and lead to amputation in extreme situations.
Part D
List five complications of wound healing
Infection
Tissue necrosis and gangrene
Osteomyelitis
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Peri wound dermatitis
Hematomas
(Guo and DiPietro, 2010)
Part E
The National Safety and Quality Health Service Standards provide a nationally consistent and
uniform set of measures of safety and quality for application across a wide variety of health
care services. Standard 3 outlines the systems and strategies to prevent infection of clients
within the healthcare system and to manage infections effectively when they occur to
minimise the consequences. Consider the organisations policies and procedures for wound
care. Discuss the wound management strategies and techniques in the facility, include the
following in your answer
Wound cleansing techniques
Wound cleansing is the process of eradicating surface contaminate, bacteria and the remains
of former dressings from the surface of the wound and the skin environs (Atiyeh, Dibo and
Hayek, 2009). Wounds should be cleaned in situations where there is contamination or
infection of the exudate (Cutting, 2010). Proper cleansing will eliminate all infectious micro-
organisms and prevent any additional damage. The Aseptic non-touch techniques is the most
preferred one and it involves precautions applied during clinical procedures to prevent further
infections from the clinician, instrument or surrounding.
Wound measurement
Wound measurement is a vital aspect of wound care. Wound measurement should involve
two and three dimensional assessments. Two-dimensional measures involve the use of tape
measure to determine the length and breadth in millimetres. If the wound edges are not
uniform, then its circumference is determined especially for chronic wounds. Digital
photography can also be used in which photos are taken at different levels of wound healing
process. In three dimensional measures, the depth of the wound is ascertained using a
dampened cotton tip applicator.
Clinical photography
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This is the routine recording of clinical conditions in patients and then use for diagnosis or for
monitoring a wound during the treatment process. The images should only be captured using
NHFT digital devices. Consent must first be obtained from the patient before any
photographs are taken for the purposes of treatment. The images should be attached to wound
evaluation documentation.
Wound tracing
Wound tracing is a two-dimensional tool for measuring wounds which involves the use of a
pen to trace the outline of the wound expressly into a sterile transparent film (Chang,
Dearman, and Greenwood, 2011). Each tracing is systematic and comparable with others and
is comparatively unobtrusive for the patient.
Wound debridement
This involves tender handling of tissues to reduce bleeding and managing initial bleeding
using compression technique. Debridement requires that only a very thin margin of skin is
excised from the wound edge.
Wound drains and wound drainage systems
A drain is any material or instrument used to exit fluid from within the body to the surface or
prevent haematoma formation. Wound drains are positioned at the wound to permit blood to
flow and other fluids to drain out of the body after operation. A wound drainage system a
post-operative surgical wound management used to drain a wound bed in order to prevent
further infection and inhibited wound healing process.
Wound specimen collection
The common techniques for collecting wound specimens include:
Tissue biopsy method is where the clinician removes a piece of viable wound tissue using a
punch biopsy tool or scalpel.
Needle- Aspiration method involves obtaining fluids using 22-gauge needle to make several
insertions into the tissue near the wound. A 10mL syringe is attached to the needle
Swab-cultures method is used in obtaining specimens in the swab culture
Surgical wounds
Surgical wounds heal in the usual pathway of inflammation, maturation or proliferation. All
surgical wounds need not support and this fosters the reduction of oedema and improves
patient comfort. Inspection of suture line is done after five to seven days
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Pressure ulcers
A localised injury to the skin or the tissue below or both caused by pressure or in
combination with shear. The pressure ulcer should be ascertained whether it is avoidable or
not using documented evidence
Venous ulcers
Venous ulcers are found in the lower third of the lower leg and are normally artificial and
discharging. Priority should be taken to manage the oedema and emphasising the growth of
the epithelium across the temporal shear. Compression bandages and zinc paste bandages are
normally used (Collins and Seraj, 2010).
Arterial ulcers
Managing arterial ulcers requires the consultation from a vascular surgeon because some
surgery can be undertaken to reinstate perfusion to the limb. If the tissue is dry and ischemic,
then it should be maintained dry. A silver or cadexomer iodine is used if the tissue in the
arterial wound is worse or infected
Mixed ulcers
Mixed ulcers is a combination of clinical features of chronic venous inadequacy and arterial
disease. This can be addressed using inelastic compression to foster the functionality of the
venous without compromising arterial blood flow (Mosti, Iabichella and Partsch, 2012).
Severe PAD requires arterial intervention to boost blood flow and permit compression
dressings.
Discharging wounds
The treatment of discharging wound require a balance between minimizing heavy drainage
and preventing maceration and sustaining a hydrated wound area. Compression and elevation
is ideal for wounds characteristic of venous insufficiency to improve perfusion. Negative
pressure therapy is most appropriate for heavy drainage.
Malignant wounds
The management of malignant wounds is generally palliative. Wound dressing using
activated charcoal to absorb odour and to treat it. But, the source of the odour should first be
ascertained in which antimicrobials are most appropriate for this. Alginate dressings can be
used for wounds with temporal bleeding (Alexander, 2009).
Neuropathic ulceration wounds
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Neuropathic ulceration wounds should thoroughly be debrided to health, bleeding tissue to
permit better evaluation of the ulcer and any other infections. The wound environment should
be hydrated during the healing process. Contact casts or therapeutic shoes are effective in
pressure reduction. If the ulcer still persists, then surgery can be done to correct the anomalies
in the foot and to eliminate excess pressure.
Infected wounds
Treatment of infected wounds should first be determine whether they are systemic or
localized to the wound environment. Systemic cure requires oral antibiotics based on the
microbiological assessment. Localized infections should be treated using topical antibiotics.
The existence of slough and devitalized tissue is a prompt to use debridement or drainage.
Bio burden can be reduced using antimicrobial dressings (Moretti et al., 2009).
Burns
The treatment of burns should first commence with ascertaining the extent of the burn.
Superficial burns can be treated using occlusive dressing and using silicon dressing. Partial
and full thickness burns can be treated using silver dressing, hydrating using sterile water or
protect using fixative.
Fistulas and sinuses
Fistulas can be treated by filling the track with hydrogel if the discharge is minimal or the
use of alginate or hydro fibre if it is high or average.
Sinuses can also be treated using hydrogel by filling the track using a syringe if the discharge
is low or using alginate if it is high or average
Skin grafts
Dressing should be used and altered based on the instructions of the surgeon
Visceral wounds
Treatment of Visceral wounds depends on whether the wound is in the abdomen or chest
cavity. A midline incision is the appropriate approach to abdominal visceral injuries. Visceral
wounds of the internal organs such as the stomach, colon and the lung should be prioritized
as high-voltage injuries and manage as fast as possible
Part F
Discuss how you have interpreted laboratory results in consultation with the registered nurse
and/or the interdisciplinary team in the nursing home.
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The laboratory results were interpreted based on the background of a reference interval that
differentiate between health and illness. This interpretation was carried out with a knowledge
of any biological variation and cognizant of the potential harm for false interpretation. The
impact of random and systematic errors on the significant of the findings was equally
addressed
Question 9
What is meant by the term “etiology”?
This is a branch of medicine concerned with the cause, origin or source of an illness or
abnormal condition (Eming, Martin, and Tomic-Canic, 2014).
Question 10
List 4 acute wounds?
Burns
Traumatic wounds
Skin abrasions
Surgical wounds
(Lee, and Hansen, 2009)
Question 11
What is a pressure ulcer?
A localised injury to the skin or the tissue below or both caused by pressure or in
combination with shear (Coleman et al., 2014).
Question 12
Part A
List the local signs of a wound infection. Name 6
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Malaise
Running fever
Exudate
Increasing pain
Swelling and redness
Hot incision site
(Ousey and Cook, 2012)
Part B
The following website may assist with this question
http://tle.westone.wa.gov.au/content/file/06143847-5ac3-4a0a-89fa-cca3f915f582/1/
Chain_of_infection.zip/index.htm
Draw the chain of infection cycle.
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Infectiou
s agent
Reservoir
Transmiss
ion mode
Portal of
exit
Portal of
entry
Susceptib
le host

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Part C
You have noticed that a client has signs and symptoms of an infected wound. The Registered
Nurse has asked you to take a wound swab. Following the organisations policies and
procedures, outline how you would take a specimen.
Confirm identity of the patient in terms of name and date of birth or check with family carer
if not possible.
Introduce myself as a staff
Put on identity badge with name and designation
Describe the procedure to patient and possible risks and benefits
Disinfect hands before commencement
Apply one us of none sterile gloves
Appropriately remove dressing
Cleanse wound with sterile to irrigate any reaming matter
Use sterile saline to moisten the swab
Apply zig-zag movements and at the same time revolving between fingers.
Sample the entire wound area and place the specimen to into the transport approach.
Then remove and dispose PPE on completion of the process
Disinfect hands after removing PPE.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
_______________________________________________________________
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Question 13
Define the term moist wound healing.
this is the practice maintaining a wound in an optimally moist state so as to foster healing
Question 14
Match the colour of the wound beds
a) Black 1.Slough
b) Pink 2.Granulating
c) Red 3.Infected
d) Yellow 4.Necrotic
e) Green 5.Epithelialising
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Question 15
Outline the four stages of a pressure ulcer
Sores are not open wounds
The skin breaks open, shear away or develops to an ulcer
The sore worsens and extends to the underlying tissue
The pressure injury is too deep to the muscle and bone (Jaul, 2010).
Question 16
What are the major causes of skin tears in aged care facilities?
Name 4?
Dressing
Removal of adhesive tapes
Falls
Transfers
(Holmes et al., 2013)
Question 17
What factors make a person more prone to skin tearing, skin deterioration, and pressure
dangers?
Age –over 75 years
Gender-prevalent in females___
Dehydrated skin
Impaired mobility
Visual impairment
(Koyano et al., 2016)
Question 18
Part A
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In most cases sutures and staples applied to surgical wounds are removed in 7-10 days. It is
important to use proper technique to promote wound healing and to prevent pain, infection
and damage. List the steps that you will undertake when removing sutures or staples.
i. To be done by RN or LPN
ii. Describe the procedure to patient or family member
iii. Place the patient to expose the sutures
iv. Open the suture kit and Disinfect the suture kit using antiseptic wipes
v. Hold the thumb forceps using one hand and the scissors in the other and slowly grasp
the suture with thumb forcepts
vi. Pull the suture slowly to allow the insertion of the scissors blade between the skin and
the suture
vii. Cut the protruding part of the suture and remove it using the thumb forceps gently
viii. Repeat the above procedures 5 to 7 to the complete removal of the sutures
ix. Wipe the incision line gently using antiseptic wipes
x. Apply appropriate dressing according to the physician direction
(Smith et al., 2010)
_________________________________________________________________________P
art B
Refer to the organisations policies and procedures. How are the sutures and staples disposed
of?
Staples are directly disposed into sharps box and sutures into a plastic trash bag
Question 19
A doppler is a non-invasive method of wound assessment. What does the doppler assess?
It measures the amount of blood flow through the arteries and veins more so those that
provide blood to the extremities
Question 20
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Mrs Francis Owen is an 86 year old widow who, until 2015, lived alone in her own home
with good family support. She was alert but was prone to confusion at times. Mrs Owen had
been a regular client of a large tertiary teaching hospital in NSW since 2005. In 210, cellulitis
of the right lower leg developed into three sloughy ulcers which in time joined to form one
large ulcer on the gaiter area above the medial malleolus.
Medical history
Mrs Owen had a complex medical history of non-insulin dependent diabetes mellitus
(NIDDM), atrial fibrillation, recurrent urinary tract infections, extensive osteoarthritis,
peripheral vascular disease (PVD), post-operative pulmonary embolism and a chronic leg
ulcer. Mrs Owen is allergic to prawns and Micropore tape.
Surgical history
Her surgical history involved an amputation of (L) great toe in 2005, R/O (R) foot bunion in
2009, a partial foot amputation in 2012 and, in 2014, amputation of the third metatarsal (L)
foot and debridement of the (L) forefoot.
Medications
On presentation Mrs Owen was taking the following medications
Warfarin 3mg nocte, Mobic 15mg mane, Losec 20mg BD, Capoten 50mg tds, Glucophage
250mg tds, Lanoxin PG mane, Tramal SR 150mg BD, Normison 10mg nocte, FGF mane,
Lasix 20mg BD, Prothiaden 50mg nocte, Digesic x2 qid prn.
Wound profile
Mrs Owen’s right lower leg ulcer was located just above the medial malleolus and occurred
secondary to cellulitis. Dressings were attended three times a week by district nurses,
sometimes daily depending on exudate levels. Previous dressing regimens used over the past
5 years included Jelonet, Adaptic, Kaltostat, Intrasite gel, Stomahesive powder, Allevyn,
Lyofoam Extra, Duoderm Thick, Gaviscon liquid on excoriated wound edges, protective
barrier wipes, Duoderm stoma paste, Eleuphrat Ung, Medihoney, SSD cream, Intrasite/ SSD
soaked gauze, Biotain, as well as resident self-treatments with over the counter preparations.
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Numerous courses of antibiotics for Staphylococcus and Pseudomonas aeruginosa infections
had been prescribed over this period. The vacuum assisted closure dressing (VAC) was used
in February 2004 when the ulcer deteriorated, with exposure of tendon and lymphatic
leakage. During this period, her blood sugar levels (BSLs) ranged between 10.9 to 21.2
mmol.
Mrs Owen was admitted into an aged care facility in September 2015. On admission, a
comprehensive holistic assessment identified multiple underlying factors which were having
a negative impact on the healing of Mrs Owen’s wound such as PVD, diabetes with high
BSLs, age, obesity and inactivity, anaemia, osteoarthritis and drug therapy.
Aetiology of the wound
Classical clinical signs of venous disease were present.
Pulses were palpable but capillary return was delayed. Variable non-dependent pain was
reported, exacerbated by cellulitis or oedema and described as burning or stinging, indicating
a neuropathic origin due to persistent nerve injury. An ankle brachial pressure index (ABPI)
of 6.0 from a previous consultation with a specialist in venous disease concluded arterial
calcification compounded by diabetes. Assessment findings indicated an ulcer of mixed
aetiology with predominantly venous characteristics.
Clinical characteristics of the wound
Location of the wound
The wound was located over the gaiter area immediately above the medial malleolus
Wound bed status
The wound exhibited deep red coloured friable granulation tissue over an ulcer that bled on
contact. No necrotic tissue was present but about 10% of the wound was covered in
slough.
Wound edge
Irregular margin with a gently sloping border.
Wound measurements
The wound measured 12.5cm x 5cm with a depth of 0.8cm with no undermining or tracking
present
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Wound odour
The wound was slightly offensive.
Peri-wound skin
The skin around the wound was dry, scaly, tight, shiny and oedematous. Ankle flare was
present with distended venules below the malleolus.
Wound exudate
Copious amounts of serous cloudy fluid were exuding from the ulcer,
Laboratory tests
A wound swab identified light staphylococcus infection. Blood tests for serum albumin
(38g/L) showed Mrs Owen had a serum albumin of 35g/l, indicating adequate delivery of
nutrients to the wound 1A low haemoglobin was treated with FGF (Fergon ferrous gluconate).
Part A
List the treatment aims for Mrs Owen.
Treat the cause
Treat the concerns of the patient or family
Manage the impact of the wound on the patient and family
Address psychological issues and coping strategies
Manage pain
Nutrition management
Treat the wound
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Part B
Holistic assessment of the client is an important part of the wound care process. A number of
local and systemic factors can delay or impair wound healing. These may include:
- Malnutrition- inadequate supply of protein, carbohydrates, fatty acids, and trace
elements essential for all phases of wound healing
- Reduced Blood supply - Cardiovascular disorders and Ischaemia
- Medication - Non-steroidal anti-inflammatory drugs and Corticosteroids.
- Chemotherapy - suppresses the immune system and inflammatory response
- Radiotherapy - increases production of free radical which damage cells
- Psychological stress and lack of sleep- increase risk of infection and delayed healing
- Obesity - decreases tissue perfusion
- Infection -prolong inflammatory phase, use vital nutrients, impair epithelialisation and
release toxins
- Reduced wound temperature - prolonged dressing changes or use of cold cleansing
products.
- Underlying Disease - Diabetes Mellitis and Autoimmune disorders
- Maceration - excess wound exudates or contact with bodily fluids reduces wound
tensile strength
- Inappropriate wound management
- Patient compliance
- Unrelieved pressure
- Immobility
- Substance abuse including alcohol and cigarette smoke
From the holistic assessment of Mrs Owen’s wound, devise a wound management plan in
consultation with the facilitator using the nursing homes documentation and attach to this
assessment.
Nutrition
The patient should take a variety of foods to supply all the needful calories, proteins, vitamins
and minerals. The food sources include vegetables, fruits, grains and proteins in varying
amounts as shown below:
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Food servings per day
Whole grains
 Minimum of 5 servings
 1slice whole bread; 1/2cup boiled cereal; 1 cup read to eat cereal; ½ cup cooked rice
or pasta
Vegetables
 2 servings
 1 cup raw or cooked vegetable or vegetable juice; 2 cups of green vegetables
Fruits
 2 servings
 ½ cup canned fruit or ¼ dried fruit
Milk
 3 servings
 1 cup yoghurt/milk
Beans/meat
 5 servings
 1 oz meat, fish or poultry; ¼ boiled beans; 1 egg; ½ oz seeds or nuts
Diabetic patient should limit or eliminate intake of flesh diet and subsist on vegetarian
diet
Oils, fats and sugar
 Appropriate source of calories but should be restricted to prescribed diets
 Vegetable oils, sauces, salad dressings, candy
Obesity and Inactivity
The patient should be engaged in routine exercise such as walking, brisking and increasing
the intensity as much as she is capable to manage.
 Engage in at least 2.5 hours of average to intense physical activity for each week.
Examples include brisk walking, jogging, swimming
 2-3 resistance sessions of resistance exercise each week
 Should not go for two consecutive days without physical activity
 Interrupted sitting after every 30 minutes during the day
(American Diabetes Association, 2017)
Proper wound management
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Treatment of the diabetic foot ulcer will involve revascularization through vascular surgery or
off-loading utilizing casting. However, the objective should be to improve the rate of healing
and to convert the ulcer from chronic to an acute healing wound using the principles of
moisture balance and debridement.
The most appropriate approach in the management of the exudate is to address the causal
factors. Thus good diabetic control and compression therapy should be used to address the
exudate problem.
Part C
Discuss the importance of an interdisciplinary approach to care for Mrs Owen’s wound.
The wound of Mrs Owen has several factors that needs to be addressed to ensure healing.
This requires a number of diagnoses to be carried out by varying experts which is possible
through an interdisciplinary approach.
The approach is consultative, collaborative and actively involves the patient and family.
The approach also is important since it helps prevent thinking that is inclined towards risk by
assessing the risk against the rewards for the patient
Part D
Discuss the nursing homes policies and procedures to minimise cross-infection during
assessment and wound care.
Hand hygiene. Hands should be decontaminated before and after assessing wounds.
Personal protective equipment should always be used when assessing wounds to avoid risk of
contamination from the wound infections. Disposable aprons and gloves should always be
worn. The gloves should appropriately be disposed after every use and before contact with
other items such as door handles etc.
Decontaminate hands after removal of gloves
Ensure that the exposure of a susceptible site is kept minimum
Part E
Discuss where you will find orders and policies and procedures for wound care in the nursing
home. Discuss the following in your answer
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- The importance of adhering to orders which may include leaving dressings intact.
- Working within a cost effective framework
- Wound assessment, monitoring and evaluation
- Documentation and reporting
- Client and family participation in wound care
Nursing homes have orders, policies and procedures for wound care and are to be adhered to
by all practitioners. This is important to avoid cross-infection, further injury, and to facilitate
wound healing. A cost effective framework is the goal of each nursing home in wound care
and this can be found in the organization’s mission and goals.
Wound assessment should always include five parameters namely type of tissue, wound
exudate, level of pain, wound size and peri wound condition. Wound monitoring has
advanced with the modern technology in which digital systems are used for measurement,
evaluation, imaging and documentation of wounds. The participation of client and family in
wound care is significant tin the process of wound treatment. This is because the involvement
of the patient in wound treatment ensures that it is done on the basis of the needs and interest
of the client. This also helps solve other psychological issues associated with the wound and
affect the healing process. The involvement of the family as well is important because they
are also affected both emotionally and physically. This helps to avoid isolation which results
to loneliness and stress.
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