Wound Management Plan for Post-Operative Wound Care: HLTENN006

This assignment presents a detailed wound management plan for a 57-year-old patient, Mr. David Pearson, who underwent a total knee replacement. The plan outlines the reason for admission, the patient's medical and social history, including osteoarthritis and hypertension. It describes the wound's characteristics, dressings used (crepe bandage), and the patient's diet and elimination habits. The assessment includes details on wound location, dimensions, stage, exudate, and surrounding skin condition. The plan also covers nursing interventions, pain assessment, and the use of various solutions and dressings like saline and Aquacell. The document provides a comprehensive overview of post-operative wound care, including regular assessments and interventions, aiming to promote healing and prevent complications. The plan also includes details about the application of the plan and the relevant course module HLTENN006.

Wound Management Plan 1
Reason for this admission : The patient has undergone total knee replecament in
the right knee.
Name of patient: Mr. David Pearson
Age: 57 years
Social History: Has a wife and four sons, with whom he migrated from England to
Australia
Occupation: Retired merchant navy one
Cognition: correct orientation to time and place
Principle diagnosis: osteosrthritis
Medical History: osteoarthritis, hypertension
Type of Wounds: wound in knee
Dressings: At right knee with crepe bandage, kept intact
Diet: through IV in the wrist
Elimination: 12 times a day
Mobility (pre-admission): passive exercises
ADLs: Assistance in showering required, for going to double storeys, meals
assistance also required
FOR OFFICIAL USE ONLY Holmesglen: fd/nursing æOct-2018 Delivery & 2\HLTENN006 - Apply principles of wound management\New Assessment 201 Mssessment Task 1-
Simple Wound\Wound Management chart.d00(

Intermittent Intermittent
(5 z
z
WOUND CARE ASSESSMENT &
PLAN
Only One (1) Wound Per Form —
Circle or tick responses as appropriate
Legend for Wound Stages Location (circle site on
Stage Skin Integrity Appearance Exudate
Intact/Non Blanchable Erythema or Discolouratjon None
2 Superficial Loss Erythema, hot, painful or
oedematous Low / Mod
3 Loss of B/c tissue wit) cavity Sloughy, Necrotic, Red Low / Mod i High
4 Loss of s/c tissue with cavity, Red
Sloughy, Necrotic,
involving bone, muscle or tendon
Low / Mod / High
Unstageable Loss of tissue with cavitv,
unab'e to view base of wauhd Slough, Necrotic, Red Low / Mod i High
Suspected
Deep [6)
Intact but suspected to have
deep tissue involvement
Intact, Discoloured or blood
filled blister None
WOUND TYPE:Pressure injurya Burn Arterial ulcer
Venous ulcerMalignant Haematoma Diabetic ulcer
LacerationAbrasion Surgical Incision
BlistersSkin Tear a Omer
Date: Time: Date: Time: Time:
Dimensions: 4incles
10 inches Widdi
Depth
Length
cm
cm cm
cm
cm
cm
Stage:
Photograph:
Consent obtained Yes / No
Photograph Yes / No Photograph Yes No Photograph
Wound Swabs: Wound Swab Yes / No Wound Swab Yes / No Wound Swab
Results of swabs:
Nurse Review: Nurse Review Yes / No I Nurse Review No Nurse Review
Duration of Wound:
mths = Months
< 3 mths / 3-6 mths /
6-12 mths / 12+ mfrs
< 3 mths f 3-6 /
6-12 mths / 12+ mths
< 3 mths / 3-6 mths /
6-12 mths / 12+ mths
baldate: Amount:
Type:
a Nil a Mod Q
Heavy
a Low a
Mod Heavy Low a
Mod Heavy
Serous Purulent
Haemoserous
C) Serous a Purulent
Haemoserous
a Serous Pun.]lent C.I
Haemoserous
Drains Insitu
Odour: Q Offensive NÉE I C) Offensive Nil Offensive Nil
Colour of Wound and
Surrounds
colour a Pink
epitheiisation Cl Red -
granulating
Yellow - slough
Green - infectious
Black -necrosis
Colour (Tick)
Pink - epithetisation
Red granulating
Yellow -
slough Green
- infectious
aack -
necrosis
Colour (Tick)
Pink - epitheiisation
a Red - granulating
Yellow - slough
Green - infectious
Black -necrosis
Surrounding skin: Healthy
fragile O Macerated
Inflamed Q Discoioured
Other
Heatthy Dry/Scaly
Fragile Q Macerated
Inflamed Discoloured
Other
Healthy C] Dry/Scaly Fragile
Macerated inflamed
Discotoured
Cl Other
Suture Line: jaggered Q Clips / Sutures insitu Clips / Sutures insitu a Clips / Sutures insitu
Present on admission:
Comments:
Pain on dressing change
Severity Score (Score 1-
10): 3
RN Printed Name:
RN Signature:

Right knee
Crepe bandage
Aquacell or tegaderm
Pearson
David
Male
Twice a day
Saline,
Ringer’s solution
Hydrogen peroxide