University Assignment: Principles of Wound Management in Clinic

This assignment comprehensively addresses the principles of wound management within a clinical environment. It covers various aspects, including the stages of wound healing (hemostasis, inflammation, proliferation, and maturation), factors influencing healing (stress, sleep, exudate), and the characteristics of wound tissues (necrotic, sloughy, granulating, and epithelizing). The assignment also details clinical manifestations of wound interventions, strategies for preventing infection, and measures to minimize cross-infection. Furthermore, it explores different types of wound drainage, the importance of wound cleaning, and the principles of wound care, including primary and secondary dressings. Periwound assessment, factors affecting psychosocial impact, wound management considerations (moist environment, pH balance), and the roles of healthcare team members are also discussed. The assignment concludes with instructions for family education, intrinsic factors affecting healing, types of dressings (hydrocolloid and hydrogel), documentation practices, and the classification and management of leg ulcers and pressure injuries.

Running Head: Principles of Wound Management in Clinic
Principles of Wound Management in Clinic
Name of the Student:
Name of the University:
Author Note:

1Principles of Wound Management in Clinic
Table of Contents
Assessment I...............................................................................................................................2
Assessment Task 2- Scenario...................................................................................................12
References................................................................................................................................20

2Principles of Wound Management in Clinic
Assessment I
1. The confidentiality and privacy of the patient is maintained by developing a patient
privacy and confidentiality policy. It is ensured that this policy is extended to the
partner. This confidential policy should be in secured systems and the best IT
security policies should be implemented.
2. A. Epidermis
B. Papillary layer
C. Dermis
D. Reticular layer
E. Subcutaneous layer
F. Hair follicle
G. Hair shaft
H. Pore
I. Dermal papillae
J. Melanocytes
K. Hair follicle
L. Blood cell
M. Apocrine Sweat gland
N. Eccrine Sweat gland
O. Pacirial corpuscles
P. Adipose connective tissue
3. The wound healing process has four steps. They are- homeostasis phase,
inflammatory phase, proliferative phase and maturation phase.
Homeostatic phase deals with the closing of the wound by clotting. The platelets
stick to the wound site and takes up an amorphous shape. These activated platelets

3Principles of Wound Management in Clinic
secrete chemicals that promote clotting which activates fibrin. Fibrin forms a mesh
like structure that enables the platelets to stick to each other and successfully form
a clot.
Inflammatory phase causes dead and damaged cells are removed from the system
by means of phagocytosis by white blood cells. The platelet derived growth factor
helps in growth and proliferation of cells.
Proliferative phase initiates the growth of new tissues. New blood vessels are
formed by vascular endothelial cells by the process of angiogenesis. Fibroblasts
secrete fibronectin and collagen and forms new extracellular matrix. This stage
ensures wound contraction as well.
Maturation phase realigning of the collagen occurs and cells which are not required
are removed by the process of apoptosis (Harper, Young and McNaught, 2014).
4. Moist environment has a positive impact on wound healing promising a faster
healing than wounds that normally dry out. Three advantages of healing wounds in
a moist environment is:
 Ensures faster healing of the wound
 Moist wound causes a hypoxic environment that prevents invading of
bacteria and maintains a proper pH ensuring angiogenesis.
 Moist wound healing reduces pain and this reduces stress followed up by
lesser fatigue in the patient promoting faster healing and mobility of the
patient (Junker et al, 2013).
The key factors that affect wound healing includes-
 Stress and negative mood that may cause social isolation
 Sleep disturbances
 The exudates from the wound and the pain (Upton & South, 2011).

4Principles of Wound Management in Clinic
It has been evident in the research studies that living with wound has psychological
impact. Research studies has demonstrated that the patient with wound suffers from
anxiety and depression as result of continuous pain. In addition to this, they sometime
feel themselves as burden on their family members (Pereira, Figueiredo-Braga, &
Carvalho, 2016).
5. The characteristic wound tissues discussed are as follows:
 Necrotic tissues indicate dead tissues in the wound area due to lack of
oxygen supply. It causes cells to be acidic which releases enzymes that
break the cell.
 Sloughy tissue is categorised under necrotic tissue and it separates itself
from the site of the wound. Tissues become fibrous in nature.
 Granulating tissue is new connective tissue growing at the wound surface.
This indicates a sign of healing.
 Epithelizing tissue forms a barrier between the wound and the
environment. This tissue is formed during the re-epithelialization phase in
the process of the wound healing.
6. a) The clinical manifestations of wound interventions if wound infection is
 Purulent drainage- This is a milky white discharge from the wound which
indicates infection.
 Serous drainage- this is a thin watery discharge from the wound that
consists of blood cells, proteins and other cells that heat the body.
b) Three strategies to prevent wound infection includes:
 The wound should be washed with antiseptic or at least soap immediately.
 After applying ointment, it should be covered with bandages or gauze.

5Principles of Wound Management in Clinic
 The dressings should be changed every day and the wound should be kept
dry.
c) Measures to minimise cross infection are:
 Early diagnosis of infection prevents the spreading of it.
 Healthy wound care practices: Sanitary wound bed preparation,
debridement and maintenance of moist environment and appropriate on
time dressings.
d) Educating patients to prevent infection of wound includes:
 Daily dressing of the infected area and keeping the wound covered.
 Pain management training should be done to avoid pain as it restricts the
flow of blood.
 Non adhesive dressing tapes should be used and wound should be dry.
7.
Type Colour Consistency Significance
Serous Clear Watery It signifies damage in the wound
Haemoserous Red Thick Signifies internal damage
Sanguinous Bright red Thick Signifies damage in blood vessels
and capillaries
Purulent translucent Mesh like
and thick
Signifies presence of infection
8. The importance of wound cleaning are:
 It prevents microbial infections on the wound site
 Helps hasten the wound recovery process

6Principles of Wound Management in Clinic
 Prevents further deterioration such as spread and formation necrotic tissue
in wound site (Pegram & Bloomfield, 2010)
The wound care is fragile and has complications. The principle of wound care
involves preserve the function of the cells and tissues affect and to prevent
complications. Any deviations from the care can lead to non-healing of the chronic
wounds.
Primary dressing is the initial dressing of the wound which involves application of
ointment and covering of the wound with tape to prevent bleeding or oozing of any
liquid. It is in direct contact of the wound. The wound is non-adhering and acts as
an absorbent.
Secondary dressing covers the primary dressing of the wound. The main purpose
of secondary dressing is to keep primary dressing in place. It includes gauze and
tapes. They do not directly come in contact with the wound but covers the wound
fully (Dhivya, Padma & Santhini, 2015).
9. Periwound are good indicators for identifying the wound type, moisture imbalance,
intruding infections and for managing the plan of care.
Periwound assessment involves:
Abscess- A painful compressible tender mass of tissues which is warm to touch.
This occurs due to collection of fluid within the tissue. This mainly occurs due to
acute or chronic localized infection.
Hyperkeratosis- inflammation due to the wound may trigger excessive keratin
secretion. As a result, the person’s skin becomes thicker than usual. This causes
callous-like tissue formation at the edges of the wound.
10. Wound pain can occur due to various issues like skin damage, blood vessel injury
or nerve damage and ischaemia. Ischaemia is a syndrome that prevents the supply

7Principles of Wound Management in Clinic
of blood to tissues resulting in lack of oxygen to carry out cellular metabolism.
These situations create a condition of hypoxia and delays wound healing subjecting
the wound to infections.
11. One of the clinical feature that impact the psychosocial life of the patient suffering
from chronic wound is anxiety. An individual with chronic wound suffers from
loss of low self- esteem, pain and social isolation. All of these negative emotions
impacts the individual emotionally and hampers the mental state of the individual.
This impacts the quality of life of the individual. Anxiety prevents the individuals
from participating wholly in their social and daily life activities leading to social
isolation and depression. These cumulative approach causes anxiety in the patient
due to chronic wound that impacts the psychosocial life of the patient.(Platsidaki,
Kouris, & Christodoulou, 2017).
12. Factors to be considered for wound management are-
 Maintaining moist environment for fast healing- The moisture content helps
in healing the wound three to four times faster than the normal conditions.
 Maintaining stable wound temperature. Prevent wound exposure or
avoiding cold solutions.
 Maintain an acidic or neutral pH to prevent wound infections. This is
because the pH plays an important role in cellular processes. It also
prevents formation of biofilms that affect the process of wound healing.
 Allow flow of drainage if there is extensive drainage flow. This is because
exudates play a major role in allowing migration of the cells across the
wound bed. This ensures distribution of growth and immune factors that
play a crucial role in healing.

8Principles of Wound Management in Clinic
13. The five members of a health care plan for wound management involves:
 Physician
 Nurse
 Radiologist
 Psychiatrist
 Physiotherapist
14. The instructions to be provided to the family to prevent wound damage is given
below:
 The family should be educated on prevention of wound drying. Ensuring
presence of moist environment as it promotes faster healing of the wounds.
Moist environment ensures better and faster healing of the wound.
Maintenance of moist environment ensures new cell and tissue formation.
It enhances the skin renewal power.
 To maintain a pH balance to prevent infections in the wound ensuring the
wound is dry and the dressing are done at regular intervals. The formation
of biofilms is essentially prevented by maintaining low pH and improves
the cellular processes.
15. Intrinsic factors that affect wound healing-
 Age
 Nutrition
 Obesity
 Repeated trauma
16. The two types of dressing are:

9Principles of Wound Management in Clinic
 Hydrocolloid dressing- This type of dressing is usually done on burns. It
involves too much of oozing out of liquid and necrotic wounds. These are
non-adhesive in nature and non-breathable. It is self-adhesive, easy to apply
and biodegradable. It prevents the bacterial infections as it is impermeable
to bacteria. Example include Duoderm, Medihoney.
 Hydrogel dressing- This type of dressing is used for wounds with less
drainage and necrotic wounds. This type of dressing maximizes patient
comfort and reduces pain. The cooling effect of the gel promotes pain
reduction. Example include Aquaform, Intrasite.
17. Five observations that a nurse should document about a patient having a wound
with staples in situ:
 The patient’s medical history
 Details of the wound and extent of cut should be examined
 The sterility of the environment should be checked
 Check the wound for any redness, drainage or accumulation of dead
tissues
 Remove any dead cells from the surface of the wound and ensure moist
environment for fast healing.
18. Wound drainage can be normal as well as abnormal. Normal drainage from wound
is watery, odourless and having a clear consistency. Minimal amount of blood loss
may be observed. It shows less redness and swelling indicating a sign of healing.
Serous and serosanguinous drainage can be considered as examples of normal
wound drain.
Purulent drainage is not a characteristic of normal healthy wound healing. The
exudates can be thick, milky that may turn yellowish, tan, grey ensuring the

10Principles of Wound Management in Clinic
presence of infection in the wound site. Abnormal wound drainage shows
excessive oozing of blood. The area is soft and tender indicating pain in the area.
The consistency is also thicker and may sometimes have bad odour. The examples
are haemorrhage and sanguinous drain.
19. The cost related factors of wound management include nursing staff for monitoring
and dressing the wound. In case of delayed healing surgical intervention and
hospitalisation may impact the expenses. Prevention, monitoring and interventions
in the wound are important cost related treatments. Psychiatrist may also help the
patient to deal with the stress factor and enable faster healing.
20. Leg ulcers can be categorised into three types. They are venous ulcers, ischemic
ulcer and neurotrophic ulcer.
Venous ulcers occur due to damage in the underlying veins of the foot. It can be
treated by keeping the legs at elevated heights and by compression therapy.
Neurotrophic ulcer occurs when an individual has sensation impairment in their
foot due to nerve disorders (Sacchetti & Lambiase, 2014). It attacks the pressure
points of the foot and are difficult to heal. It requires wound debridement to ensure
successful healing.
Ischemic ulcer is seen in patients who have cardiovascular disease and the arteries
are affected. These ulcers are painful but bleeding of the ulcers is not frequent
(Yotsu et al, 2014).
21. Pressure injuries occur on the skin or tissue over a bone due to shear pressure. The
stages involve
 Stage I- Non-blanchable erythema which indicates redness of the region
which might be warmer than the surrounding, tender and painful to touch.

11Principles of Wound Management in Clinic
 Stage II- Partial thickness skin loss has no bruising indicating a primary
shallow open ulcer which is dry. Change in consistency of the tissue,
tenderness, heat and pain observed (Stankiewicz et al., 2016).
 Stage III- Full thickness skin loss suffers loss of subcutaneous fat but
tendons and bones are not exposed. Slough is also observed.
 Stage IV- Full thickness tissue loss exhibits exposure of tendons, bones,
ligaments due to loss of subcutaneous fat. Slough with tunnelling may also
be observed.
 Stage V- Depth unknown and deep tissue injury involves purple or maroon
localized area. This discoloration occurs due to damage of the tissues in
that area (Skórkowska et al., 2013).
22. The major causes of pressure injuries involve-
 Pressure- A prolonged pressure on a particular part of the body reduce the
flow of blood to that region. Blood flow is very important for the cells to
receive the required oxygen and nutrients. Cells depleted of nutrients can
get damaged and eventually die which leads to the development of pressure
injury.
 Friction- When there is rubbing skin rubbing observed against bed sheets or
any clothing it leads to friction. This action makes the skin in contact with
clothing or bed sheets fragile and it becomes vulnerable for pressure injury.
 Shear- When two surfaces move in direction opposite to each other it
results in shear. When shear occurs, the skin over the bone in our body
might stay in same place which is essentially pulls the skin in opposite
direction. If this process occurs continuously, then this two opposite
direction force develops into pressure injury.

12Principles of Wound Management in Clinic
23. The intrinsic factors of the patient that lead to sustaining of pressure injuries
include lack of mobilisation due to old age, cognitive deficit, chronic medical
condition of the patient example diabetes mellitus, poor nutrition and use of
steroids.
24. a) The classification system for identification of the skin type is Skin Tear Audit
Research, STAR (Koyan et al., 2016).
b) There are three broad classes of skin tear with sub classes. These are
 Category 1- the edges of the skin tear can be realigned with that of the
normal skin without stretching. The injured skin colour is not pale and
darkened. It can be assessed as a tear where realigning to the normal skin
does not need stretch.
 Category 2a-The skin tear edges can be realigned with the normal skin
normally. The skin looks pale, dark and dusky which indicates ischaemia or
haematoma.
 Category 2b- the edges of the skin tear cannot be realigned with the normal
skin. The skin is pale, dark and dusky indicating probability of ischaemia or
haematoma.
 Category 2c- Skin tear cannot be realigned with the normal skin. The
affected skin is not pale dark and dusky.
 Category 3- There is complete absence of the skin flap.
c) The appropriate dressing categories for skin tear includes-
 Proper cleaning of the wound with saline water
 If the flap of skin can be realigned easily then the needful will be done by
the clinician but it is difficult to realign the skin flap is rehydrated with a
wet non-woven swab.

13Principles of Wound Management in Clinic
 Skin tears which require dressing has few options. Petroleum based gauze
wrap is used which is non-adhesive and absorbing in nature (LeBlanc &
Baranoski, 2017).
25. The wound dressing should be carefully monitored to check the presence of any
exudates from the wound. The wound should not get in touch with water and
should be kept dry. The multidisciplinary team to be involved includes the general
physician, nurse, nutritionist and psychiatrist (Moore, Webster & Samuriwo,
2015).
26. Wound care management involves the essential care required for healing of the
wound ensuring the fastest route for the healing. It can be direct as well as indirect
in nature. The main aim of both the technique is to prevent skin breakdown. These
may involve dressings and the required palliative care. Wound care management is
essential to prevent microbial infection intervention and other related
complications that may lead to sepsis and can even lead to death (Powers et al.,
2016).
27. Wound drain is a tube inserted by the surgeons or the radiologists. This fluid
removes pus, blood and other exudates from the wound. Example is Jackson Pratt
drain (Wilkes & Sanders, 2013). It is the most common type of wound drain. The
blood and exudates are carried by the surgical drain or tube to a collection bulb.
Assessment Task 2- Scenario
Answers to scenario one-
1. E.coli is usually transmitted from person to person by the oral-faecal route. The
source of E.coli was from Mary Gordon to the nurse’s hand and that unwashed
hand dressing the wounded patient.
 Infectious agent is the faeces of Mary Gordon

14Principles of Wound Management in Clinic
 Reservoir is the intestine of Mary Gordon
 Portal of exit is the faecal route of Mary Gordon
 Mode of transmission is through the hands of the nurse
 Susceptible host is the patient with the abdominal visceral wound. The immunity
of the patient was low.
2. A good hygiene of the nurse would have avoided the infection. Cross infection can
be prevented by frequently was the hands and wearing sterile gloves, frequent
changing of the hospital beddings to prevent the spread of contamination.
Cleaning of the ward rooms with UV rays to kill all the potential microbes. This
should be done in absence of the patients. No human should be projected to direct
UV rays.
3. Acute wounds are superficial may cause the redness and inflammation. The
healing of such wounds is predictable and occurs at an expected rate. Chronic
wounds are those wounds that are deep and has affected a larger area. The healing
of such wounds is not predictable and does not occur at an expected rate (Bryant &
Nix, 2015).
The importance of individualised plan is that it helps in fast healing of the wound
and prevent any infection that may occur. It also reduces probability of other
complications with it and the onset of wound infection. It decreases the discomfort
of the patient and promotes the quality of life of the patient.
4. The standards with respect to National Safety and Quality Health Service ensures
improvement in the quality of the health services.
5. A)

15Principles of Wound Management in Clinic
Wound Type Dressing options Review times
Dry necrotic wound Moisture retention eg hydrocolloid, semi
permeable 3-4 days
Slough - covered wounds Hydrocolloid dressing, Hydrogel dressing 2-3 days
Infected wound Alginates, Hydrocolloid dressing Daily
Graze, abrasions - clean Hydrocolloid Daily
Graze, abrasions – soiled Hydrocolloid Daily
Puncture wounds or bites Hydrocolloid Daily
Laceration – sutured
Lacerations Hydrogels Every 4 hours
Burn-minor Burns
Thin layer of ointment is required. Prevention of
rubbing the area against any object should be
avoided. Running water helps in cooling the
burn
NA
Burn-major or requiring
admission example special
areas, Burns
Layer of silver sulfadiazine and covered with a
petroleum jelly gauze Twice per day
Chronic wounds eg ulcers,
PEG sites etc Foam, antimicrobial and alginate dressings 1-3 days
5. B) It is opined by Vowden & Vowden, 2017
Dressing
types
Example
s
Advantages Disadvantag
es
Indication
s
Contraindicatio
ns
Semi-
permeable -
thin,
adhesive,
transparent
polyurethran
OpSite,
Tegader
m
Some
moisture
evaporation,
Reduces
pain. Barrier
to external
Exudate may
pool, may be
traumatic to
remove.
Superficial
wounds.
As a
secondary
dressing.
Highly exudative
wounds.

16Principles of Wound Management in Clinic
e film contaminatio
n. Allows
inspection.
Non adherent
Moist (Tulle
Gras
Dressing) -
Gauze
impregnated
with paraffin
or similar.
May be
impregnated
with
antiseptics or
antibiotics
Non-
stick
gauze,
ouchless
dressing
Fabric does
not stick to
the wound.
No pain
during
removal. It
has a gentle
nature and
won’t disrupt
healing
Requires a
secondary
dressing for
well
absorption
Open
wounds
which has
light to
moderate
exudate
Light to
moderate
exudates, Allergy
Non adherent
Dry Thin
perforated
plastic film
coating
attached to
absorbent
pad
Melolin
tricose
Absorb light
exudate and
no adherence
to the wound
Not used in
heavy
exudates,
may dry out
and adhere to
both.
Requires
secondary
dressing
Acute
traumatic
wounds
Dry wound
Fixation
Sheet Porous
polyester
fabric with
adhesive
backing
Mefix,
Hypafix
Directly used
on wound
site, relieves
pain and
prevents
onset of
edema.
Dressing can
persist till 7
days
Dressing
needs to be
washed with
soap and
water daily.
Prior oil
application is
required.
Mild
exudates
Infected
wounds
(adhesives as
well as allergy)
Calcium
Alginate
Natural
polysacchari
de from
seaweed
Kaltostat Formation
of gel on the
wound site,
is pain
relieving in
nature,
promotes
homeostasis,
prevents
allergy
Requires
secondary
dressing. It is
not used in
anaerobic
infection.
Moderate
to high
exudate
Dry wounds
Foam
Dressings
Polyurethane
foam
dressing with
PolyME
M
Promotes
protection
and is moist
in nature and
shows high
The size of
the foam is
restricted by
wound size
Mild to
moderate
Dry wounds

17Principles of Wound Management in Clinic
adhesive
layer
incorporated
absorption
rate
Hydrocolloid
Dressings
Polyurethane
film coated
with adhesive
mass
Duoderm Retention of
moisture and
painless
removal
Not used in
high exudates
Burn,
abrasions
Dry wound and
infection
Paper
adhesive
tapes
Adhesive
tape may be
applied
directly to
healing
laceration
Micropor
e
Low in
allergy and
supports
wound.
It is non
absorbent
Small
wounds
usage
Large wounds
Answers to scenario two-
1. There are three stages of burning-
 First degree- This affects the outer layer of the skin and involves redness
and irritation majorly.
 Second degree- This is partial thickness burn which affects the dermis and
the epidermis of the skin. It involves pain, swelling, redness and blistering.
 Third degree- this is complete thickness burn that not only affects the
dermis and the epidermis of the skin but also penetrates the same affecting
the tissue embedded deep inside. This causes blackening or charring of the
particular region (Jones et al, 2013).
 Treatment for John was the treatment for third degree burn which involves
application of tetanus shots, skin grafting, medicine administered to reduce
pain, intravenous administration of electrolytes, debridement for the burnt
region, ensuring moist environment for healing and providing nutritional
supplements and maintaining high protein diet (Yastı et al., 2015).

18Principles of Wound Management in Clinic
 Hydrocolloid dressing, hydrogel and collagen dressings can be exploited for
dressing the burns (Rowan et al., 2015).
2. John is likely to suffer mental trauma and inculcate a sense of helplessness and fear
due to his circumstances. The physical impact includes the immense pain due to the
burn injury as well as the medications required for the treatment of the burn like
skin grafting and dressing (Stavrou et al., 2014).
3. The multidisciplinary team to aid in medication and discharge of John includes- the
burn specialist, the nursing staff to monitor the dressing and the progressive
healing, the nutritionist who ensures a protein rich diet for John keeping an account
of the food allergies he is susceptible to. A psychiatrist to enable him to mentally
cope up with the trauma and educate him about the progress in his health condition.
A surgical specialist and anaesthesiologist (Butler, 2013).
4. Sterile swabs are to be used to collect the sample from the wound. This is done to
check the micro flora of the wound and whether there is any sign of infection.
Since there is purulent discharge from the wound it is not a dry sample so
moistening the swab is not required prior to sampling. The equipment used for the
swab test is a cotton buds wrapped on a small rod of paper or wood. This cotton is
dipped in a saline solution before taking the swab from the wound site. The doctor
wanted to go for a swab test by collecting the pus or fluid from the wound site to
ensure that there is no wound infection.
5. The wound should not be exposed to debridement because this will wash of the
micro flora of the wound. Saline solution dipped swab should be used to take the
sample. It is important to know whether the wound is infested with infections and
the progress in the healing process. A sterile swab is used to collect cells or pus
from a superficial wound site. The wound is swabbed from margin to margin in a

19Principles of Wound Management in Clinic
10 point zigzag fashion. Pressure should be exerted so that fluid ooze out from the
wound site for the swab test. It is advisable not to clean the wound before taking
the swab as cleaning would remove the potent pathogens if any in the wound site
and give faulty result.
6. The potential cause of the infection is medical negligence in the process of the
grafting surgery. The onset of infection in the wound should be prevented because
it has a negative effect on the health of the individual. It not only delays healing in
the wounds, also causes inflammation, pain and in chronic conditions can lead to
sepsis and death.
7. The small amount of purulent in the wound indicates proliferative healing phase of
John. The exudates from the wound is a normal progressive sign of healing.
Though slight inflammation and infection is expected in the wound better
understanding of it will come from the swab test. But it can be concluded that the
healing is happening and there is no visible sin of infection in John’s wound.
Documentations regarding any changes in his physiological health should be noted
as an impact of the burn. His metal state and nutrition should be checked. He
should include a diet rich in protein and if pain increases regarded painkiller
administration.
Answers to scenario three-
1. The pathophysiology of diabetes is that either insulin resistance or damage of the
insulin producing cells like pancreatic β cells causes increase in the level of
glucose in the blood. The symptoms include excessive thirst, frequent urination,
blurred vision, fatigue, nausea and slow healing of wounds (Paneni et al., 2013).

20Principles of Wound Management in Clinic
Pathophysiology of arterial and venal ulcer is the damage of arteries and veins of
the lower part of the body like foot and leg. This mainly occurs due to lack of
oxygen supply to the surrounding tissues. The symptoms of arterial ulcer include
reddened hairless area, no bleeding and leg pain at night, deep wound, the affected
area is cold to touch as it receives minimal or no blood circulation. The symptoms
of the venal ulcer are inflammation, swelling, aching, discharge and brown stained
skin (Vasudevan, 2014).
2. The tools used to diagnose ulcer can be- endoscopy or biopsy, X-ray, urea breath
test, blood test, stool test, computerized tomography (CT) scan (Pannier & Rabe,
2013).
3. The management can be done by debridement of the dead tissues in the ulcer,
revascularization surgery, foot elevation, mechanical compression, blood glucose
level management (Alavi et al., 2014).
Wound care practices have been going on since the early ages and it involved the
use of oil which allows minimum bacterial growth (Maida, 2013). Use of beer and
wine was also prevalent which exploited the presence of alcohol in it that acts as a
disinfectant. Sometimes green paints were used. Green indicated life and paint has
copper that is bactericidal. The water was boiled and vinegar and wine were added
and this solution was used to clean the wound.
4. The healthcare team for Cathy would include a general physician, nurse, surgeon,
and nutritionist (Buggy, & Moore, 2017).
5. The management would include debridement of dead tissues and proper dressing,
prevention of infection and maintaining the blood glucose level in normal limits
(Uçkay et al., 2014). Debridement process helps in cleaning dead and
contaminated material from the wound site and aid in healing. Debridement also

21Principles of Wound Management in Clinic
ensures decreased scarring. Dressing provides optimum conditions for wound
healing and protecting the wound from invasion by pathogen and further trauma
infliction. Thus, these evidences would support the education of the family for the
essentiality of wound management.
6. Slough is a type of necrotic tissue which separates itself from the wound site and is
often stringy (Percival & Suleman, 2015). Most slough tissues are dead so they
have a yellowish or cream colour. Debridement of sloughy tissue is very crucial.
Debridement means to clinically remove dead tissues that is, sloughy tissues from
the area of the wound. This would result in efficient healing of the wound at a
faster pace and consecutive prevent of the wound infection. The process of
removing slough from a wound is known as de-sloughing. The scope of practice is
to successfully remove the slough from the wound around 6 o’ clock. Majority of
the wound debridement occurs by autolysis. This causes removal of the necrotic
tissues autolytically. Majority of the dressings like hydrogels, hydrocolloid
dressings promote debridement by autolysis. The running of water on the wound
site also helps in removing the dead cells from the surface of the wounds. This is
mechanical debridement.

22Principles of Wound Management in Clinic
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