Wound Management Case Study: Assessment of Maree Smith's Burn

This case study examines the wound management of Maree Smith, an 18-year-old paraplegic female with a burn injury. The assessment includes a detailed evaluation of the wound's depth, size, exudate, appearance, and pain level, along with the aetiology of the burn, identified as a thermal injury from boiling noodles. Factors affecting wound healing, such as wound characteristics, infection, patient behavior, nutrition, and hygiene, are thoroughly discussed. The study outlines short and long-term goals for wound and patient therapy, including pain management, infection control, and promoting patient understanding. A suitable dressing regimen, utilizing foam dressings like Biatain, Allevyn, and Mepilex, is proposed, with a rationale based on the wound's exudative nature and the need for infection prevention. The case study also considers alternative dressing options and identifies other crucial factors in Maree's overall management plan, such as addressing her disruptive behavior and ensuring adherence to medical appointments. The paper emphasizes the importance of a moist, clean environment to facilitate healing and reduce complications, ensuring a comprehensive approach to Maree's care.

Running head: BURNS 1
WOUND MANAGEMENT CASE STUDY
Student’s Name
Institutional Affiliation
Course
Instructor
Date

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Introduction
Maree Smith is an 18-year-old female who has been paraplegic following a car
accident at the age of 16 years. She presented with a burn injury with moderate exudate. The
has poor adherence to the medical appointments recommended by her GP. With regard to
this, the paper will discuss the skin and wound assessment and establish the aetiology of the
wound. The paper will identify the factors which affect the process of healing of Maree’s
instance including short and long-term goals of wound and patient therapy. The paper will
discuss a suitable regimen of dressing for Maree and a rationale for the chosen regimen. The
will also discuss the alternative dressing therapies or options highlighting both the
inappropriate and appropriate dressings for her wound. Lastly, the paper will identify other
three factors that should be considered in Maree’s overall management plan.
Skin and Wound Assessment
Parameter Clinical Observation Indicator
Measure Wound depth, size, volume,
area, width, and length. The
wound is large, extensive,
and has a depth of second-
degree burn (Greatrex‐White
& Moxey, 2015).
Increased surface area of the
wound on both legs of the
patient.
Exudate Decreased exudate with a
foul smelling odour.
The wound has decreased
purulence and decreased
(moderate) amount of
exudate compared to its
previous state the visit to the

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GP (Hollywood & O’Neill,
2014).
Appearance Appearance of the wound
bed
The wound has a decreased
percentage of granulation
tissue with no necrotic
tissue, and friability of the
granulation tissue. The
wound does not have the
deep tissue structures like
bones, and sweat glands
(Greatrex‐White & Moxey,
2015).
Suffering Level of pain of the patient
using the validated pain
scale of 0-10
The pain related to the
wound is improving at a
scale of 3/10.
Undermining Present Decreased
Re-evaluate Regular monitoring of all
the parameters in a period of
about 1 to 4 weeks
On assessment and follow
up, the patient’s condition of
the wound is improved
evidenced by reduced
amount and purulence of the
exudate (Berman, Snyder, &
Frandsen, 2016).
Edge Condition of the
surrounding skin and the
The wound has an attached
edge with an advancing

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wound edges. epithelium border with no
induration, erythema, and
maceration (Hollywood &
O’Neill, 2014).
Aetiology for the wound
The aetiology of burns can be attributed to multiple factors including thermal,
electricity, chemical, and radiation. According to the case study, Maree is paraplegic which
resulted from a car accident some time back. She developed a disruptive behavior which
primarily led to her burn by the cup of boiling noodles. This can be named as a thermal burn
which might happen with the direct impacts of the flames with a lot of heat, hot liquids,
contact with very hot objects, and hot vapors (Han & Ceilley, 2017). Thermal burns develop
as flame burns and hot waters. There are skin injuries as a result of excessive heat from the
hot liquid. The skin damage as a result of thermal burns results in the cellular death due to the
high temperatures of the liquid and the duration the patient was in contact with the fluid.
According to the case study, Maree was alone at home with no one to giver first aid after the
burn. This could have resulted to the extensive impacts and severity of the burn (McCance &
Huether, 2014).
A burn injury results in both systemic and local changes in the body thus causing the
burn scars. After the occurrence of burns, the skin has cell proteins which denature and
coagulate resulting in the development of thrombosis in the blood vessels (McCance &
Huether, 2014). Consequently, this results in the increased vascular permeability and
increased intercellular osmotic pressure due to the particles of the denatured particles of cell.
The vasoactive amines like kinin, histamine, serotonin, and prostaglandins released from the

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burn-related tissues. Leukocyte and platelet adhere to the endothelium. This results in the
activation of the complement system leading to an increase in the number of cytotoxic T
cells. As a result of this, a tissue develops in the open area for infection (Gillenwater &
Garner, 2017).
Heat injuries can be categorised into two phases. The first phase involved the
development of coagulative necrosis in the tissues and epidermis. On the other hand, the
second stage involves cell lysis due to the progressive dermal ischemia which occurs in the
first 24 to 48 hours following the occurrence of the burn. Vascular permeability and
vasodilation in the skin and other subcutaneous tissues are increased secondary to local
reaction. A systemic response to the burn results in the significant effects to the internal
organs (Gillenwater & Garner, 2017).
Burns are usually classified into first, second, and third degree based on the depth and
severity on the skin surface. The first-degree burns are known as superficial burns since they
impact the epidermis only. The site is usually dry, red, and painful with no sores or blisters.
The second-degree burns primarily affect the epidermis and some parts of the dermis. The
burn site is usually blistered, red, painful, and may be swollen. The impacts of the third-
degree burns involve the epidermis and the dermis and sometimes may destroy the
subcutaneous tissues. The site of burn injury usually appears charred or white. The fourth
degree occurs when the burns damages the muscles, bones, and the tendons. They are
characterized with reduced sensation due to the damage of the nerves in the burn site
(Nielson, Duethman, Howard, Moncure, & Wood, 2017).
Factors that affect wound healing
Wound healing is regarded as one of the complex sequences of events which is
categorised into haemostasis and tissue regeneration and repair. Haemostasis refers to a rapid

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response to the physical injury and its essential in the control of bleeding. The components
involved in the process of haemostasis include vasoconstriction, biochemical response, and
platelet response. Tissue regeneration and repair has three major phases namely
inflammation, reconstruction, and maturation (Harper, Young, & McNaught, 2014).
During the inflammatory phase which occurs within 4 days, the body responds to the
injury. This phase results in the activation of vasodilation resulting in increased flow of blood
to the injury site thus causing pain, redness, heat, loss of function, and swelling. During this
phase, there maybe an exudate which is considered as a normal response by the body. The
reconstruction phase occurs between two to twenty-four days whereby the body forms new
blood vessels to cover the wound surface. It includes epithelialization and reconstruction thus
making the wound become smaller. The last phase is the maturation which extends from 24
days onwards to one year and it involves the formation of a scar tissue (Kaddoura, Abu-
Sittah, Ibrahim, Karamanoukian, & Papazian, 2017).
The process of healing of the patient may be affected by multiple factors including
local and general. The wound characteristics affects its healing whereby larger wound may
take a longer time to heal compared to smaller ones. The linear wounds also heal faster
compared to the circular and rectangular wounds. Presence of necrotic tissue, foreign bodies,
and desiccation slows down the process of wound healing. According to the case study,
Maree’s wound is somehow circular and rectangular in some areas and has some necrotic
tissue and yellow-granulations which may result in infection thus inhibiting the process of
healing (Zarchi, Latif, Haugaard, Hialager, & Jemec, 2014).
Infection affects the wound healing since open skin is exposed to bacteria, fungus,
and virus which result in more complications which delay the healing process. According to
the case study, the patient is paraplegic with disruptive behaviour. This exposes her to risk of

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repeated injuries and trauma since the wound may be reinjured thus inhibiting healing. The
patient behaviour also affect the process of wound healing due to failure to observe the
requirement measurements and recommendations. Maree cares less about the condition of her
wound and she even refuses to adhere to the clinic appointments by the GP. This may affect
the process of healing since the patient does not turn up for appoints which are essential for
monitoring of the progress of the wound to ensure faster healing (Wu, Shi, Jin, Liu, Cai,
Zhao, & Yu, 2015).
Poor nutrition is associated with poor wound healing since it results in insufficient
resources in the body which are essential in tissue regeneration and wound repair. Inadequate
nutrition is associated with increased patient’s needs for proteins and calories. Inefficiency of
calories in the body results in the breakdown of proteins for generation of energy thus
depleting the ability of the body to heal. According to the case study, Maree does not seem to
be eating a balanced diet since she keeps on criticizing the cooking of the mother. This may
indicate that she does not take the foods cooked by the mother (Lewis, Dirksen, Heitkemper,
Bucher, & Camera, 2015).
Poor hydration is also associated with poor wound healing since lack of moisture in
the wound surface may decrease blood oxygenation and prevent cellular migration thus
delaying the process of wound healing. Dehydration is attributed to depletion of water or
sodium in the body which can delay other physiological aspects required in the entire process
of wound healing. Poor hygiene also puts the wound at a high risk of infections especially if
the patient is not keen enough with cleanliness. According to the case scenario, Maree is
careless and disruptive, indicating that she puts less consideration on the level of hygiene for
her wound and the whole body (Han & Ceilley, 2017).
Short and long term wound and patient goals of Therapy

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Short Term Goals:
1. To ensure that the patient reports controlled or reduced pain evidenced by the display
of relaxed facial expressions and normal body posture.
2. To ensure that the patient demonstrates comfortability and relief
3. To ensure the wound is free of the purulent exudate to reduce the risk of infection
4. To ensure adequate hygiene of the wound to promote healing and reduce the risk of
infection (Urden, Stacy, & Lough, 2017).
Long-Term Goals
1. To ensure that the patient takes part in activities and rests appropriately
2. To ensure that the patient demonstrate adequate nutritional intake thus meeting the
metabolic requirements evidenced by adequate tissue regeneration for wound healing.
3. To ensure that the patient demonstrates proper understanding of her situation,
potential complications, prognosis, and other appropriate techniques required for a
proper and timely healing of the wound (Gillenwater & Garner, 2017).
Suitable Dressing Regimen and its Rationale
The choice of dressing regimen is primarily determined by the stage of the healing
process of the wound. The process of healing progresses rapidly in the environment that is
moist, clean, and protected from bacterial invasion, heat loss, and trauma. Using an
appropriate dressing would be essential in minimizing bacterial contamination, and wound
related pain thus improve the quality of wound healing. For the wound which heal by primary
intention require little interventions other than observation and protection from
complications, the recommendable dressing regimens include island dressing, dry non-
adherents, hydrocolloids, foams, and semi-permeable films (Dabiri, Damstetter, & Phillips,
2016).

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The burn wounds are usually dynamic since their appearance changes within 48
hours. Initially, the burn dressing should be intact for at least a period of 48 hours for
prevention of infections. The patient should be dressed using an antimicrobial dressing for
improvement of the outcomes through the reduction of infections. For instance, the
nanocrystalline silver dressing releases silver slowly, which kills the microorganisms, thus
preventing the risk of infections especially the bed of the burn wound. Based on the condition
of the patient’s wound, the choice for the dressing would be the foams like Biatain, Allevyn,
and Mepilex (Rowley-Conwy, 2014).
The reason for this choice is that the dressing moistens and the prevents the wound
from infections. The foams are highly absorbent dressings are for burns which are highly
exudating and are available silver and plain. The dressing absorbs the exudate well thus
helping in the management and prevention of maceration and hypergranulation (Norbury,
Herndon, Tanksley, Jeschke, & Finnerty, 2016). The foams also reduce the requirement for
changes of dressing since they have wet dressings. The foams dressings are biodegradable
and highly absorbent since they contain calcium thus, they are essential for use on a moist
and granulating tissue and burns occupying small superficial dermal regions. The foams are
importance for haemostasis if there is fragility or superficial bleeding (Sood, Granick, &
Tomaselli, 2014).
As a first aid, Maree’s mother had applied non-adherent and Jelonet dressing which
has a soft base containing paraffin, comprehensive range of size, and sterile leno weave type
of presentation. The dressing was suitable since it helped in soothing and protecting the
wound and allowing free flow of the viscous exudate from the wound. Since Jelonet is low-
adherent and soothing, it allows for free draining of the wound to the absorbent secondary
dressing. The Jelonet resists fraying and maintains shape due to its interlocking threads
forming a gauze. The dressing was suitable since it allows for the application of topical

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medications for prevention of infections. Based on this, it was suitable for the GP to
recommend Maree for Flamazine Cream which has moisturizing and antibiotic benefits to the
wound to prevent infections and promote healing (Sood, Granick, & Tomaselli, 2014).
Alternative Dressing Options
One of the appropriate therapies for Maree is the administration of antibiotics to
prevent and cover infections which may inhibit the process of healing of the wound.
Alternative dressings that can be used are hydrocolloids, hydrogel, and alginate (Saco, Howe,
Nathoo, & Cherpelis, 2016). Infections may also lead to other complications such as tissue
necrosis, wound dehiscence, and septic wound which lead to other outcomes such as
prolonged patient hospitalization. The second appropriate therapy for the management of
Maree’s condition is education on her condition (Ghanem, Heppert, Spangehl, Abraham,
Azzam, Barnes, & Hitt, 2014).
The education plan should incorporate the causes and complications of the wound,
self-management approaches such as personal hygiene and nutrition, preventive measures,
and the benefits of the management therapies applied in relation to her health condition
(Lewis, Collier, & Heitkemper, 2017). One of the inappropriate dressing alternatives is cloth
since they can stick on the wound causing more harm and injury to the patient. The second
inappropriate therapy is lack of use of aseptic techniques when handling the patient’s wound
thus increasing the risk of infections which inhibit the process of healing of the wound
(Berman, Snyder, & Frandsen, 2016).
Factors to consider in the overall management Plan
1) Past medical history of Maree such as Paraplegia
2) The current condition of the patient’s wound in relation to the set goals
3) Post discharge care for Maree to prevent further injuries or accidents

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Conclusion
In wound assessment, it is essential to incorporate multiple aspects including the size,
volume, and depth of the wound, the odour and amount of exudate, the general appearance of
the wound, undermining, suffering, edges, and a re-evaluation of the wound for healing.
Thermal burns are usually caused by flames and hot waters resulting in systematic and local
skin damage. The second-degree burns affect the epidermis and some parts of the dermis. The
process of wound healing involves two major components namely haemostasis and tissue
regeneration and repair. The process of wound healing is influenced by multiple factors such
as poor adherence to the prescribed medical management, poor hygiene, trauma, poor
nutrition, and increased risk of infections. The choice of dressing is significantly influenced
by the nature and stage of wound healing.
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