Diploma of Nursing: Wound Management Plan Case Study Analysis

This assignment presents a comprehensive wound management plan derived from two detailed case studies. The first case involves a septuagenarian with arterial and diabetic foot ulcers, while the second focuses on an octogenarian with a malignant wound and venous ulcer. The plan begins with a holistic assessment of each patient, including medical history, examination of the wounds, and identification of wound types, causes, and any necessary investigations. The core of the assignment lies in the evaluation of each wound, utilizing the TIME framework to assess tissue, infection/inflammation, moisture, and edge. The plan delves into wound bed status, wound characteristics, measurements, the condition of surrounding skin, and exudate analysis. Furthermore, the assignment covers the physiology of wound healing, factors affecting the healing process (such as diabetes, old age, and cancer), and specific wound management strategies, including cleaning, dressing, debridement, and monitoring. It also addresses health education for patients, focusing on foot care, nutrition, and lifestyle modifications. Pain management strategies, including medication, are also discussed. The assignment provides a detailed analysis and treatment approach for different types of wounds, offering insights into their assessment, healing, and management.

Running head: CASE STUDY
Wound management plan
Name of the Student
Name of the University
Author note

1CASE STUDY
Table of Contents
Case study- Will Jackson...........................................................................................................2
Holistic assessment................................................................................................................2
Evaluation of the wound........................................................................................................2
Physiology of healing.............................................................................................................4
Wound management...............................................................................................................4
Health education.....................................................................................................................5
Pain management...................................................................................................................5
Case Study 2- Miriam Gold.......................................................................................................6
Holistic assessment................................................................................................................6
Evaluation of the wound........................................................................................................6
Physiology of healing.............................................................................................................8
Wound management...............................................................................................................9
Health education.....................................................................................................................9
Pain management.................................................................................................................10
References................................................................................................................................11

2CASE STUDY
Case study- Will Jackson
Holistic assessment
Jackson is a septuagenarian who had been diagnosed with rectal cancer five years ago.
The reason for his present admission to the healthcare setting is intermittent pain from the
wounds that are a manifestation of arterial ulcer and diabetic foot ulcer. Also referred to as
ischemic ulcer, the condition is marked by poor perfusion in the lower extremities that
deprives the skin of oxygen (Wilkinson, 2014). In addition, diabetic foot ulcer has been
identified as a common complication of diabetes mellitus and occurs due to diabetic
neuropathy that results in absence of sensation in the nerves. Medical history of the patient
includes ischemic heart disease, in addition to coronary artery bypass graft, COPD, postural
hypotension, gastro-oesophageal reflux disease, and was under insulin administration for
treating his diabetes.
Evaluation of the wound
Diabetic foot ulcer is a common complication of increased blood glucose levels and
creates an adverse impact on the health and wellbeing of the diabetes patients like Jackson
(Armstrong, Boulton & Bus, 2017). In addition, arterial ulcer are generally located on the
ankle lateral surfaces and caused due to peripheral artery diseases. Wound assessment
comprises of observing the wound, which in turn is concomitant with conducting a survey
and comprehensive examination of the patient, besides recording relevant clinical
information from the physical health status and health history (Paul et al., 2015). The TIME
framework will prove effective in wound evaluation and will focus on different components
like Tissue, Infection/Inflammation, Moisture, and Edge (Ousey, Rogers & Rippon, 2016).
This will help in the formulation of a framework for treatment and application of appropriate
interventions. Following are the details for Jackson’s wound assessment:

3CASE STUDY
 Wound bed status- On assessing the wound, the region around both the ulcer have
been found swollen and red. Presence of red steak in all the wounds act as a warning
indication for wound infection. Besides appearing swollen, the infected ulcers also
indicate presence of pus draining from the wound, thus proving invasion by pathogen
(Rehim, Singhal & Chung, 2014). Presence of granulation tissue in the wound also
suggests angiogenesis and stimulation of fibroplasia that impedes the wound healing
process.
 Wound measurement- Measuring the depth, width and length of ulcers forms a crucial
aspect of wound management that facilitates keeping a track of the consequences of
the interventions on the wound, thereby determining their efficacy. On using the
PEDIS score for measuring diabetic foot ulcer, the score was 7, thus indicating the
non-healing nature of the ulcer, which might call for the need of limb amputation if
not managed properly (Chuan et al., 2015). Arterial Doppler was also used for
determining the arterial ulcer lesion. In addition, use of Braden scale assessment
suggested that the pressure ulcer was of stage III.
 Surrounding skin- The skin was red coloured and warm that indicated the presence of
inflammation and infection of the wound. There were signs and symptoms of oedema
as well, and the surrounding regions were firmer that the wounds.
 Wound exudates- Wound exudate release is a normal characteristic of wound healing
process (Sabino et al., 2015). The exudate from the arterial ulcer was milky in
appearance, in contrast to the diabetic and pressure ulcer that released brown thick
exudates, suggesting signs of infection
Physiology of healing
Wound healing refers to a complex phenomenon where the tissues present beneath the
skin undergo repair, following an injury. However, the wound healing process had been

4CASE STUDY
interrupted due to several risk factors namely, diabetes mellitus, old age, arterial disease, and
poor oral intake (Dunnill et al., 2017). The phases of wound healing involve blood clotting,
inflammation, tissue growth, and tissue remodelling. In other words, wound healing
encompass a distinct timeline of several physical phases that are imperative for the post-
trauma repairing phase. The wound healing process might have been affected the fact that
Jackson suffered from type 2 diabetes and cardiovascular complications.
According to Baltzis, Eleftheriadou and Veves (2014) diabetic individuals report
lower ability for acute wound healing since the metabolic syndrome encompasses hypoxia,
dysfunction of fibroblast and epidermal cells, impaired angiogenesis, and reactive oxygen
species damage. In addition, poor oral intake also hindered wound healing since
carbohydrates and fats provide energy that is imperative for healing of wounds (Armstrong et
al., 2014). Poor blood flow due to ischemia also resulted in cell death and tissue damage that
made the wounds take longer time to get healed (Mills et al., 2014). In addition, Jackson’s old
age also lowered his skin elasticity and lead to loss of collagen fibres, thus affecting wound
healing.
Wound management
 Sterile saline solution will be taken to clean the wounds and lacerations
 Use of cyanoacrylate glue, bandages, staples, and sutures for closing the wound is
vital (Jeon et al., 2015).
 Proper dressing is imperative for preventing further exacerbation of wound. A moist
wound environment needs to be created to facilitate gaseous exchange, preventing
growth of pathogens, and offering thermal insulation to the wounds (Sood, Granick &
Tomaselli, 2014).
 Antiseptic cleansing agents will be used for cleaning the wounds while changing the
dressings

5CASE STUDY
 Wound healing will also be promoted by repeating the debridement processes
 The wound status and measurement will be monitored at regular intervals to
determine the rate of wound healing.
Health education
Jackson will be taught about the strategies that he should implement for protecting his
feet from further wound complications. Patient education would also involve encouraging
him for consuming adequate nutrients to promote wound healing, in addition to adhering to
dietary modifications that will reduce diabetes and cardiovascular disease related
comorbidities (Yazdanpanah, Nasiri & Adarvishi, 2015). He will be provided appropriate
footwear, pressure relieving mattresses, and taught to abstain from smoking.
Pain management
Pain management will involve providing a comfortable dressing. Silicone dressings
will be used for the same. In addition, he will also be administered NSAIDs like naproxen
(220 mg per 8 hours) and ibuprofen (200mg per 6 hours) for providing pain relief (Morgado
et al., 2017).

6CASE STUDY
Case Study 2- Miriam Gold
Holistic assessment
Miriam is an octogenarian who had been admitted to the hospital owing to his
presenting problems that are associated with overload of fluids, metastatic cervical cancer
and pneumonia. Malignant wounds have been identified as the manifestation of cancerous
cells that try to infiltrate the skin and associated lymph and blood vessels, thereby leading to
loss in vascularity. In addition, the condition might also result in death of the affected person
(Fromantin et al., 2014). Miriam was also found to report presence of rectovaginal fistula and
venous ulcer. While the former refers to an abnormal connection between large intestine
lower parts with the vagina, the latter condition is commonly manifested in the form of
improper venous valve functioning (Corte et al., 2015; Nelson & Bell‐Syer, 2014). The
patient also had a history of coronary artery bypass graft, COPD, and gastro-oesophageal
reflux disease.
Evaluation of the wound
Malignant wounds are found to occur in an estimated 5-10% of patients who have
been diagnosed with metastatic cancer, primarily during the last few months of their lives.
The lesion generally occurs due to metastasis of a local tumour to the skin or a distant site,
which later on takes the form of an open area, cavity, or skin nodules that extend from the
surface (Maida et al., 2016). With the aim of preventing the metastatic wound from further
deteriorating, there is a need to conduct a thorough evaluation. Furthermore, conducting a
physical examination of the venous ulcer is imperative since it is a prevalent occurrence in
most cases of leg ulcer and commonly develops along medial distal leg, creating substantial
negative impacts on the quality of life (Lal, 2015). The fistula might have occurred due to
radiation treatment that has put the patient at a risk for life threatening condition. Therefore,

7CASE STUDY
wound evaluation would help in determining the wound bed, status, and exudate consistency.
Below given are the wound assessment details for the patient:
 Wound bed status- The malignant wound at the groin has the appearance of a
fungating lesion and looks like a fungus. The wound is marked by breaks on the skin
in the form of ulcerations and also reports a foul smelling odour. Time and again it
has been proved that fungating lesions are common in different types of cancer such
as, melanoma, breast cancer, and advanced squamous cell carcinoma (Tilley, Lipson
& Ramos, 2016). Thus, on assessing the wound bed it can be suggested that the
wound appeared like a neoplastic growth and had several necrosing sections. In
addition, the venous ulcer had sloping edges and oedema, that could be accredited to
the increase in hydrostatic pressure which in turn contributed to 'atrophie blanche'
(Alavi et al., 2014). Owing to the fact that local infection, heavy exudate were found
in the fungating lesion, there is a need to implement appropriate wound management
techniques.
 Wound measurements- Measuring the depth, width and length of wounds is
imperative for keeping a track of the progress of the patient, which in turn provides an
overview of the efficacy of the intervention that has been implemented. On using
wound measurement tools, presence of erythema was observed. In addition, wound
measurement also provided evidence for the deteriorating condition of Miriam, owing
to the fact that the wound had spread to the deep layers of the skin, and severely
hampered her ability to conduct activities of daily living.
 Condition of surrounding skin- Periwound and surrounding skin assessment forms a
crucial part of evaluating chronic wounds since they act as an indicator of the
presence of active infection and also help to determine normal flow of blood. On
analysing the surrounding skin, it was found that the surrounding skin was warm, and

8CASE STUDY
firm, in comparison to the affected regions. Furthermore, the surrounding region also
indicated presence of oedema, thus suggesting increased risk of infection in the areas
that were swollen.
 Wound exudates- Determining the type of exudate that is released from the wound site
is essential for determining the wound status and recognising possible signs for
infection. The exudate is assessed for its colour and odour in order to assess bacterial
infection (Vowden, Bond & Meuleneire, 2015). Presence of serous exudates in acute
inflammatory stages is considered normal. Presence of purulent drainage at the site of
wound indicated the presence of infection and the exudate was milky in appearance.
Physiology of healing
The procedure of wound healing is a multifaceted phenomenon and typically involves
repair of the tissues that are present beneath the skin. However, the process is fragile and has
been identified to be vulnerable to failure or interruption that subsequently results in the
formation of chronic wounds that are non-healing. The stages that are encompassed by
wound healing include haemostasis, inflammation, proliferation, and maturation (Olczyk,
Mencner & Komosinska-Vassev, 2014). Some of the common factors that might have created
an impact on the wound healing process observed in Miriam were cardiovascular
complications, cancer diagnosis, and old age. Time and again it has been proved that venous
hypertension often results in stretching of the veins that leads to leakage of blood proteins in
extravascular space, thereby isolating growth factors and extracellular matrix, and preventing
wound repairing (Scotton, Miot & Abbade, 2014). In addition, venous insufficiency might
have also resulted in the accumulation of white blood cells in small blood vessels, thus
triggering the release of reactive oxygen species and inflammatory factors, which contributed
to chronic venous ulcer formation. Malignant wound can be associated with infiltration of the
skin and the surround lymph and blood vessels due to presence of the metastatic tumour

9CASE STUDY
(Morton & Phillips, 2016). Furthermore, old age of the patient reduced her skin elasticity and
slowed down the replacement of collagen, thus stalling the process of wound healing.
Wound management
 Use of sterile saline solution for wound cleaning (Powers et al., 2016)
 Use of non-elastic below knee compression for countering reflux impact on venous
pump failure
 Use of compression dressings for preventing wound exacerbation
 Administration of medications such as, sulodexide and pentoxifylline for lowering
blood clot formation (Hoppensteadt & Fareed, 2014)
 Use of Therapeutic Touch (TT) before changing the dressings (O'Mathúna, 2016)
 Regular supervision of the wound to record healing process
 Administration of tricyclic antidepressants
Health education
Patient education will form an essential aspect of malignant wound and venous ulcer
management and will focus on helping the patient gain a sound understanding of general
wound care steps. In addition, Miriam and her family members will be provided instructions
not to rub or scrub the incisions, or expose the wound sites to sunlight. They will be
encouraged to seek immediate medical help under circumstances when changes are observed
in the odor, size, redness or discharge from the wounds (Norman et al., 2016). Necessary
information will be provided to Miriam on adequate dietary modifications that would
facilitate wound healing. Her husband will also be educated on the steps of wound dressing
and wound care procedures.

10CASE STUDY
Pain management
With the aim of lowering the severity of pain from the wound, Miriam will also be
administered analgesics such as, ibuprofen (200mg per 6 hours) (Morgado et al., 2017).
Dressings coated with soft silicone will also act as a wound contact or adhesive layer.

11CASE STUDY
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12CASE STUDY
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