Wound management coursework

awma. com. au/home http://www. smith-nephew. com/australia/about-us/what-we-do/advanced-wound-management/ http://www. _________ Part E What is a discharging wound? ____A discharging wound is one that has heavy and or purulent discharge and that produces large amounts of serous, sanguineous, serosanguineous or purulent discharge indicating a localized defect or a excavation of the skin and or the underlying tissue (Wound Healing and Management Node launched!, 2011). ______ _ Part F What is a malignant wound? __A malignant wound is an open and cancerous lesion of the skin what may or may not be draining. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Part G What is a neuropathic ulceration wound? ___These are ulcers that occur as a result of peripheral neuropathy. It is caused by local paresthesisas over pressure points leading to microtrauma, disintegration of overlying tissue and finally ulceration (Wound Healing and Management Node launched!, 2011).

_________ Part H What is an infected wound? __An infected wound is a localized excavation of the skin or the underlying tissue whereby pathogenic organisms have invaded the surrounding viable tissue. _____ Question 6 Name four intrinsic and four extrinsic factors that inhibit healing. ________Intrinsic factors include: Age, chronic conditions such as diabetes, weak/suppressed immune system and reduced sensation. Extrinsic factors include; medical intake, poor nutrition, stress and lifestyle habits such as smoking_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Question 7 Match the following terms: a) Primary Intention - 3. Wound edges are held sutures, clips b) Delayed Primary Intention- 1. Closure 3 to 5 days later c) Secondary Intention- 2. 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? __IN order to provide holistic care some of the issues to focus on include the history of the patient. This ensures that the healing of the patient is not hindered by concomitant conditions. They family should learn wound care techniques that would ensure that the wound is properly assessed and prevent it from becoming worse and infection control to prevent the infection of the wound (WoundSource, 2018).

Part D List five complications of wound healing Some of the complications of wound healing include; Infection Osteomyelitis tissue necrosis hematomas Dehiscence _________________________________________________________________________ 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 measurement Clinical photography Wound tracing Wound debridement Wound drains and wound drainage systems Wound specimen collection Surgical wounds Pressure ulcers Venous ulcers Arterial ulcers Mixed ulcers Discharging wounds Malignant wounds Neuropathic ulceration wounds Infected wounds Burns Fistulas and sinuses Skin grafts Visceral wounds __The successful treatment of serious wounds requires a proper assessment of the patient and not just the wound.

Understanding the type of wound; whether it is a surgical wound, a pressure, venous, arterial or mixed ulcer is a vital aspect of wound management in that different wounds have different methods of treatment. Understanding the types of wound, such as discharging, malignant, neuropathic ulceration, burns and or infected wounds means understanding their various stages of progression and treatment method applied to any of the wound variations. The best wound treatment management plans permit for versatility and dealing with wounds that might be hard to examine since they are visceral wounds such as fistulas and sinuses (WoundSource, 2018). ______________________________________________________________________________ Part F Discuss how you have interpreted laboratory results in consultation with the registered nurse and/or the interdisciplinary team in the nursing home.

__When it comes to wound management there are five critical lab tests that should be considered and they include albumin, prealbumin, hemoglobin A1c, Glucose and a complete blood count. ____sense of overall malaise 3. _____purulent or malodorous drainage 4. _____redness around the wound 5. _____loss of function and immobility ______ Part B The following website may assist with this question http://tle. westone. The Registered Nurse has asked you to take a wound swab. Following the organisations policies and procedures, outline how you would take a specimen. ___The following are the steps necessary when taking a wound swab; 1. Gathering the equipment needed to clease the wound, obtain the specimen and redress the wound. Explain the procedure to the patient. documenting the procedure, assessing findings and patient's responses____________ (WoundSource, 2018) _ Question 13 Define the term moist wound healing.

____This is the practice of ensuring a wound is optimally moist in order to promote faster healing. This practice has proved that it is three to five times faster than if the wounds are allowed to dry out. _______________________________________________________________________________ Question 14 Match the colour of the wound beds a) Black-4. Necrotic b) Pink-2. The final stage of the pressure ulcer is characterized by the deepening of the wound past the tissue under the skin. Fat, muscle and bone might show which causes extensive damage. There may be damage to tendons and joints. ______ Question 16 What are the major causes of skin tears in aged care facilities? Name 4? _-lack of a safe living environment environment - tears from medical treatments such injections. -accidents within the living care facilities -Physical abuse from their carers.

The next step is cleansing the incision and applying steri-strips. The final step is removing all the used equipment, sutures and gauze and disposing them in a bio-hazard bag for final inceneration______________________________________________________________________________________________________________________________________________________ Part B Refer to the organisations policies and procedures. How are the sutures and staples disposed of? The sutures and staples are immediately disposed off in a bio-hazard bag that is then disposed off via inceneration. Question 19 A doppler is a non-invasive method of wound assessment. What does the doppler assess? ____The doppler unltrasound assesses the blood flow that moves through veinds and arteries usually in arms and legs. 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.

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. 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 Wound odour The wound was slightly offensive. 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.

Mrs. Owens's Wound Management Plan Assessment Nursing Diagnosis Patient Outcomes Interventions Evaluation of Outcomes Objective Data: -Right foot with an ulcer -Open wound -proper dressing -Pain upon movement grimacing, shaking -used to self medicate -requires assistance in mobility #1: compromised tissue integrity, leg ulcer wound, presence of infection. wound was not infected. Teach carers and family members on wound management as well as infection control. Subjective Data: -Pain is worst during mobility -cant perform physical therapy Medical Diagnoses: diabetes mellitus (NIDDM), atrial fibrillation, recurrent urinary tract infections, extensive osteoarthritis, peripheral vascular disease (PVD), post-operative pulmonary embolism and a chronic leg ulcer Assessment Nursing Diagnosis Patient Outcomes Interventions Rationale Evaluation of Outcomes 4. decreased size of wound with increased granulation tissue. Patient verbalizes functional pain reduction by 80percent by the end of the treatment.

______________________________________________________________________________________________________________________________________________________________________________________________________________________ Part D Discuss the nursing homes policies and procedures to minimise cross-infection during assessment and wound care. ____During assessment and wound care, there are a numner of policies and procedures that the nurse has to abide by. They include; • Standard precaution. • Observing hand hygene. • having personal protective equipment. Nurses and other healthcare practitioners should document and report any and all incidences of wound care for future reference during treatment. The nurses in the nursing home should ensure that the client and their families are well versed in wound care so that in case of primary care, they can manage wounds as effectively as possible without risking additional harm. ______________________________________________________________________________________________________________________________________________ References Nutritional Healing, L. 5 Critical Lab Tests for Proper Wound Care - Nutritional Healing.

[online] Nutritional Healing. westone. wa. gov. au/content/file/06143847-5ac3-4a0a-89fa-cca3f915f582/1/Chain_of_infection. zip/index. For this literature review, three peer reviewed articles were analyzed with the intention of determining the similarity and differences asserted by the authors regarding the causes, treatments and preventive measures that can be taken by healthcare facilities, able patients as well as family members so as to prevent pressure ulcers. According to Wang, Wlaker and Gilespie (2018), the diagnosis and treatment of pressure ulcers only become worse as the disease worsens and so does the situation that the patient is in. Wang, Wlaker and Gilespie (2018) also asserts that pressure ulcers can be categorized by their severity; from stage one to stage four, with the former being the most mild and severity increasing with the stages and stage four being the most intense.

The article by Wang, Wlaker and Gilespie (2018) seeks to identify the five key methods that can be used in pressure ulcers prevention. At the conclusion of their study, Wang, Wlaker and Gilespie (2018) came to the conclusion that skin inspection as well as inter-professional communication as a means of preventing pressure injuries was defective in practice. Medical care of older persons in residential aged care facilities (2013) assert that some of the most effective strategies when it comes to taking action to prevent pressure ulcers include a daily inspection of pressure points, protection of the skin through measures such as routine inspection, moisturizing dry skin and avoiding harsh cleansers. Other measures include pressure relieving interventions and devices as well as capitalizing on proper nutrition and sufficient hydration.