Wound care management - Essay Example

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Of Hertfordshire Department of Adult Nursing and Primary Care No: Phaik Ong 07.01.13 Module WoundAssessment and Management Module Code: 6NMH0251 GRADE: 36 (Grade is subject to ratification by a Board of Examiners) FOCUS Identification of relevant issues v Relevant issues poorly identified Excellent breadth and depth v Lacks breadth/depth Excellent range of sources v Poor range of sources Consistently accurate referencing v Inconsistent/inaccurate referencing PRESENTATION Logical structure v Lacks structure Excellent introduction v Poorly introduced Clear development of ideas v Ideas poorly developed Robust conclusion v Weak conclusion Fluent expression v Poor expression THEORETICAL LEVEL Excellent knowledge base v Superficial knowledge base Effective handling of theoretical knowledge v Poor handling of theoretical knowledge Comprehensive understanding of issues v Limited understanding of issues Recognition of wider issues v Limited recognition of wider issues INTEGRATION Excellent integration of theory with practice v Poor integration of theory with practice Clear reflection on implications for practice v Limited reflection on implications for practice Excellent suggestions for development of v Limited suggestions for development of Practice Practice LEARNING OUTCOMES Relevant learning outcomes achieved N Relevant learning outcomes not achieved Signed……………………. (1st Marker) Name …Irene Anderson……………… Date…19.01.13… Internal Moderator: Signed…………………2nd Marker Name ……………………Date……………… Ong Phaik Hoon (KDU 18577) January 2013 Summative Assignment Mrs. Stanley (a pseudonym) is a 65 years old lady admitted from a care home with a chest infection, and she is frail and emaciated. She had a stroke at nine months ago. She developed left side hemiplegia. At present, she is able to sit on a wheelchair and needs help with activities on daily living. She also has type 2 diabetes, which is controlled with oral hypoglycaemic drugs. She developed pressure ulcer at sacral area over 2 - 3 week period. She was treated by a clinic doctor who instructed the home care nurses to do daily povidine gauze dressing. Mrs. Stanley is a retired school teacher and an extremely proud lady. She insists on maintaining her dignity at all times and she refused to accept that she had a pressure ulcer. She has a married daughter who stays in Singapore with her own family. She flew back from Singapore to accompany Mrs. Stanley on the day of her admission to hospital.v On testing, she was discovered to have a pressure ulcer at her sacrum. When the wound was examined, she groaned with pain and tried to stop the nurses from touching the wound. The pressure ulcer to her sacral was measured approximately 10cm by 12 cm with a central area of slough which was surrounded by softer yellow tissue and some necrotic tissue. This is under the stage of dying. The surround tissue was erythema and oedematous (Fig 1). The dark staining to the surrounding edge of the wound shows iodine related staining. There is some tenderness and mild oedematous been detected by using gentle touch. Malodour was a concern and Mrs. Stanley was distressed by it. She was prescribed with intravenous antibiotics, subcutaneous hypoglycemic agent, and alternating mattress. v A holistic approach has been performed on Mrs. Stanley to initiate an effective wound healing to occur. Bale (2007) describes if the patient’s psychological needs and comprehensive understand of wound healing are met, the move from sick health to health might move ahead quickly and more proficiently. The two initial areas of concern for Mrs. Stanley were wound pain and exudate. Literature review for these two main areas has been done by using databases such as Medline and CINAHL. The key words which have been used for searching were pressure ulcer, pressure sore, decubitus, wound, ulcer, debridement, exudates, wound fluid, wound drainage, wound pain equipment, alternating mattress, and bed. Some limits which have been set during the net searching were only using English language, human studies and relevance to adult patient group. The database is dated from 2006 onwards to capture the full catalogue. Living with pressure ulcer is devastating for Mrs. Stanley. The pain and discomfort due to excessive exudate that the patient associate with can lead to serious psychological problems especially without family’s support. Mrs. Stanley described being worried, depressed, feeling burdensome, inadequate and having a sense of powerlessness. “That was the worst part, the pain. They give me pain killers and sleeping tablets but I wake up with it,” Said Mrs. Stanley. Literature review states that this is one of the hardest challenges in would management. It is not often the problem of physical management of the wound that include the pain, bleeding, exedute and odour but also the psychological impact of the wound to the patient. Pain The nursing staff team adopted a holistic approach by explaining what measures had been taken to minimize her pain and reduce part of Mrs. Stanley’s fear and anxieties (Baker & Leaper, 2006). Mrs. Stanley was informed that her pain could be managed while dressing changed by administered intravenous analgesia prior the procedure in emergency room. Mrs. Stanley was agitated but managed to be calmed by her daughter who seems very patient with her. Wound pain assessment was unable to be performed in A & E Department as Mrs. Stanley refused to cooperate. People’s mind can be harder to treat than his / her body. However, pain control is still neglected most of the time. Previous studies show that fingating of wounds pose challenge to wound management. Wound pain, bleeding and odour are often neglected but they seem to pose a challenge in relation to the physical impact they bring. Wound pain assessment has been carried out in all aspects which include physical, psychological aspects and social impacts. Wound pain assessment is based on the characteristics of pain including intensity, type, frequency, location and duration (Baker and Leaper, 2006). Mrs. Stanley reported that her pain was intolerable. She felt stinging and sharp pain at home care while the nurses were changing her dressing. At night she felt stabbing and sharp pain which could awaken her up from her sleep. She preferred not to be touched or positioned at times. The most significant feature of this was Mrs. Stanley reluctance to move as this caused more pain. Cumming et al. (2009) state that frequent repositioning are required in pressure ulcers management. The behaviour of Mrs. Stanley has explained why her pressure ulcer was not shown any progress of healing in care home. v Eichenbaum suggest that the wound pain often has an influence on a person’s perception of painful stimuli. Patients can experience throbbing, soreness, stinging, burning and many more types of pain which are associated with wounds (Baker and Leaper, 2006). The two types of pain inspected here are nociceptive pain and neuropathic pain. Eichler & Carlson (2006) explain that prostaglandins behave as messengers that are chemical related, where they deal with cells and will excite and sensitize nociceptors and this implies that the patient gets to heal slowly and the pain gets to move away. Mrs. Stanley experiences soreness of pain during procedure of changing dressing because studies show that correct dressing, used as part of holistic care of the patient, can have a significant impact on the healing of chronic and problem wounds. Therefore her clinic doctor was prescribed oral NSAID that can reduce her pain as prostaglandins biosynthesis can be blocked by NSAID which reduces the nociceptors sensitization because there is lack of effective wound management which requires an understanding of the processes of dressing available. It is therefore true from this that holistic assessment is essential before choosing a wound dressing. However, Mrs. Stanley refused to take Ibuprofen 400mg tds regularly in care home as she worried about the side effect of NSAID. Gurtner (2008) defines sneuropathic high pain as the one brought on by harm or brokenness of neurons. The pain sensed with this type is likely to be continuous, stabbing, sharp, throbbing, fiery, and burning. Opiate analgesics play an important role in relieving this type of severe wound pain which can affect a patient’s ability to sleep and causing patient’s reluctance to continue with treatment. Unfortunately, the clinic doctor did not prescribe any opiate; this can be likened to Mrs. Stanley situation. Mrs. Stanley absorbent layer was combined and thus was helpful in moderating wounds. The membrane dressings in Mrs. Stanley were used for low to high exudate and required a simple absorbent secondary dressing. The clinic doctor who treated Mrs. Stanley was contacted. He explained that blanching erythema presented over the prominent bony sacral region of Mrs. Stanley was identified by a home care nurse about 2 months ago. Mrs. Stanley was bedridden for about 6 to 7 months at the beginning of her stroke attack. She was under weight and having dry type of skin. The clinic doctor had instructed home care nurses to use a ripple mattress and 2 hours repositioning to be carried out. However, this was not done to Mrs. Stanley and was the subject of her slow healing in the wound. The emotional impact of pain varies from each individual to another and may manifest itself as sorrow, anxiety or fatigue (Baker and Leaper, 2006). Mrs. Stanley was fearful and anxious of wound assessment by the nurse. She “tenses up in the anticipation” of wounds assessment. This anticipation for wound assessment can be as a result of concomitant therapies that are used to repair musculoskeletal structures. Additionally, promoting the health of the patient and creating an environment to foster natural healing processes was the reason behind Mrs. Stanley’s anticipation for assessment. She prepared herself mentally in an attempt to avoid the pain. Her previous negative experiences of poorly managed wound pain in care home have left a lasting impression on her. While talking to her, her facial expression and body language has been observed and monitored. Mrs. Stanley responded to her stroke and pressure ulcer with fear about her future. She felt frustrated with the lack of progress in healing. Mrs. Stanley was treated with respect. Nursing team has addressed the issues by encouraging her to share her thoughts about her experiences in wound healing. Involving Mrs. Stanley in the progress of healing is critical. All these sensitive approaches lead to control of patient’s pain. How can tracing and photographs control pain? Tracing and photographs can be helpful in controlling pain since the pain is brain centered and from there the patient can control it. Studies show that pain related medicine is slowly moving towards a more unified and ancient sounding where by the mind and body are one thing (Baker and Leaper, 2006). At the initial assessment, the nursing staff thought that taking a photo of the wound was necessary. Mrs. Stanley disagreed and had not consented her wound photo to be taken. The nursing staff adopted a good practice by explaining what plans had been taken to minimize the pain and anticipated that would reduce some of Mrs. Stanley’s fear and anxieties (Gurtner, 2011). Mrs. Stanley was fearful of dressing changes. There was a big gauze pad and a Melolin dressing stuck onto the pressure ulcer at her sacrum.v The gauze pad and Melolin dressing appeared soaked with dark yellowish color fluid. The strong adhesive on the fragile skin induced extreme pain when dressing needs to be removed.v Hinz (2006) state that according to a multinational survey which conducted in year 2006 by EWMA clearly reported that dressing removal was the most painful aspect of the dressing procedure for their patients.v The nursing staff reassured Mrs. Stanley that prescribed intravenous analgesic (IV Pethedine 50mg) would be served first prior to removing her dressing and she was informed how the dressing would be removed.v Mrs. Stanley’s pain assessment was not conducted by ward nursing team on the day of admission after receiving her from emergency department. It seems like pain assessment tools are underused as a strategy to monitor wound pain, although simple tools are important to be consistent with the method selected. There are many validated pain scale made available (Woolf, 2006). It is a challenge for healthcare providers to convert this complexity of pain into a simple numeric pain scale. Choiniere et al. (2009) describes a visual numerical pain scale by using a 0 to 10 rating which is easy to use and analyze. A 10cm horizontal line with numbers from 0 – 10 which indicate ‘no pain’ at zero and ‘worst pain’ at 10 is used (Fig 5). It has been selected to assess Mrs. Stanley pain’s intensity. Mrs. Stanley refused to cooperate with nursing staff who has attempted to assess her pain since her day one admission. Positive comments were produced and she has already been informed that there are other patients worse off than her and this is helpful for her pain relieving process and other patients with similar problem of depression. Positive thinking was seen as a part of getting on with her life. Mrs. Stanley was willingly to complete the pain chart after every dressing change from the fourth day of her admission. She has shown her willingness to participate in her wound healing and this difference in her mood was as a result of her long process to pain relieve and her realization that the mind is critical to her healing process too. The pain assessment also uses to monitor her existing pain and at times when wound pain exacerbated, such as during repositioning. Nursing staff acted on pain relieving strategies which have been documented. Strategies to relieve wound pain Practical pain relieving strategies for Mrs. Stanley can include pharmacological intervention, non-pharmacological intervention and strategies for managing wounds. Mrs. Stanley was prescribed intravenous Pethedine 50mg at A & E Department. Opiate analgesics play an important role in relieving wound pain. The nursing team was hesitating to serve the medication as fear of opiate addiction might happen to Mrs. Stanley. However, IV Pethedine 50mg was given ultimately to ensure adequate pain relief to be provided. The advantages of intravenous opiate are predictable absorption and rapid onset. Mrs. Stanley was prescribed non-steroidal anti-inflammatory drug such as ibuprofen 400mg tds and Fentanyl transdermal patch 25mcg / hour 72 hours for the first 3 days in ward. Mrs. Stanley and her daughter were concern the side effects of NSAID. A proper explanation has been given and Mrs. Stanley has been encouraged to take adequate analgesia. Mrs. Stanley assessed her pain as eight on the fourth day of admission after wound dressing change but by the end of the first week, she noted an immediate reduction in pain (score of six). Mrs. Stanley was informed about the procedure and dressing used. She picked up the knowledge fast and shown interest to ask questions. Her sense of loneliness and frustration at a loss of physical capacity has reduced. She appreciates a nurse who endeavours genuinely to understand how she feels and show compassion in all aspects of care. This is helpful in pain relieving as the patient is free with the doctor and this makes the mind to be relieved and hence wound healing. The healing progress was demonstrated through consecutive wound tracings. Mrs. Stanley’s involvement in wound healing process is a very practical way and effective strategy for her pain relieving. Mrs. Stanley was using alternating mattresses in ward. She was assisted to change position every 2 hourly. Repositioning is an integral component of pressure ulcer management measures and is widely used in clinical practice. Mrs. Stanley was well taking care and she was dry, warm and comfortable at all time. Nursing team was providing appropriate pressure relief to ensure her wound healing. She managed to rest and sleep well for about 6 hours on her fourth night in hospital onwards. King (2008) states that the psychological issues such as disruption of patient’s sleep or rest patterns and associated anxiety can result to glucocorticoids. Therefore, in order to reduce all these negative factors which may prolong the healing process, Mrs. Stanley is carefully assessed and an appropriate intervention has been taken care of. The wound of Mrs. Stanley was cleaned with irrigated warm isotonic saline rather than wiping across the wound with gauze at emergency room. Mrs. Stanley cooperated as her pain was bearable after IV Pethedine 50mg was given. As her primary consultant still instructed her wound to be dressed with soaked povidine-iodine gauze, it means that the adhesives of micropore plaster still can cause pain and tissue trauma on removal. Therefore, skin care product, Cavilon No Sting Barrier Film (3M) had been applied to reduce skin stripping by providing a contact layer which interfaces between the adhesive plaster and the actual skin surface (King, 2008). After hyrofibre dressing was prescribed by the orthopedic specialist, Mrs. Stanley felt less pain (score of 4) while her dressing was removed. Robinson states that a hydrofibre presentation reduces pain in a range of wounds and easy to change compared with traditional products. This is due to the aquacel wound dressing that uses the main ingredient of the hydrocolloid dressing in a new way to produce hydrofibre dressing. There are different ways through which a patient with a wound can be affected psychologically. For care to be holistic, psychological aspects should be considered, approached, and the speed of recovery should be optimized. However, although wound pain is a complex issue, it can be treated without a comprehensive assessment but it can affect a patient’s willingness to continue with treatment (Woolf, 2006). The wound pain also significantly affects the quality of a patient’s life. There are many practical approaches that nursing staff can take to monitor and relieve the patient’s wound pain, thereby enhancing Mrs. Stanley’s care and management is essential. As the range of wound management products is various, nurses who are taking care of Mrs. Stanley need to know the different product properties. Exudate In emergency room, the pressure ulcer to her sacral was measured approximately 10cm by 12 cm with a central area of slough which was surrounded by softer yellow tissue and some necrotic tissue. The surround tissue was erythema and oedematous (Fig 1). The skin surrounding the wound had become macerated due to moderate exudate which was not well managed. Thomas defines exudates as a fluid that produced as part of normal wound healing process and is essentially blood which the red cells and platelets have been filtered out. It emits from vessels in the tissues encompassing a wound as a result of expanded fine porousness. Capillary permeability occurs increasingly either as part of the inflammatory response that follows any tissue injury or as part of the host response to large amount of microorganism invading the wound bed (Jia & Pamer, 2009). Due to this phenomenon, fluid leaks into the interstitial spaces and ultimately into the open wound bed. Even though certain amount of moisture in the wound is necessary for optimal wound healing (Woolf, 2006) but it the wound bed becomes too wet, it cause problems. Baker and Leaper (2006) explain that the high level of proteinases which found in wound exudates can destroy healthy tissue and consequently complicate the wound healing processv. Mitchell (2007) expresses that minimizing wound exudates is vital when preparing wound beds for healing, as excessive amount of fluid within the wound margin will create a ‘dead’ space and delay in the overall pace of wound healing.. Five objectives of wound care include: relieve the pressure that cause ulcer, decrease further occurrence of maceration at peri-wound, minimize frequency of dressing changes, if exudates increased, consider infection and maximize nutrition and hydration and these are linked Mrs. Stanley exuding to know the pressure the patient underwent through in the process of wound healing. Initially surgical debridement under general anesthesia was considered by her consultant in emergency department but was unsuitable due to her chest infection and uncontrolled hyperglycemic. Mrs. Stanley was having difficulty in moving and feels breathlessness due to her chest infection. She also has incontinence at times in ward. Her sacral dressing was easily wet from urine. From the wound assessment, the wound bed was produced excessive exudate and shown no sign of healing on day 3 admission. Central area of her pressure ulcer remains sloughy and surrounded by necrotic tissue which indicated that her wound was not being managed successfully and this is demonstrated by studies such as by Woolf (2006) that show wound management including wound assessment and care are related to the healing process of a patient. Due to the vast amount of exudate, the skin surrounding the wound had involved more area become macerated, indicating deterioration in the wound condition (Fig 2) (Woolf, 2006). Mrs. Stanley was prescribed 6 litres / min oxygen supplement via simple face mask and an intravenous antibiotic, imipenem 1gram bd for one week. Subcutaneous Insulin was given 3 times a day prior her meal time and the dosage was given according to the sliding scale as instructed by her consultant. Her hyperglycemic episode was under control from her day 2 admission onwards. A continuous bladder catheter was inserted as Mrs. Stanley was at risk of infection due to her co-morbidities and possibility of urine and faecal contamination. The initial assessment also highlighted that Mrs. Stanley had a reduced in appetite and she was prescribed nutritional supplements too while the exuding had reduced. Mrs. Stanley’s daughter was worried about her mother’s condition and hospital cost. Besides Mrs. Stanley’s chest infection treatment, the management of her excessive exudate wound care can mean a longer stay in hospital. Nguyen et al. (2009) state that for health aid, the administration of abundance exudate can mean respectable expenses as far as health professionals' time used is utilizedv. Mrs. Stanley’s daughter was referred to finance executive staff who can give estimation cost of the hospital stay. The ward nurses had cleaned Mrs. Stanley wound’s with normal saline and dressed with povidone-iodine soaked gauze daily according to her primary consultant instructions from the day of admission.v On day 3 of admission, the wound was inspected. The wound borders are defined and shown absent epithelial cell signs. In Mrs. Stanley case, the perception of exudate misfortune was made on the support of the immersion of the wound dressing at specified interims, for example each 24 hours. However, the nursing team was more concentrating in progress of expected wound bed healing rather than measuring amount of exudate. Mrs. Stanley’s wound bed is failing to progress as expected, the surrounding skin is excoriated and dressing was being changed 3 to5 times a day (Fig 7). The primary consultant of Mrs. Stanley felt frustrated in management her wound as he has limited knowledge of good management strategies to be implemented. He referred the case to an orthopedic specialist since this would give the patient advice on the management of her wound. The orthopedic specialist suspected a bacterial burden within the wound which can lead to excess exudate production as a result of increased capillary permeability due to infection? The present of purulent and malodour was the key clinical signs of infection evidence for this view? For Mrs. Stanley, a wound swab was taken during the assessment (Fig 2). However, the result showed no significant of microorganism growth after 72 hours of incubation. He decided to perform a sharp debridement in ward after consented by Mrs. Stanley’s daughter. Bale (2007) suggests that wound debridement is essential in order to prevent bacterial colonization progressing to clinical infection. However, Pollock (2009) states that a holistic approach should be made, inclusive patient assessment to be used before deciding on preferred modality of debridement. This is crucial in maximizing patient comfort and acceptability of treatment method selected to remove necrotic material successfully. Song et al. (2010) also argue that aggressive tissue removal is surgical debridement. The orthopedic specialist had managed to remove around 85 -90% of the necrotic tissue. He also stated that sharp debridement can remove the malodour of the wound. He had performed the procedure expertly without causing exacerbated pain to Mrs. Stanley. A postoperative instruction to manage the wound was to continue with the IV Imipenem 1gram bd for ten days. The orthopedic specialist had instructed the wound to be dressed using a hydrofibre related dressing. The high fluid retention capacity of the hydrofibre (Woolf, 2006) would manage the exudate at the wound bed level. Hyrofibre absorb the exudate into the actual dressing fibres and it turns gel-like on contact with axudate and provides a moist interface with the wound. It also promotes autolysis and granulation. The secondary dressing which manufactured from polyurethane is able to absorb moderate to large amount of exudate and serve to prevent further maceration to the surrounding skin. It also provided a protection barrier against microorganism (Baker and Leaper, 2006). The whole dressing was near to the anus and it requires specific skin protection against faecal contamination. Mrs. Stanley’s chest infection had dissolved progressively and she was managed to sit out from bed on day 3 of admission. She was able to sit on a comode for her bowel opened 2 to 3 times per week. Skin care product, Cavilon No Sting Barrier Film (3M) had been applied to prevent erythematous skin damage resulting from contact with wound exudates. The product also reduces skin stripping by providing a contact layer which interfaces between the dressing and the actual skin surface (Bale et al., 2007). Initially, daily changing of dressing took place but after week 3, the wound’s malodour and exudate fell significantly. Mrs. Stanley was discharged on the 24th day of her admission. Her home care nurses are educated and thought to manage her wound care prior the discharge. She has been scheduled for weekly follow up in orthopedic clinic. Mrs. Stanley only came for follow up once. Her daughter has transferred her to Singapore where she can be closed and care for her. Wound debridement is important in the papain-rich material that is got from scratching the skin and affects the treatment in most wounded patients (Tong, 2009). Conclusion Managing Mrs. Stanley’s sacral ulcer was challenging. It relied on skilled assessment and a thorough knowledge of the available options of care. A comprehension of the underlying physiology of wound recuperating is vital to the auspicious administration of patient. Today there is a wide range of treatment choices for wounds (King, 2008). King (2008) define that this undoubtedly means that dressings are sometimes used inappropriately. It is essential to match the correct type of dressing to the patient’s wound. Healthcare practitioners should utilize their knowledge and carefully adhere to the instructions of the manufacturers. This study evaluated the critical requirements of a patient and it is crucial to ensure the patient remains the central to the choice made. v References Baker, E. A., & Leaper, D. J., 2006. Proteinases, their inhibitors and cytokine profiles in acute wound fluid. Wound Repair and Regeneration, 8 (5), 392 – 398. Bale, S., 2007. A guide to wound debridement. Journal of Wound Care, 6 (4), 179-182. Cumming, B. D et al. 2009. A mathematical model of wound healing and subsequent scarring. Journal of the Royal Society Interface, 7 (42), 19–34. Eichler, M. J., & Carlson, M. A., 2006. Modeling dermal granulation tissue with the linear fibroblast-populated collagen matrix: a comparison with the round matrix model. Journal of dermatological science, 41 (2), 97–108. Gurtner, G. C., 2008. Wound repair and regeneration. Nature, 453 (7193), 314–21. Gurtner, G. C., 2011. Improving Cutaneous Scar Formation by Controlling the Mechanical Environment. Annals of Surgery, 254 (2), 217–25. Hinz, B., 2006. Masters and servants of the force: the role of matrix adhesions in myofibroblast force perception and transmission. European Journal of Cell Biology, 85 (3–4), 175–81. Jia, T., & Pamer, E. G., 2009. Dispensable but Not Irrelevant. Science, 325 (5940). King, B.M., 2008. Assessing nurses’ knowledge of wound management. Journal of Wound Care, 9 (7), 343-346. Mitchell, R.S., 2007. Robbins Basic Pathology. Philadelphia: Saunders. Nguyen et al. 2009. Biomaterials for Treating Skin Loss. London: Woodhead Publishing. Pollock, R. E., 2009. Schwartz's Principles of Surgery, Ninth Edition. London: McGraw- Hill Professional. Song et al. 2010. Use of the parabiotic model in studies of cutaneous wound healing to define the participation of circulating cells. Wound repair and regeneration: official publication of the Wound Healing Society [and] the European Tissue Repair Society, 18 (4), 426–432. Tong, M., 2009. Stimulated neovascularization, inflammation resolution and collagen maturation in healing rat cutaneous wounds by a heparan sulfate glycosaminoglycan mimetic, OTR4120. Wound Repair and Regeneration, 17 (6), 840–52. Woolf, C. J., 2006. Pain: moving from symptom control toward mechanism – specific pharmacologic management. Annals of Internal Medicine, 140, 441 – 451. Appendix Wound Assessment Chart Initial Assessment in Emergency room Patient Name : Mrs. Stanley (not her real name) Age : 65 years old Type of wounds : Pressure ulcer at sacrum Wound Dimensions : Sacrum was large (10cm x 12 cm) Sacrum Wound Bed : Slough in central area with softer yellow tissue and surrounded by some necrotic tissue. : Malodour. Exudate Level : Moderate Wound margin / surrounding skin : Erythema, oedematous and mild macerated. Factors that may impeded healing : - Immobility Diabetic Mellitus Poor nutritional status Infection Pain Excess exudate Wound Tracing 1 (Fig 1) Wound Tracing 2 (Fig 2) Wound Tracing 3 (Fig 3) Wound Tracing 4 (Fig 4) Pain Chart (Fig 5) Diagrammatic Wound Assessment (Fig 6) Wound Care Chart (Fig 7) Read More