Principles of Wound Management in the Clinical Environment - Assignment Example

ly рrinсiрlеs оf wоund mаnаgеmеnt in thе сliniсаl еnvirоnmеnt Name Institution Date Аррly рrinсiрlеs оf wоund mаnаgеmеnt in thе сliniсаl еnvirоnmеnt Event One of Three: Acute Wound 1. Discuss your assessment of the wound shown in Image 1(Element 2) The wound in Image 1 is an acute wound. An acute wound usually proceeds through the healing process within a timely manner. The reason is that, it generally does not have any underlying aetiology that can be disruptive of the normal inflammatory response. Acute wounds are usually expected to heal within 4 to 6 weeks. If they do not heal within this time or they develop complications that lead to delay of their healing, acute wounds become chronic and further assessments and treatment measures should be taken. The wound in image 1 is located at the elbow joint of the patient’s hand. It is a wound that is caused by the tearing of the skin by an accident or a sharp object. The depth of the wound is superficial since the skin loss involving the dermis does not undermine the adjacent tissue. The length and width of the wound is approximately 5 centimeters. The edge of the wound is sloping while the wound bed is granulating since it appears red and it requires protection. Regarding the wound exudate, the wound bed is dry since there is no visible moisture and the primary dressing is not marked. Therefore, dressing the wound will be important to give it a good environment for healing. The surrounding skin of the wound is red and it does not have any signs of infection because one cannot see any signs of swelling, heat, or redness of the tissue. It is a fresh wound that needs to be managed. 2. Discuss the immediate management (within 48 hours) of this type of wound and the rationale which supports the management you have chosen (Element 3) The immediate management within 48 hours of this type of wound is wound cleansing and then dressing. To cleanse, using a sterile normal saline is necessary so as to clean the wound effectively. After cleaning, using an antiseptic cleansing agent is important to remove any microbial agents that may be present in the wound. The rationale for cleansing the wound is to remove the debris such as foreign bodies on the wound, devitalised tissue as well as any dressing residue. Cleansing is also necessary with 48 hours so as to exudate from the surrounding skin and also refresh the patient. Cleansing will also help in effectively cleaning the granulating wound so as to remove bacteria. After cleansing, it is essential to dress the wound with a film dry dressing for waterproof, protect the wound and reduce pain for the patient. Applying a skin barrier product will be appropriate to protect the surrounding skin of the wound (NHS Foundation Trust 2012, p.7). 4. Present your assessment of the wound as a learning session plan. A learning session plan will be provided to you by the Assessor. Lesson Plan Topic: Wound Assessment Topic Description The registered nurses and enrolled nurses should apply the contemporary principles to the assessments of patients with acute wounds. This lesson is delivered in collaboratively with the principles of wound management in the clinical environment. Leaning outcomes At the end of the lesson, students will be able to; 1. Define a wound 2. Understand different types of wounds (acute wounds) 3. Demonstrate the importance of wound assessment 4. Describe the process of wound assessment 5. Evaluation and documenting wounds Subtopics to be covered in this lesson What is a wound? Factors influencing wound and wound healing Types of acute wounds How do acute wound occur Classification of skin tears Assessment of skin tears Importance of wound assessment Process of acute wound assessment Evaluating and documenting wounds Learning Strategies Lecture Small group work Facilitated class discussion Self-directed learning Presentations Formal classroom 5. Describe how you would educate the client and/or family/carer on wound management strategies (Element 4) In nursing, educating the client and family or carer on wound management strategies is usually undertaken by the enrolled nurse in consultation or collaboration with the registered nurse. To educate the client and/or family/carer on wound management strategies, the first thing to do is to educate them on how to identify a wound and its cause. For example, in our scenario, image 1 is a skin tear. To identify a skin care, the client and the family or carer will learn what it is. A skin tear is a breakage within the outer layers of the skin (CSI Guide and Resource Pack 2013, p.93). Skin tears result from the peeling back of the skin, partially or total loss of the skin. In learning wound management, I will educate the client and family or carers on what to do in managing the wound. For example, in managing a skin tear, the client and family or carer is required to wash their hands and gently clean the wound with warm as well as clean water. They should pat dry the wound with the use of a clean towel. In the event that the skin flap is still attached, one should replace it by rolling the skin gently back over the wound. It is not advisable to cut the skin flap off since it exposes the wound more to bacterial infections. I will educate the client and family or carer that, they should cover the wound with a clean and non-stick pad. After taking the above described wound management strategies I will also educate them on the importance of contacting a health professional for further wound treatment and care (CSI Guide and Resource Pack 2013, p.93). Considering that wound management best results are also influenced by the nutrition status of the patient, I will educate the client and family or carer on the important of consuming a nutritious diet that is high in protein content. To enhance the wound healing, it is important to keep warm, seek advice on pain management on the wound since pain can hinder the circulation of blood flow to the wound. I will also educate them on the need for keeping the wound dressings dry at all times. A dressing type that does not stick to the wound is the one that is suitable to be used for dressing the wound. Regarding on how often the dressing should be changed, I will educate the client and family or carer to consult with the health professional on how often the dressing should be changed (CSI Guide and Resource Pack 2013, p.104). Event Two of Three 1. Assess the wound in Image 2. The wound image 2 is a chronic wound. Generally, the characteristics of chronic wounds are the presence of underlying pathology as well as persistent state of inflammation that interrupts the wound healing process. The wound is a pressure ulcer that occurred as a result of friction or pressure. It is located on the heel of the leg. The wound depth is full thickness skin loss since the damage involves a subcutaneous layer that exposes fat, bone and the joint capsule without undermining the adjacent tissue. The wound length and width is about 5 centimetres. The wound edge is punched out while the wound bed is infected and granulating. The wound surface is dry, there is no visible moisture as well as the primary dressing is unmarked. The wound has signs of infection, it is red, swelling, delayed healing, it is painful, and has redness. The surrounding skin is also red with cellulitis. The wound is also painful due to the infection and the sedentary lifestyle of the patient. 4. Discuss your assessment of the wound in Image 2 using appropriate language and include any wound assessment tools you would use The wound in image is an acute pressure ulcer. It is a type of pressure injury. A pressure injury is an injury that is localised to the skin as well as the underlying tissue. It usually occurs on a bony prominence because of pressure or a combination of pressure and friction (CSI Guide and Resource Pack 2013, p.82). To carry out the wound assessment, I will use a validated tool to perform and document the assessment. Using a validated pain assessment tool or a pain scale, I will access the pain of the patient. A validated pain assessment tool is usually used to assess the presence of pain in patients with pressure injuries (Registered Nurses’ Association of Ontario 2011, p.2). This will help in developing a pain management plan. I will assess the skin for pressures using a pressure injury risk assessment tool (Stechmiller J et al 2008, p.151). The risk factors that I will determine when undertaking the assessment are; immobility or reduced physical movement of the patient, loss of sensation, impaired level of consciousness, inconsistencies in urinary or faecal, poor nutrition or weight loss, dry skin and severe illness. To gain assessment knowledge on wound characteristics, I will assess the location, dimensions, stage, and exudate characteristics, surrounding skin, any presence of odour from the wound, signs of infection, wound bed characteristics and undermining or tracking characteristics as well as the progress of healing of the wound. Here I will use a validated pressure injury healing assessment scale (Australian Wound Management Association 2012, p.15). 5. Describe appropriate cleansing techniques for the wound and provide four examples of how disease is spread and infection is developed throughout wound assessment and care (Element 1) To cleanse wounds, the cleansing techniques that are appropriate include; cleansing with the use of normal saline, tap water, topical antimicrobial or antiseptic cleansing agents and potassium permanganate. The sterile normal saline which contains 0.9% of sodium chlorine is highly recommended for the use in cleansing wounds if tap water that is clean is not available. It is not recommended to use pressurised canisters because splash back may happen. Tap water is also used to cleanse chronic wounds. Tap water or water that is suitable for drinking, bathing or showering is recommended. When cleansing the wound, one should use mechanical force at minimum (NHS Foundation Trust 2012, p.7). Irrigation of the wound is also necessary when cleansing so as to clean the hollow ulcer. The appliances that are used should be cleaned prior as well as after use with the use of a multi-purpose detergent, dried and then wiped with an antiseptic. Antiseptic cleansing agents or topical antimicrobial agents can be used for cleansing the wound only once to avoid causing pain and reduce the proliferation of macrophages as well as lymphocytes that are important in the healing process of the wound. Potassium Permanganate can be diluted in lukewarm water and then used to soak the wound for not more than 20 minutes to cleanse the wound. Examples of how disease is spread and infections are developed throughout wound assessment and care. 1. When nurses use tools that are not sterilised in handling the wound during the assessment 2. When the wound comes into contact with hands that are not clean, the wound may be infected with pathogens such as bacteria that develop infections to the wound 3. Disease can be spread and infections developed when the presence of granulation tissues are assessed and not removed immediately to avoid in spreading in the whole wound bed. 4. Failure to remove any recognised discharge from the wound during assessment also increases chances for disease spreading and infections developing all over the wound. 6. Discuss your rationale for the appropriate wound care interventions and relate your answer to the physiological and biochemical processes associated with normal wound healing. Appropriate wound care interventions are essential in achieving a fast wound healing. Various interventions that can be used include; interactive wound management materials, active wound management material, new technologies as well as complementary therapies. Wound care interventions are carried out until wound closure (Collier 2003, p.1). Appropriate wound interventions are essential in maintaining or achieving the physiological as well as biochemical processes that are associated with wound healing. Appropriate wound care interventions work to achieve effective cellular as well as biochemical interplay that consist of the normal wound healing response. Such a response involves a process of intricate interactions among different types of cells, growth factors, proteinases and structural proteins. This achieves the normal wound healing process of three phases including; inflammation, proliferation as well as remodelling. The process occurs in a sequence that is predictable and consists of cellular as well as biochemical events that regulate the wound healing (Stadelmann, Digenis & Tobin 1998, p.26). 7. Identify the cost effective products you would use and discuss the rationale behind your decision. Include reference to databases and websites you have used to inform your decision. (Element 5) The cost effective products that I would use in wound care and management include; a barrier cream, barrier ointment, moisturizer, protective barrier wipes, and skin barrier removers. The reason for using these products is because they are the minimum range recommended for skin care (Braun 2015, p.1). The products that are recommended for retention of the wound and I would use include; a tabular retention bandage, tabular support bandage, tabular protection as well as paper tapes. I will also require using normal saline, a dressing pack, sterile instruments, hand hygiene products, plastic aprons, wound tracing equipment and wound resource folder. These products are the minimum recommended range of wound care products (Nurses for Nurses Network 2013, p.35). 8. Discuss how you would monitor the progress of the wound healing including how you would assess the effectiveness of interventions and wound products (Element 5) To monitor the progress of the wound healing, I will assess it dimensionally, visually and physiologically. I will measure the level of pain, the wound edge whether it is healing and other wound characteristics (Barber 2008, p.42). With the use of a pressure Ulcer Scale for healing, I will be able to measure the surface area, the length and the width as well as the depth of the wound as well as the type of tissue and evaluate the healing stages of the wound. A completely healed wound is indicated by 0 out of 16 in the ulcer scale. In assessing the effectiveness of the interventions as well as the wound products, I will capture the pain scores from the wound. This will provide evidence of pain patterns all through the wound healing (The Royal Children's Hospital Melbourne 2015, p.4). Little or no pain means the interventions and the wound products are effective. 9. Describe how you would educate the client and/or family/carer on wound management strategies (Element 4) In educating the client and family or carer on wound management strategies, I will teach them on how to help in caring for a pressure injury. What they need to do is to relieve the pressure from the injury area and ensure to seek advice from the doctor or nurse on the special equipment that can be used in relieving pressure (CSI Guide and Resource Pack 2013, p.102). The client and family or carer should apply moisturiser on the pressure ulcer two times a day. It is also advisable to use mild, pH neutral, non-irritant skin cleaners as well as body products. The part of the body that is exposed to friction should be protected and also ensure the patient takes a nutritious diet. The client and family or carer should also make use of a pillow and form wedges for protecting bony prominences. References Australian Wound Management Association, 2012, PanPacifi Clinical Practice Guideline for the Preventionand Management of Pressure Injury, Osborne Park, WA: Cambridge Media, Available at: http://www.awma.com.au/publications/2012_AWMA_Pan_Pacifi_ Guidelines.pdf Barber, S, 2008, A Clinically Relevant Wound Assessment Method to Monitor Healing Progression, Ostomy Wound Manage, Vol.54, Iss.3, pp.42-49. Braunm B, 2015, Skin and Wound Management, Products, Available at: http://www.bbraun.com/cps/rde/xchg/bbraun-com/hs.xsl/products.html?id=00020742770000000280 Collier, M, 2003, The elements of wound assessment, Wound Care, Nursing Times, Retrieved from http://www.nursingtimes.net/nursing-practice/specialisms/wound-care/the-elements-of-wound-assessment/205546.article CSI Guide and Resource Pack, 2013, Promoting Health Skin: Champions for Skin Integrity, Institute of Health and Biomedical Innovation. Nurses for Nurses Network, 2013, Wound Management: What you need to know, Available at: http://www.nursesfornurses.com.au/admin/uploads/NfNWoundCareMasterClassWhatyouneedtoknowPowerPoint.pdf Registered Nurses’ Association of Ontario, 2011, Risk assessment and prevention of pressure ulcers. (Revised). Toronto, ON: RNAO, Available at: http://rnao.ca/sites/rnao-ca/fies/Risk_Assessment_and_Prevention_of_Pressure_Ulcers.pdf The Royal Children's Hospital Melbourne, 2015, Wound Care, Clinical Guidelines Nursing, Available at: http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Wound_care/ Stadelmann, W., Digenis, A., & Tobin, G, 1998, Physiology and healing dynamics of Chronic Cutaneous Wounds, American Journal of Surgion, Vol.176, Iss.2, pp.26-38. Stechmiller J et al, 2008, Guidelines for the prevention of pressure ulcers, Wound Repair and Regeneration, Vol.16, pp.151-168. http://onlinelibrary.wiley.com/doi/10.1111/j.1524-475X.2008.00356.x/pdf Read More