HLT54115 Diploma Of Nursing

Wound Management Plan – please address the following:
1. Principle diagnosis of the patient which includes:
Presenting problem
Other medical conditions (including chronic health conditions)
Reason for admission to hospital
2. Evaluation of the wound management plan including:
Wound bed status (include colour/s)
Wound measurements
Condition of surrounding skin (ie intact, breaking down) 
Wound exudate (colour, consistency, odour)
Frequency of dressing change
3. The progress notes must include:
Explanation of the wound management

Pain management; includes education about pain management for patient
Expectation of healing process (elaborate more towards the physiology of healing process, ie. chronic health condition, age of the patient, location of wound) and also the type of wound healing (eg. Primary intention or secondary intension)
Actual or potential impacts of the wound discussed. You may wish to consider inability to perform normal Activities of Daily Living and complication of post-op wound

1. Principle Diagnosis Of The Patient

The main problem which made David Pearson to seek for help from the hospital is osteoarthritis which has troubled him for the past 10 years, he has history of hypertension which developed 6years ago, he also has breathing difficulties at night which is relieved when he sits up, he has polyuria, he goes to the toilet 12 times a day and twice during the night which disturbs his night sleep. The main reason for admission to the hospital is because of osteoarthritis which its intervention is total knee replacement (Caplan, & Kader, 2014).

2. Evaluation Of Wound Management Plan

Wound beds can be assessed for presence of granulation tissue which is red, fibrin sloughs which is yellow .Dark red granulation is danger sing, it bleeds on contact and indicate the presence of wound infection (Lozano-Platonoff, Mejía-Mendoza, Ibáñez-Doria, & Contreras-Ruiz, 2015). Health granulation is pink in color. Leucocyte level increases at wound bed after 2-3 days specifically macrophages, macrophages help cleanse the wound. (Percival, Hill, Williams, Hooper, Thomas, & Costerton, 2012).

Frequency Of Dressing change of dressing is not done until sutures are removed 12-14 days following surgery. Dressing should remain in place up to seven days from placement in theatres unless dressing has moved out of place, it is fully saturated, if dressing is leaking, if there is increase in pain or odor, increased discharge or foul smelling and if the surrounding skin has become red or swollen

Wound Measurement

A centimeter ruler is used to measure the length of the wound (Shetty, Sreekar, Lamba, & Gupta, 2012). It should be done regularly so that wound size is determined and its progress measured to show if its healing or deteriorating. Measurement is taken from open wound edge to open wound age at longest point, the direction of the wound is from head to toe, use a 7cm ruler to measure the width of the wound.

Wound Exudate

Wound exudate is produced by the body in response to tissue damage. Wounds should always be moist to prevent skin breakdown. Exudate that is milky or thick liquid that may turn to yellow or brown is an indicator of infection which should be treated promptly by use of antibiotics. Exudate contains proteins and variety of nutrients, growth factors and enzymes which facilitates healing (Sherman, & Barkley, 2011). Exudate increases mostly during inflammatory phase of healing, it help bathe the wound with nutrients and also cleans wound surface

Condition Of Surrounding Skin

It can be done by checking temperature, color and shape of surrounding skin. Increased Temperature of the surrounding skin is an indicator whether active infection is present or Not. Check if there is normal blood flow in surrounding skin,check for dryness or cracking of surrounding skin. Also check for skin turgor for any sign of dehydration. Check moisture level because moisture –associated skin damage is important in preventing further skin breakdown (Voegeli, 2013). Using liquid dressing because it helps protect surrounding skin from moisture while adhesives reduce friction forces. Surrounding skin breakdown can delay healing and can worsen wound.

1. a) Explanation Of Wound Management

wound care which include wound dressing, removal of stitches and control of infection, changing dressing is not done until sutures are removed at 12-14days but  unless the dressing is wet or soiled, this reduce chances of infection, signs of infection should be monitored for example swelling , pain around the knee, redness , increased heat  and leakage from the wound. Antibiotics should be taken to curb infection but in case of those signs the patient should contact physician immediately

1. b) Pain Management

Replacements are often done to reduce caused by arthritis, Pain medications  such as morphine 10mg  4 hourly should be taken as prescribed and instructed by the surgeon, patient legs to be raised and cold to be applied after activities such as exercise or walking, patient to keep taking medications gradually rather than stop taking them suddenly

1. c) Expectation Of Healing Process

Wound healing process is the process of repair that follows injury to skin, wound healing process involved repair of injured tissue where it is replaced by connective tissue and forms scar on fully healing. Wound healing process involves three phase: vascular response, injury to the dermis causes bleeding because blood vessels are damaged, damaged end of blood vessels constrict to minimize blood loss, the exposure of blood to air initiates the clotting process which is facilitated by aggregation . Inflammatory response is another stage where inflammatory mediators such as prostaglandin and histamine are produced by mast cells stimulated by activation of clotting factors and tissue damage in turn wound exudate is produced. At proliferation stage wound is filled with new connective tissue, wound size decreases because of combination of physiological process of granulation, contraction and epithelialization and maturation. In health individuals   it begins at 3 weeks after injury and can last for months. Many factors can also contribute to delayed wound healing, general health of and individual will influence the ability of healing in different ways. Conditions resulting in reduced tissue perfusion cause reduced blood flow to tissues hence delayed healing. As people age, there skin elasticity reduces due to wearing out elastic tissue and collagen fibers in outer dermal layer  also reduces

1. d) Potential Impacts Of Wound Discussed

Arthritis of the knee in particular affects the quality of life the individual physically but also emotionally and socially (Neogi, 2013). Arthritis of the knee compromise activities of life such as walking, climbing stairs, doing stairs will be hard for even 6 weeks, and self-care activities such as bathing and dressing is compromised. Dislocation of a knee can happen in some cases, getting up and down of the floor is limited and someone need to be careful, use the help of a chair to stand. Since washing and dressing compromised, one shouldn’t bathe unless the wound is fully healed, patient should sit on the side of the bed or chair when getting dressed

4. Evaluation Of Would Management

Dressing should not be changed unless dressing are soiled then it should be changed to avoid infection, patient to keep medications until the pain is fully gone, if further medication is needed doctor should be seen, swelling is normal, patient   need to move regularly . Stocking helps reduce swelling, patient to keep wearing them day and night, exercises are important by physiotherapist or can be done at home. After 6 weeks patient to try all domestic tasks, dancing, speed walking and cycling

References

Caplan, N., & Kader, D. F. (2014). A comparison of four models of total knee-replacement prostheses. In Classic Papers in Orthopaedics (pp. 169-171). Springer, London.

Lozano-Platonoff, A., Mejía-Mendoza, M. D. F., Ibáñez-Doria, M., & Contreras-Ruiz, J. (2015). Assessment: cornerstone in wound management. Journal of the American College of Surgeons, 221(2), 611-620.

Neogi, T. (2013). The epidemiology and impact of pain in osteoarthritis. Osteoarthritis and Cartilage, 21(9), 1145-1153.

Percival, S. L., Hill, K. E., Williams, D. W., Hooper, S. J., Thomas, D. W., & Costerton, J. W. (2012). A review of the scientific evidence for biofilms in wounds. Wound repair and regeneration, 20(5), 647-657.

Sherman, A. R., & Barkley, M. (2011). Nutrition and wound healing. Journal of wound care, 20(8), 357-367.

Shetty, R., Sreekar, H., Lamba, S., & Gupta, A. K. (2012). A novel and accurate technique of photographic wound measurement. Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India, 45(2), 425.

Voegeli, D. (2013). Moisture-associated skin damage: an overview for community nurses. British journal of community nursing, 18(1), 6-12.