NURS 5133 Wound Management
Questions
- It is the nurse’s responsibility to observe and document healing progress. With regard to a surgical wound with staples insitu, what 5 specific observations would you make?
- State 5 criteria you would use in evaluating the effectiveness of wound management strategies.
- State 5 criteria you would use in assessing the effectiveness of a dressing product for a particular wound taking into consideration cost effective framework.
- Ulcers occurring on the lower leg may be complex in their aetiology and are a sign of underlying disease, trauma or allergic response. Define the following types of ulcers that typically occur on the lower leg indicate what type of treatment would be used on each type of ulcer, for example compression therapy:
- Arterial ulcers
- Venous ulcers
- Mixed Arterial/Venous
- Neuropathic ulcerating wound
- What is Doppler Ultrasound used for
- Pressure Injury is one of the most common hospital acquired injuries. In order to accurately assess the depth of a Pressure Injury we utilise a 5 stage assessment model. State the key characteristics for each of the five stages.
- State the 3 principle causes of Pressure Injury and include a brief description of how each cause contributes to the development of a Pressure Injury.
- State 3 intrinsic factors that may lead to a person sustaining a Pressure Injury.
- Skin Tears are the most commonly acquired traumatic wound by people living in residential aged care. a) State the name of the classification system used to identify the severity of a skin tear b) List the 3 categories of Skin Tear and state the assessment criteria for each c) State the 3 most appropriate dressing categories to be used for dressing skin tears.
- Your patient had skin graft to his lower left leg which has taken well. The order is daily dressing and weekly wound measurement. His donor site is on right thigh, covered with dry dressing which is now oozing through. The order is not to disturb the dressing for another 5 days. What are you going to do? Which members of the interdisciplinary team are you going to consult about this issue?
- Find current nursing article from the Clinical Key On line library on wound management which discusses best practice and latest research and attach to the assessment. Write a short summary and why you chose the article.
- Under what circumstances you will see wound drain and why?
Answers
1. The specific observation that would be taken during the wound management and healing process are mentioned below:
- Conditions of the periwound area
- Check for contamination
- Level of pain during dressing change
- Check exudation in the wound
- Moisture balance of the wound (Powers et al., 2016)
2. To evaluate the effectiveness of wound management 5 criteria’s can be used and they are mentioned below:
- Wound bed: whether healthy tissues started appearing in the wound or dead tissue present in the wound.
- Measurement of wound: Either two or three dimensional measurement can be taken.
- Surrounding area of the wound
- Presence of infection
- Wound exudate: whether any exudate present in the wound during healing process (Powers et al., 2016)
3. Five criteria that can be used to measure the effectiveness of particular dressing product is given below:
- Availability of the in the range and size
- What is the daily cost and wear time of the product
- Whether the product passed the standard quality check
- Availability of evidence supporting the product’s effectiveness
- Availability of the product to the buyers and consumers (Powers et al., 2016)
4. Treatment type for the following ulcers are mentioned below:
- Arterial ulcers: Surgical options such as angioplasty
- Venous ulcers: compression therapy
- Mixed Arterial/Venous: Revascularization
- Neuropathic ulcerating wound: Debridement, reduction of pressure in the wound and therapeutic shoes.
- Doppler ultrasound is generally used for the measurement of blood flow in an individual’s veins and arteries (Dealey et al., 2015).
5. Characteristics of the each stage of the pressure injury is provided below:
Stage 1:nonblanchable erythema with intact skin
Stage 2: partial loss of the skin with exposed dermis
Stage 3: Adipose fat is visible with total loss of skin
Stage 4: exposed tendon, muscle, and ligament with total and full loss of skin
Unstageable: cannot be determined as it is concealed by eschar or slough (Dealey et al., 2015).
6. Three principle causes for pressure injury are:
Pressure: decreased mobility lessen the blood flow in the tissues. Without adequate blood flow tissues became deprive of essential nutrients and oxygen which lead to damaged tissue.
Shear: shear force or tension in muscle from opposite direction leads to the tissue damage.
Friction: friction between and individual’s skin and clothing can lead to the damage of the skin as it became vulnerable due to friction (Dealey et al., 2015).
7. Intrinsic factors which can lead an individual’s sustaining pressure injury are:
- Chronic illness
- Nutritional intake
- Oxygen delivery system (Dealey et al., 2015)
8. Severity of the skin tear can be identified using Skin Tear Audit Research (STAR) classification system (Newall et al., 2017).
Assessment techniques for three category skin tears are:
Type 1: Primary intention
Type 2: Secondary intention
Type 3: Secondary intention
Appropriate dressing category for dressing skin tears are:
- Non- adherent based dressing
- Non- adhesive based dressing material
- Non- viable and necrotic flaps should be used.
9. In case of oozing in the area of the skin graft, blood or seroma can be drawn out from the area by inserting a green needle in the skin graft. Care must be taken as to needle does not reach the recipient bed (Dreifke, Jayasuriya & Jayasuriya, 2015).
A clinician who performed the skin graft can be contacted for this process.
10. This selected article aim to provide a holistic and interdisciplinary approach for wound care management. This includes training of the general practitioner which will be led by nurses. According to the authors, this investigation will enhance wound management and better patient satisfaction (Innes-Walker et al., 2018).
The reason behind the selection of this article is that it will empowered nurses as well as improves wound management in general.
11. Wound drainage plays vital role in healing of the wounds. It supplies electrolytes and nutrients to the healing tissues. Wound drainage is required in case of excess exudates in the wound as this will wet the dressing and macerated the periwound area.
References
Dealey, C., Brindle, C. T., Black, J., Alves, P., Santamaria, N., Call, E., & Clark, M. (2015). Challenges in pressure ulcer prevention. International wound journal, 12(3), 309-312.
Dreifke, M. B., Jayasuriya, A. A., & Jayasuriya, A. C. (2015). Current wound healing procedures and potential care. Materials Science and Engineering: C, 48, 651-662.
Innes-Walker, K., Parker, C. N., Finlayson, K. J., Brooks, M., Young, L., Morley, N., … & Edwards, H. E. (2018). Improving patient outcomes by coaching primary health general practitioners and practice nurses in evidence based wound management at on-site wound clinics. Collegian.
Newall, N., Lewin, G. F., Bulsara, M. K., Carville, K. J., Leslie, G. D., & Roberts, P. A. (2017). The development and testing of a skin tear risk assessment tool. International wound journal, 14(1), 97-103.
Powers, J. G., Higham, C., Broussard, K., & Phillips, T. J. (2016). Wound healing and treating wounds: Chronic wound care and management. Journal of the American Academy of Dermatology, 74(4), 607-625.
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