Reference no: EM131844869

Apply principles of wound management in the clinical environment Assessments

ASSESSMENT TASK 1 - QUESTIONING

1. How would you ensure that your client's privacy and dignity are maintained during holistic assessment and wound management activities?

2. Label the following diagram of the skin layers.

3. List the stages of wound healing. For each stage describe the critical changes that occur at cell, biochemical and tissue level, using appropriate medical terminology.

4. Outline 5 key factors that may affect wound healing, including psychological impact of a wound on the person's activities of daily living. What is the ideal environment for wound healing?

5. The clinical appearance of a wound is very important in the assessment of healing progress and also to identify the stage of healing that a wound is at.

Define the following characteristics of wound tissue:

a. Necrotic

b. Sloughy

c. Granulating

d. Epithelizing

6. Wound infection is a serious complication which may delay or reverse healing leading to greater tissue damage or systemic illness. State the 5 common clinical manifestations of wound infection. How can you prevent, minimise cross-infection, consider client/family education.

7. Wound exudate can be described as being serous, haemoserous, sanguinous or purulent.

State the characteristics of each:

a. Serous

b. Haemoserous

c. Sanguinous

d. Purulent

8. List 3 other characteristics of wound exudate that you would include in your assessment of a person's wound.

9. List 3 criteria to consider when undertaking assessment of the skin surrounding a wound.

10. Pain related to a wound needs to be assessed and treated promptly and appropriately. List 5 factors that may contribute to pain related to a wound.

11. State 4 ways wounds can have a psychosocial impact on an individual.

12. State 10 factors you would consider in developing a wound management plan and provide rationale for each factor stated.

13. List the members of the health care team who may be involved in wound management in the hospital setting.

14. As part of the management plan, what 4 key instructions should be included when educating the client/family in regard to wound-damage prevention strategies?

15. State 5 intrinsic client factors/conditions that may increase the risk of wound development and/or delay wound healing.

16. For the following dressing categories, identify the key indication for use and provide rationale for your answer. Also state one example (brand) of the product.

a. Semipermeable film

b. Foam

c. Hydrocolloid

d. Hydrogel

e. Alginates

f. Multilayer absorbent pad

g. Odour absorbing

h. Pressure reducing

i. Silicone

j. Ionic Silver

k. Haemostatic agent

l. Manuka honey

m. Negative pressure therapy devices

17. 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?

18. State 5 criteria you would use in evaluating the effectiveness of wound management strategies.

19. State 5 criteria you would use in assessing the effectiveness of a dressing product for a particular wound taking into consideration cost effective framework.

20. 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:

a. Arterial ulcers

b. Venous ulcers

c. Mixed Arterial/Venous

d. Neuropathic ulcerating wound

e. What is Doppler Ultrasound used for

21. 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.

22. 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.

23. State 3 intrinsic factors that may lead to a person sustaining a Pressure Injury

24. 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

25. 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?

26. 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.

27. Under what circumstances you will see wound drain and why?

ASSESSMENT TASK 2- SCENARIO

Scenario One - Group one

Mary Gordon is an elderly lady who was admitted to a medical ward for treatment of a gastrointestinal infection. Mary is on bed rest and requires full assistance with all activities of daily living. She has frequent uncontrolled diarrhoea and her nurse has been providing excellent care to maintain her cleanliness, comfort and dignity. Following one episode of providing perineal care for Mary and changing the bed linen, the nurse is called immediately to another client to attend to a dressing that has started to fall off a person's large abdominal visceral wound. The nurse's hands were not washed before attending to the dressing. That client subsequently developed an infection in her wound - the pathogen was identified as Escherichia Coli.

1. Clearly explain what is visceral wound, type of dressings suitable to use and the origin of Escherchia Coli pathogen. Identify each of the following the chain of infection criteria in relation to scenario 1; for each criteria identified explain how you arrived at your answer:

• Infectious agent
• Reservoir
• Portal of exit
• Mode of transmission
• Susceptible host and immunity

2. State 3 ways this cross infection episode could have been avoided. Provide an explanation for each of the ways you identify.

3. State the principle clinical manifestations associated with wound infection and explain the fundamental physiological reasons for each of the symptoms and how it affects the person's activities of daily living.

4. Define National Safety and Quality Health Services Standards as related to this scenario.

5. What would be the appropriate dressing to use on large visceral wound? The wound is de heased surgical incision healing by secondary mode of healing. It is oozing large amounts heamoserous.

Scenario Two - Group two

John Henderson is a 45 year old man who is in patient in the Burns ward. He sustained 3 degree burns to his abdomen and legs when he tried to control accidental fire in his shed. He undergone grafting surgery to cover area on his abdomen. It is day 5 since Mr. Henderson's surgery. Last night he was febrile 37.9 and when his dressing was changed it was noted that the wound was red, warm to touch and swollen. A small amount of purulent discharge was also observed. Mr. Henderson's treating doctor has requested a wound swab for micro culture and sensitivity (MC&S).

1. Describe staging of burns. What treatment will be given to Mrs Henderson during his stay in hospital, include choice of dressing to manage grafts and donor sites and pain management care, outline the plan.

2. Describe psychological and physical impact on Mr Henderson

3. Include members of multidisciplinary team who will be part of his treatment and discharge planning, including community support post discharge.

4. The registered nurse you are working with has delegated the task of collecting the specimen to you. What equipment will you need to gather in preparation for collecting the specimen? Why the doctor did ordered the swab?

5. Describe how you will perform the specimen collection: ensure that all aspects of patient care are addressed and the specimen collection method you employ is based on best available evidence, is it advisable to clean the wound before collecting the specimen or after? Give rationale.

6. What is the potential cause of suspected infection, describe the importance of infection prevention in patients with burns

7. Define National Safety and Quality Health Services Standards as related to this scenario

8. State the documentation you would include in Mr. Henderson's progress notes.

Scenario Three -

Cathy Cartwheel is 77 years old lady, she is living independently with her husband. She has a past history of Hypertension Type 2 Diabetes, OA in her right knee. She developed an ulcer which has been diagnosed as Diabetic ulcer. In the past she suffered from venous ulcer due to Hypertension and impaired circulation.

1. Define pathophysiology of Diabetic, Venous and arterial ulcer, include signs and symptoms and how would you differentiate those.

2. What tools are used to diagnose ulcers?

3. Describe treatment for Diabetic, Venous and Arterial ulcers. Compare contemporary treatment strategies with available treatment in the past. Outline historical development in wound care practices.

4. You are her community nurse, create a care plan with time frames for reviews using primary health care principles and holistic

Approach to plan her wound care, consider dietary intake, diabetes management. What health care professionals you will involve to help Cathy to manage her wound and wound healing effectively. Include need for pain relieve for Cathy.

5. Create an educational lifestyle program for her and her family, including infection prevention and understanding modes of transmissions.

6. During the wound assessment you have noticed that there is significant amount of slough covering area from 1200 o'clock to 6 o'clock of the wound bed. Define the terminology of slough and why would you need to debride the area. How is debridement done and what is your scope of practice in this instance? 

ASSESSMENT TASK 3 - SKILLS ASSESSMENT

In a simulated setting and using your Tollefson Essential Clinical Skills: Enrolled/Division 2 Nurses manual, you will be assessed on the demonstration of each of the nursing procedures listed below on an adult, child and infant manikin. You must achieve a satisfactory result on each of the following nursing procedures.

• Aseptic technique
• Dry dressing
• Wound irrigation, wound swabs
• Packing of wound
• Suture, clip and staple removal
• Drain removal and shortening
• Wound Assessment

ASSESSMENT TASK 4 - PROFESSIONAL PRACTICE EXPERIENCE

Prior to attending work placement, you will be issued with a Professional Practice (PP) Record Book. This book is to provide you and the Clinical Assessor with performance criteria for a standard of competency that would be expected of an Enrolled Nurse at the completion of each Professional Practice (Aged Care, Mental Health, Community, Sub-Acute Care and Acute Care). The performance criteria articulates to the expected knowledge, skills and attitudes required of an Enrolled Nurse and aligns to the domains of practice in the Enrolled Nurse standards for practice.

This book will outline:

• Professional Practice Objectives
• The roles and responsibilities of the Student and the Clinical Assessor
• Clinical Skills
• Formative and Summative assessments.

It is critical that during the professional practice, you will consistently demonstrate achievement of the required skills, knowledge and the ability to complete tasks as outlined in the elements and performance criteria of this unit, manage tasks and contingencies in the context of your role within your scope of practice. You must undertake nursing work in accordance with the Nursing and Midwifery Board of Australia Professional Practice Standards, Codes and Guidelines during your placement.

This includes the ability to:

1. Performed wound care management, including wound assessment, health education and evaluation of the person's wound care in the workplace on 3 wounds, of which

At least 1 must involve a simple wound dressing and

At least 1 must involve a complex wound dressing.

Attachment:- Assignment File.rar