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HLTENN006 Apply The Principles Of Wound Management To The Clinical Environment

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Question:

Task instructions:

You are required to write a wound management for Noel Frost (Case Study) who has undergone a total knee replacement surgery. This assessment requires you to fill out a 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
  1. 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
  1. Physiology of the healing process taking into consideration the wound and any factors that may impact on the healing process (ie chronic health conditions, location of wound, age ofresident)
  • 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)
  1. Evaluation of the wound management plan including:
  • Dressing/s
  • Frequency of dressing changes
  • How the wound is cleaned
  • Progress being made
  1. Health education that may be provided to the resident in regards to their wound
  • 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. Pain management relating to the wound including:
  • Medication/s accurately discussed
  • Time, frequency and dose provided
  • Justification for using particular medication provided
  • Patient’s education about pain management
  1. Completed wound care assessment plan, wound chart and progress notes chart with allrequired details fill out (provided to students via Brightspace)

Case Scenario

Mr. Noel Frost is a 65 year old male who has been admitted into Bolton Clarke (community nursing). He had total knee replacement on 1st December 2018. The post-surgical course was complicated by a wound infection and he was treated with IV antibiotics for 3 days while in hospital. After 5 days, the IV antibiotics was changed to oral antibiotics to transition to home. Mr. Frost went home after been hospitalised for 10 days and will continue with community rehabilitation 3x a week. GP follow up was scheduled on 12th December 2018 for ½ staples removal.

Prior to the Total Knee Operation, Mr. Frost has been suffering from osteoarthritis for around 3 years. He is a civil engineer who has been working as a senior lecturer in the university. For the last 1.5 years, Mr. Frost has been using single point stick (SPS) to walk. The pain was quite excruciating at times especially when he is doing long standing.

Mr. Frost lives with a supportive wife. They’ve been married for 40 years and has been blessed with 2 daughters and 5 grandchildren. Mr. Frost found it harder to move around and this is the reason why he decided to have TKR surgery. He doesn’t like to be a burden and still very independent with ADLs.

On day 3 post-discharge from hospital (13th December 2018), you are sent to visit Mr. Frost at home. This will be the 1st visit from community nursing. You are required to do a compete wound assessment plan, remove other ½ of staples as per doctor’s order and dressing the wound as necessary.

 

Answer:

Principle diagnosis of the patient

The given case depicts the condition of a patient Mr. Noel Frost who is 65 year of age and is admitted to the Bolton Clarke which is a community nursing. The patient had undergone a total knee replacement and followed by this his condition was complicated due to the wound infection. According to the current health condition of the patient, the orientation of the patient is proper and is properly oriented to time and place. The patient was admitted to the hospital due to the total knee replacement that was required of the right knee of the patient.

The patient had been a civil engineer by profession and his past medical history shows that he has been suffering from osteoarthritis for the past three years now along with hypertension and type 1 diabetes. It should also be noted that the patient is allergic hazelnuts.The medical condition of the patient reports that he has been using single point stick (SPS) to walk. He also reports that pain was quite excruciating at times especially when he has to stand for long hours. Recently it has been very difficult to move around and this made him make up his mind for the total knee replacement surgery. In spite of his condition he does not want to become a burden for his family and is independent enough with his activities of daily life (ADLs).

The pain scale is quite high when in motion. In order to manage his post-operative wound infections, the patient was provided with IV antibiotics and later this was changed to oral antibiotics while the transition was made to home. The social life of the patient showed that he has been married for 40 years and has been blessed with 2 daughters and 5 grandchildren. Severe problems is faced by the patient during mobility because of which he has to use a 2 wheel walker which he continues to use around the house along with crutches and a wheelchair outside the house. The ADLs status of the patient shows that the top half is 100% independent and the lower half is 70% independent. The condition of the patient also required a community rehab along with occupational therapy and follow ups with the general physician and the community nurse care that is Bolton Clarke.

 

Evaluation of the wound management plan

Wound bed status (include colour/s) – The wound on the leg shows a bruising that shows ecchymosis. This is then followed by the surgery. The wound color shows blue to deep red on the wound bed. There is inflammation in the first stage of the wound bed, this is followed by proliferation and the final one is the maturation of the wound (Daeschlein, 2013). The status of day one after the total knee replacement surgery shows the presence of the staples and the wound bed all swelled and red. On day 10, the wound is covered and dressed to keep away infection. On day 13, the staples are out however the jiggered mark of the incision is present whichis15 cm.

Wound measurements – The wound measurement shows that the incision is about 15 cm.

Condition of surrounding skin (ie intact, breaking down) – The condition around the wound shows that the skin is intact since the wound have been stitched after the surgery. However there is necrosis of the soft tissues in some places (Itatsu et al., 2014).

Wound exudate (colour, consistency, odour) – The wound exudate is clearless to pale in color with a thick consistency, which a pungent odour.

Frequency of dressing change- The dressing change is done twice a day, once in the morning and once in the night

Cleaning of wound- The incision wound should be cleaned gently with soap and water and the crust needs to be removed. Things like rubbing alcohol, hydrogen peroxide or iodine should be used which can harm the tissue and in turn slow down the process of healing.

 

Physiology of the healing process

The process of healing largely depends on the location of the wound, as well as the age and chronic health condition of the given patient. In relation to the situation presented here, the patient has a condition of chronic health conditions like diabetes. Therefore the presence of this makes the process of wound healing much slower. The presence of disease makes the wound quite less susceptible to healing making the wound less susceptible to drying (Pierpont et al., 2014). Additionally the age of the patient also matters, since the patient presented here is an older adult, therefore the age of the person also becomes an inhibiting factor for wound healing.. With the increase of age, the immunity of the person declines so does the secretion of the coagulating factors therefore the healing process becomes long enough.

The process of wound healing mainly occurs through two distinguished processes. These are the primary intension healing and the second intension healing. According to the primary intension healing, this process occurs only when the tissue surface has been closed. This might be because of the stiches, or skin glue or staples and tapes (Rosenberg et al., 2014). When there is a closure of this kind, there is very little tissue lost. This process is also often called the primary union or the first intension healing. In case of surgical incision, the process is primary intension. Another method is the secondary intension healing which occurs when the wound is extensive and also involves a considerable amount of tissue loss (Yu-Wai-Man &Khaw, 2015). It is in such cases that the edges of the tissues cannot be brought together to heal. Through this process the pressure ulcers heals. In terms that the secondary intension is different from the primary is intension is that the repair time required is longer, the scarring is greater and there are higher chances of infection.

Almost all of the wounds which are the surgical wounds are seen as the acute wounds therefore there rises incidences of complications which are caused due to the extrinsic and the intrinsic factors (Pierpont et al., 2014). Complications are also present which a result of the infection and dehiscence are. There are a number of factors that are associated with the complications like smoking, rheumatoid arthritis and diabetes. Additionally there are factors also present like the effects of malnutrition along with the presence of obesity that plays a role in the breakdown of obesity and the reduction of the tissue oxygenation.  

Health education

With the purpose of pain management, the pain education also plays an important part. This is defined as any of the planned activities which are designed in order to improve the health behaviour of the patient along with the improvement of the health status of the patient. The process of pain management helps in the facilitation of the knowledge of the patient so that they are able to interpret their plan and also to be able to help them to them get directed towards an effective along with the ongoing self-management (Kosins et al., 2013). The process of bringing about understanding the pain and also the complexities of the pain, it is possible to understand the importance of self-determination as well as sustainable self –management, it is important to develop skills that are facilitatory in nature. The process of healing is a long one since this process takes a long time for getting healed just after the incision has been made in order to conduct the surgery of the total knee replacement (Monstrey et al., 2014). There are also persistent wound leakage which increases the risk of the periprosthethic infection of the joint.

Actual or potential impacts of the wound- The potential impacts of the wound include pain, along with infections. The impact on the activities of daily life includes that the activities like showing would take longer hours and become more difficult for the individuals having a chronic wound.

 

Pain management

The wound care or wound management plays a significant role in the prevention of the process of contamination from taking place in the area of the wound. This also includes the proper cleaning of the wound in the area of infection that is related to the surgical closure or the healing of the second intension (Soares et al., 2015). With the purpose of obtaining the objective of the assessment of the wound that is required in order to provide a complete sedation as well as anaesthesia which is required as which might be required (Dreifke, Jayasuriya & Jayasuriya, 2015). It is possible for the wounds to be elevated and to be debrided immediately. Often there also exists a scope of biopsy that is needed for most of the chronic as well as the non-healing wounds. In order to treat the wounds, there is an aseptic technique implemented that makes use of the things like the sterile gloves, instruments, and bandage materials. It must also be kept in mind that the process of wound healing occurs in a moister and wet condition (Gause, Wynn & Allen, 2013).

Medication- the medications that were used for the sake of managing the post-operative wound infection involved Ciproflaxin and Warfarin.

Time, frequency and dose provided- Ciproflaxin was administered in 500mg dosage before dinner and for 7 days straight.  Warfarin was given in 2mg dosage on a daily basis for 10 days.

Justification for using particular medication- The drug ciproflaxin is used for treating a wide variety of wound infections. This helps to stop the growth of the bacteria, therefore only acts against the bacterial infections. The drug Warfarin is used to treat the blood clots like in case of deep vein thrombosis-DVT or pulmonary embolus-PE. This helps to prevent the formation of new clots from occurring in the body.

 

Progress notes

After the total knee replacement, the situation of the patient was complicated by antibiotics. When the patient went home. The post-surgical pain was experiencedfor few days which gradually subsided. The surgical wound is kept and dry until the area heals. Soaking that is bath is prohibited by the patient for 6 weeks after the surgery. The patient experienced a low-grade fever for few days followed by the surgery which was sometimes accompanied by chills, sweating and pain.Some drainage was seen at the incision site. Swelling was also seen at the site. The leg of the patient was elevated for 30–60 minutes every day can help reduce swelling. The patient was made to have a healthy diet. The patient was provided with walker or crutches until stable. The patient was encouraged to use handrails while taking the stairs.

 

References

Daeschlein, G. (2013). Antimicrobial and antiseptic strategies in wound management. International wound journal, 10(s1), 9-14.

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.

Gause, W. C., Wynn, T. A., & Allen, J. E. (2013). Type 2 immunity and wound healing: evolutionary refinement of adaptive immunity by helminths. Nature Reviews Immunology, 13(8), 607.

Itatsu, K., Sugawara, G., Kaneoka, Y., Kato, T., Takeuchi, E., Kanai, M., ...&Nagino, M. (2014). Risk factors for incisional surgical site infections in elective surgery for colorectal cancer: focus on intraoperative meticulous wound management. Surgery today, 44(7), 1242-1252.

Kosins, A. M., Scholz, T., Cetinkaya, M., & Evans, G. R. (2013). Evidence-based value of subcutaneous surgical wound drainage: the largest systematic review and meta-analysis. Plastic and reconstructive surgery, 132(2), 443-450.

Matatov, T., Reddy, K. N., Doucet, L. D., Zhao, C. X., & Zhang, W. W. (2013). Experience with a new negative pressure incision management system in prevention of groin wound infection in vascular surgery patients. Journal of vascular surgery, 57(3), 791-795.

Monstrey, S., Middelkoop, E., Vranckx, J. J., Bassetto, F., Ziegler, U. E., Meaume, S., &Téot, L. (2014). Updated scar management practical guidelines: non-invasive and invasive measures. Journal of Plastic, Reconstructive & Aesthetic Surgery, 67(8), 1017-1025.

Pastar, I., Stojadinovic, O., Yin, N. C., Ramirez, H., Nusbaum, A. G., Sawaya, A., ... &Tomic-Canic, M. (2014). Epithelialization in wound healing: a comprehensive review. Advances in wound care, 3(7), 445-464.

Pierpont, Y. N., Dinh, T. P., Salas, R. E., Johnson, E. L., Wright, T. G., Robson, M. C., & Payne, W. G. (2014). Obesity and surgical wound healing: a current review. ISRN obesity, 2014.

Rosenberg, L., Krieger, Y., Bogdanov-Berezovski, A., Silberstein, E., Shoham, Y., & Singer, A. J. (2014). A novel rapid and selective enzymatic debridement agent for burn wound management: a multi-center RCT. Burns, 40(3), 466-474.

Rosenberg, L., Krieger, Y., Bogdanov-Berezovski, A., Silberstein, E., Shoham, Y., & Singer, A. J. (2014). A novel rapid and selective enzymatic debridement agent for burn wound management: a multi-center RCT. Burns, 40(3), 466-474.

Soares, K. C., Baltodano, P. A., Hicks, C. W., Cooney, C. M., Olorundare, I. O., Cornell, P., ... &Eckhauser, F. E. (2015). Novel wound management system reduction of surgical site morbidity after ventral hernia repairs: a critical analysis. The American Journal of Surgery, 209(2), 324-332.

Stevens, D. L., Bisno, A. L., Chambers, H. F., Dellinger, E. P., Goldstein, E. J., Gorbach, S. L., ... & Wade, J. C. (2014). Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clinical infectious diseases, 59(2), e10-e52.

Webster, J., Scuffham, P., Stankiewicz, M., &Chaboyer, W. P. (2014). Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention. Cochrane Database of Systematic Reviews, (10).

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