Answer To: Shilpa_0100ABF_Apply principles of wound management in the clinical environment.pdf by Shilpa --...
Abhishek answered on Mar 27 2021
HLTENN008
Apply Principles of Wound Management in the Clinical Environment
Assessment Task 1
Knowledge Questions
Q. 1.
Acute injure
Acute wounds recover by the normal cycles of inflammation, tissue development, and remodelling, all of which take place in a timely manner.
Chronic wound
Chronic wound does not heal or respond to treatment within the usual time period for healing (4 weeks).
Dermis
The deepest layer within the skin is the Demin. It is constructed of two layers- upper and
Exudate
In case of tissue damage, exudate is the particular liquid produced by the body.
Purulent
Purulent drainage is a type of fluid that is released from a wound. It is thick with a yellow, green or brown colour. It indicates an infected wound that must be treated.
Epithelialisation
Epithelialisation is the process of epithelial cells migrating upwards to heal a wound. During the proliferative phrase of wound healing, this particular process exists.
Granulation
In wound healing Granulation is a specific stage in where pink tissues, lumpy, consisting of new connected capillaries and tissues develops in the areas of the wound.
Erythema
The increased blood flows in superficial capillaries are generally caused by the Erythema, which reddens the skin or the mucous membranes.
Macerated
Maceration occurs when the moisture skin is exposed for an extended span of time. Skin that has been macerated is light-toned in colour as well as wrinkled. It can sense soggy, damp or even fuzzy to the touch.
Cellulitis
The bacterial skin infection is very painful diseases. Cellulitis typically affects the layer of the skin, which can also affect the tissue within it. This particular infection has the potential to spread to lymph nodes and the bloodstream.
Q. 2.
Surgery was only part of medicine in the 18th century and reserved for the rich, and those eager to be experimented on essentially. Antibiotics and antiseptic methods were discovered in the 19th century, and when they were adopted, they had a huge impact on reducing infection rates and decreasing mortality rates. Modern wound care developed in the twentieth century, with thousands of simple-to-use items being widely accessible to the public, and as a result, we now have longer life spans, better access to care, and a higher quality of life than every previous generation (History and Future of Wound Care - Team Medical, 2021).
Q. 3.
The Comprehensive Care Standard sets out the standards that health-care organisations must meet in order to make sure that every patient receives organised comprehensive care that is according to their needs and goals, as well as that their risks of harm are minimised. Health service organisations are implementing the NSQHS Standards to establish systems and processes for pressure injury prevention and wound management.
All assessments, management, interventions and outcomes must be documented in the patient’s healthcare record. Individual patient monitoring can be done when needed, but at least once a week, using validated tools to track healing. Organizations are encouraged to use agreed-upon quality metrics in routine reporting, assessing the procedures and results for pressure injuries on a daily basis. This involves the occurrence and prevalence of pressure injuries (Preventing pressure injuries and wound management, 2020).
Q. 4.
Wounds causes can be internal and external origin. These are as below:
Internal Wounds
· Debilitated dissemination: This can be either from ischemia or from balance. Ischemia is a condition where the blood stream is diminished because of the narrowing or obstructing of veins. Balance is brought about by delayed idleness or disappointment of the controlling valves in the veins, causing pooling of blood and neglects to stream typically to the heart (Causes of Wounds, 2021).
· Neuropathy: This is especially normal in patients with long haul uncontrolled diabetes mellitus, in which raised blood sugars, subsidiary proteins, and metabolites develop and harm the sensory system. Patients are ordinarily uninformed of any wounds or wounds because of an absence of feeling in the influenced zone.
· Clinical sickness: Chronic clinical ailments can prompt weakness of the invulnerable framework capacities, lessening the course and harming different organs and frameworks.
External Wounds
· Wounds: These are sports injury, where a direct unpolished injury can harm the little veins and vessels, muscles and basic tissue, too the inward organs or bone.
· Hematomas: Hematomas comprises any injury that harms the little veins and vessels bringing about blood gathering and pooling in a restricted space.
· Pulverize wounds: Crush wounds are brought about by an outer high-pressure power that crushes part of the body between two surfaces (Causes of Wounds, 2021).
Q. 5.
· Fungus originates from various fungal infection of skin. Tissues are infected by this fungus, which thereby causes certain disease, which starts with the skin and increasingly grow up all over the body, bones, organs and many more.
· The common indication arises from fungal infection are redness, scaly skin, swelling, itching and blisters. The primary test for diagnosing a fungal infection is a fungus culture.
· . Nurses should use proper PPE for avoiding the spread of infection. Fungal infections can be treated by using antifungal medications. It can be managed by keeping infected area clean and dry followed by wound dressing.
· Ringworm of the body
· Athlete’s foot
· Jock itch (Johnson, 2018)
Q. 6.
· A viral infection is the transmission of a contagious virus in the body. Viruses are unable to replicate without the aid of a host. Viruses infect humans by inserting their genetic material into cells and hijacking the cell's internal machinery to produce more virus particles.
· Doctor may diagnosis viral infections based on symptoms. They do blood tests and cultures, or examination of infected tissues based on symptoms.
· Many viral infections are self-resolving and do not need treatment. Antiviral drugs may stop viruses from reproducing or improve the immune system‘s response to a viral infection.
· Gastroenteritis
· Common cold (What's a Virus? Viral Infection Types, Symptoms, Treatment, 2021)
Q. 7.
· Bacterial infections are caused by normal flora bacteria such as species of staphylococcus and streptococcus. They may also be caused by colonising bacteria which may be resistant to some antibiotics such as MRSA.
· Bacterial infections can be detected through bacterial culture, gram stain, antimicrobial susceptibility, fungal culture and blood culture.
· Bacterial infections can be managed by antibiotics. It can also be managed by maintaining proper nutrition and hydration.
· Bacterial cellulitis
· Bacterial vaginosis (Infected Wounds, 2020)
Q. 8.
· Class I: these are treated as clean wound, which produces no signs of inflammation and infections and thereby often involved the section of skin, eye or vascular system.
For example Mastectomy and thyroidectomy
· Class II: these injuries are often considered as clean -contaminated. Although with the fact that this wound does not provide or show any kind of infection but still its existence took it at the higher risk zone.
For example, tonsillectomy and gastrointestinal tract arises from the surgical wound.
· Class III: an outside substance exposed from infection wound often comes out into the contact of the skin, which thereby produce a higher risk of infection.
For example, gunshot wound, haemorrhoidectomy
· Class IV: this particular section of wound is thereby treated as dirty, contaminated, which contains the wound that is being exposed to the faecal material.
For example, chronic wound debridement and abscess drainage (Surgical Wounds: Types, Risk Factors, and Treatment, 2017).
Q. 9.
Pressing factor ulcers are otherwise called bed bruises. These injuries can go from shut to open. They for the most part structure in the wake of investing an excessive amount of energy sitting or lying in one spot. Due to stability, blood supply to certain zones of your body is cut off, causing tissue harm. Regular spots for bed injuries to create incorporate back of the head, shoulders, elbow, back, butt, hips, lower legs, heels.
Phases of pressing factor ulcers
· Stage 1: The principal stage is the most un-genuine. It makes the top layer of skin turn a ruddy tone. Albeit the injury has not yet opened, the earnestness of the condition comes to past the outside of the skin. While the influenced region is delicate to the touch, there are no surface breaks or tears.
· Stage 2: The ulcer would probably cause torment in the subsequent stage. The sensitive region of skin has gotten through the top layer and a portion of the layer underneath. The break ordinarily makes a shallow, open injury and you might see any seepage from the site.
· Stage 3: Sores in the third stage have broken altogether through the best two layers of skin and into the greasy tissue under. It might likewise smell awful. In this stage, it is critical to search for indications of contamination like foul scent, discharge, redness, stained seepage.
· Stage 4: In the stage 4, ulcers are the most genuine. These bruises stretch out underneath the subcutaneous fat into your profound tissues like muscle, ligaments, and tendons. There is a high danger of contamination at this stage. These wounds can be very agonizing (Anthony, 2018).
Q. 10.
The common type of leg ulcer is known as venous ulcers, which are caused by the damaging veins and are responsible for bringing out the bloods from several section of the body towards the heart through one-way valves. These valves there after flows away from the heart by preventing blood.
The various possibilities for venous leg ulcers are as below:
· Obesity
· History of blood clots in the legs
· Varicose veins
· Blockage of the lymph vessels, which causes fluid to build up in the legs
· Family history of venous insufficiency
· Smoking
· Long periods
· Older age, being female or being tall
· Pregnancy
(Encyclopaedia and self-care, 2021)
Q. 11.
Ischemic ulcers are often known as arterial ulcers, which thereby are caused by poor or imperfect perfusion to the lower extremities. The oxygen supply to the overlying skin and tissues is then cut off; destroying the tissues and can creates an open wound. The most usual as well as familiar causes of this arterial ulcers are reduction to blood vessels due to high blood pressure, renal failure, increased age, peripheral vascular disease, limit joint mobility chronic vascular insufficiency, diabetes mellitus.
Risk Factors
There are following various possibilities, which may support towards the development of arterial ulcer, are as follows:
· Obesity
· Limited joint mobility
· Poor footwear that protects against the shear and high pressure
· Absence of protective sensation due to peripheral neuropathy
Diagnostic measures for arterial ulcers
· Buerger’s test
· Absolute toe systolic pressure
· Arteriography
· Arterial Doppler studies (Arterial Ulcers, 2020)
The combination of venous and arterial disease gives rises to mixed ulcers. Changing of characters quickly are the complications arises from mixed aetiology ulcers such as when this arterial disease progresses quickly. Since arterial disease is progressive, if it is not treated, it will ultimately become the most important thing to consider when making medical decisions (Urgo Medical » Leg ulcers, 2021).
Q. 13.
There are different types of exudates commonly seen in wound such as
· Drainage of Serous: During the normal inflammatory healing period, the body produces serous drainage as a normal reaction. On the other hand, a huge volume of drainage of serous, which therefore give rises to high bio burnt count
· Drainage of Sanguineous: Sanguineous drainage is only usual in case of the occurrence during the inflammatory stage of healing. Sanguineous drainage may be caused by damage to the wound if it occurs outside of the inflammatory process.
· Drainage of Serosanguinous: This is the most usual types of exudate, which is being found in wound. It is generally watery as well as pink in presentation.
· Drainage of purulent: This is milky in colour, has a smoother consistency, and can appear grey, green, or yellow. It is a sign of infection if the fluid becomes very thick (Wound Exudate: Assessment and Management Strategies, 2020).
Q. 14.
Malignant wounds are generally caused by several cancerous tissues or cells, which enter the skin and support the lymph vessels and blood, resulting in tissue death due to a lack of vascularity. The injury might be the consequence of an initial cancer or a skin metastasis from a local tumour or a tumour in another place.
Three principles underpinning malignant wound management
· Local wound management
· Symptom control
· Treatment of the underlying problem and co-morbid condition (Symptom Control (Symptom Management Guidelines: CARE OF MALIGNANT WOUNDS, n.d.)
Q. 15.
Peripheral neuropathy causes neuropathic ulcers, which are most common in diabetic patients. Lack of sensation, over pressure points on the foot leads to extended microtrauma, breakdown of overlying tissue, and results ulceration. Furthermore, neuropathy can lead to minor scrapes or cuts not being adequately handled, eventually leading to ulcers. Neuropathic ulcers will depend on the patient’s circulation from reddish to brown/black (Neuropathic Ulcers and Wound Care: Symptoms, Causes, and Treatments, 2010).
Q. 16.
Wounds that are not properly cleaned and covered can allow bacteria, viruses or fungi to invade through openings in the skin and cause infection. On the other hand, sepsis occurs when the body overreacts to an infection, releasing chemicals into the bloodstream and eventually causing organ failure or death.
Signs of wound infection:
· Wound may become more painful.
· Wound looks swollen.
· Wound looks red around the infected area and feels warm or hot.
· Fever is also sign of wound infection.
· Wound drainage which may be smelly (Sepsis and Wounds - End Sepsis, n.d.).
Q. 17.
Several Burns are divided into first, second, third as well as fourth degree burn varying on how greatly they pierce the surface of the skin.
· First-degree burns: Firstly, the burn affects the epidermis, the skin’s outer section. The burning portion becomes painful, red and free from blisters. For example, Mild sunburn
· Second-degree burns: Secondly, the burning area affects the lower section of the skin and the epidermis. The burn location is red, swollen and painful.
· Third-degree burns: Thirdly, the burn damages the dermis as well as the epidermis. They can go inside the inner layer of the skin— the subcutaneous layer. The burn area may look white or black and burnt.
· Fourth-degree burns: Fourthly, the burns pass through both the section of skin and underlying tissues, possibly affecting muscles and bones. There is no stimulation in this area, as the nerve endings are destroyed (Classification of Burns, 2020).
Q. 18.
The several planning that are important in preventing and controlling the burn infection are:
· Isolate patient in a single room to prevent infection from spreading to other patients.
· Healthcare providers also recommend that wounds be exposed to a significant amount of oxygen to help in the healing process.
· Drink lots of water, six to eight glasses per day.
· Focus on antioxidant-rich foods to enhance cell health and recovery.
· It is essential to keep hands clean during cleansing steps.
· Patients and medical professionals may emphasise the importance of keeping dressings sterile. This action prevents bacteria out of the wound and decreases the...