Supporting document
Patient Details: Mrs. Miriam Gold, 85 years’ old
Presenting Problems: Fluids overload (dialysis will be ceased due to palliative approach),
Pneumonia & metastatic cervical cancer
History: COPD, GORD, CABGs
Cognitive: drowsy and vague
Social: lives home with husband. Patient and family want no further treatment
Diet: mild thick fluids (as tolerated)
Continence: incontinent, pad in situ
Mobility: RIB
Medications: patient is receiving medication via a syringe driver:
Fentanyl 200 mcg + Midazolam 10 mg (24/24
PRN medication: Fentanyl 25-50 mcg (S/C), Midazolam 2.5-5 mg (S/C)
Mrs. Gold was admitted to the ward for palliative treatment. Husband and children are not coping at home and she was in a lot of pain due to her malignant wound on her L) groin.
The malignant wound on her groin is purulent and it has developed a sinus. The odour coming out from the wound is offensive.
The patient requires pain relief before dressing change and for any pad changes/hygiene care. It was reported that her groin and peri-anal area is red due to bowel incontinence & discharge from her cervical cancer.
Mrs Gold is complaining of burning pain in her groin and perianal region.
Mrs Gold’s history notes state that she has developed a rectovaginal fistula as a result of the disease progress and radiotherapy.
Mrs gold also has a long-standing venous ulcer that is not healing.
You are required to write an individualised wound management plan for Mrs Gold.
Malignant fungating wound in groin.
Venous Ulcer
1. Holistic assessment of the patient that includes:
- medical history and examination of the patient and the wounds
- type of wounds with definition and the causes of wounds –example injury, fungal infection, micro-organism, viral
infection, disease.
- any investigation required for the wound
- wound management principles
- 4 potential common problems/complications of complex and challenging wounds.
2. Evaluation of each type of wound:
- wound bed status (include colour/s)
- wound characteristics
- wound measurements
- condition of surrounding skin (example- intact, breaking down)
- wound exudate colour, consistency, odour) - any further assessment required example doppler, wound swab.
3. Expectation of healing process for each type of wound; taking into consideration the wound and any factors that
may impact on the healing process-example, chronic health conditions, location of wound, infection, mobility, age, nutrition.
4. Wound management plan (for each type of wound), includes:
- moist wound healing
- skin & risk assessment
- wound cleansing
- pressure support and relieving devices
- prevention programs
- selection of wound dressing products (choose 1 product as a primary dressing for each wound).
- Secondary dressing (if required)
- pain management timeframes appropriate to wound care (if required)
- Referral for wound care expert assistance.
5. Health education for the patient regarding the wound. (ie. nutrition, elimination, mobility and any preventative
measures) in consultation with a registered Nurse.
6. Pain management relating to the wound in consultation with the RN prior to wound care including:
- medication/s accurately discussed
- frequency and dose
- justification for using a medication
- pain education for Mrs Gold
Marking criteria for each product document/s supplied.
1. Holistic assessment of the patient including:
-medical history and examination of the patient
and the wounds
-type of wounds with definition and the causes
of wounds –example, injury, fungal infection,
micro-organism, viral infection, disease.
-any investigation required for the wound
-wound management principles
Unsatisfactory
Holistic assessment of patient not included
Multiple errors in diagnosis (5+)
Satisfactory – Pass
Holistic assessment of patient provided.
Minor errors in diagnosis (2-4)
Three (3) of the required elements are missing or no
justification as to why it was not included OR
Two (2) errors in required elements
6 Marks
Credit
Holistic assessment accurately provided
Two (2) of the required elements are missing or no
justification as to why is was not included OR
One (1) error in a require element
8 Marks
Distinction
Holistic assessment accurately provided
One (1) required element not included or no
justification as to why it was not included (ie – this
resident has no other medical issues)
9 Marks
High Distinction
Holistic assessment of patient accurately provided
All required elements accurately included.
12 Marks
2. Evaluation of the wound including:
-Wound bed status (include colour/s)
-Wound characteristics
-Wound measurements
-Condition of surrounding skin (i.e. intact,
breaking down)
-Wound exudate (colour, consistency, odour)
-Any further assessment, Example-Doppler,
wound swab.
Unsatisfactory
No evaluation of wound provided or
Multiple errors in evaluation (5+)
Satisfactory – Pass
Evaluation of wound provided.
Minor errors in evaluation (2-4)
Three (3) of the required elements are missing or no
justification as to why it was not included OR
Two (2) errors in required elements
6 Mark
Credit
Accurate evaluation of wound provided
Two (2) of the required elements are missing or no
justification as to why is was not included OR
One (1) error in a require element
8 Marks
Distinction
Accurate evaluation of wound provided
One (1) required element not included or no
justification as to why it was not included (i.e. – there
is no wound exudate)
9 Marks
High Distinction
Accurate evaluation of wound provided
All required elements accurately provided
12 Marks
3. Expectation of healing process for each type of
wound, taking into consideration the wound and
any factors that may impact on the healing process
example: chronic health conditions, location of
wound, infection, mobility, age, nutrition.
Unsatisfactory –
Physiology of the healing process provided, four + (4)
errors in description
Type of wound not discussed
Factors that impact on healing not included
Satisfactory - Pass
Physiology of the healing process provided, three (3)
errors in description
Type of wound discussed, not linked back to wound
healing process
Any factors that may impact on the healing process of
chosen resident describe (1-2 errors) or reasons as to
why there are no factors that may impact on wound
healing provided
6 Marks
Credit
Physiology of the healing process provided, two (2)
errors in description
Type of wound discussed, not linked back to wound
healing process
Any factors that may impact on the healing process of
chosen resident accurately describe or reasons as to
why there are no factors that may impact on wound
healing provided
8 Marks
Distinction
Physiology of the healing process provided, one (1)
error in description
Type of wound discussed in relation to the healing
process
Any factors that may impact on the healing process of
chosen resident accurately describe or reasons as to
why there are no factors that may impact on wound
healing provided
9 Marks
High Distinction
Physiology of the healing process accurately describe
Type of wound discussed in relation to the healing
process
Any factors that may impact on the healing process of
chosen resident accurately describe or reasons as to
why there are no factors that may impact on wound
healing provided
12 Marks
4. Evaluation of the wound management plan
including:
-Moist wound healing
-Skin risk assessment
-Wound cleansing
-Pressure support & relieving device
-Prevention program
-Dressing product (primary dressing)
-Secondary dressing (if required)
-pain management timeframes appropriate
to wound care (if required)
Unsatisfactory –
Evaluation of the wound management plan described
with three + (3) errors
Three + (3) required element missing.
Satisfactory - Pass
Evaluation of the wound management plan described
with two (2) errors
Two (2) required element missing.
All provided elements accurately describe or reasons
as to why they have not been included provided (ie
there have been no changes to the wound management
plan during clinical placement)
12 Marks
Credit
Evaluation of the wound management plan described
with one (1) error
One (2) required element missing.
All provided elements accurately describe or reasons
as to why they have not been included provided (i.e.
there have been no changes to the wound management
plan during clinical placement)
16 Marks
Distinction
Evaluation of the wound management plan accurately
described
One (1) required element missing.
All provided elements accurately describe or reasons
as to why they have not been included provided (ie
there have been no changes to the wound management
plan during clinical placement)
18 Marks
High Distinction
Evaluation of the wound management plan accurately
described
All required elements accurately describe or reasons
as to why they have not been included provided (i.e.
there have been no changes to the wound management
plan during clinical placement)
24 Marks
5. Health education that may be provided to the
resident regarding their wound
Unsatisfactory –
Three + (3) errors in information provided
Satisfactory - Pass
Description of wound education provided with three (3)
errors
Wound education is relevant to chosen resident
6 Marks
Credit
Description of wound education provided with two (2)
errors
Wound education is relevant to chosen resident
8 Marks
Distinction
Description of wound education provided with one (1)
error
Wound education is relevant to chosen resident
9 Marks
High Distinction
Accurate description of wound education provided
Wound education is relevant to chosen resident
12 Marks
6. Pain management relating to the wound including:
-Medication/s accurately discussed
-Frequency and dose provided
-Justification for using particular
medication provided
-Patient’s education about pain
management
Unsatisfactory –
Pain management not appropriate for chosen resident ☐ ☐
Satisfactory - Pass
Pain management discussed
Three (3) required elements missing
6 Marks
Credit
Pain management discussed
Two (2) required elements missing
8 Marks
Distinction
Pain management discussed
One (1) required element missing
9 Marks
High Distinction
Pain management discussed
All required element accurately described
12 Marks