HLTENN006: Principle of Wound Management in Clinical Environment - Wound Cleansing - Nursing Assessment Answer

HLTENN006: Wound Management Assessment Answer

Task: You are required to write an individualised wound management plan for 2 case scenarios above. For each scenario you are required to address all the points below : 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 (ie. injury, fungal infection, micro-organism, viral infection, disease,etc).
•  any investigation required for the wound
•  wound management principles

2. Evaluation of each type of wound :

• wound bed status (include colour/s)
• wound characteristics
• wound measurements
• condition of surrounding skin (ie intact, breaking down)
•  wound exudate (colour, consistency, odour)
•  any further assessment required (doppler, wound swab, etc)

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 (ie chronic health conditions, location of wound, infection, mobility, age, nutrition,etc) 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)

5. Health education for the patient regarding the wound. (ie. nutrition, elimination, mobility and any preventative measures) 6. Pain management relating to the wound including:

• medication/s accurately discussed
•  frequency and dose
• justification for using a medication
•  patient's education about pain

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