hlten506b apply principles of wound management in …€¦ · · 2012-04-23delayed primary...

HLT07 Health Training Package

Learner resource

Version 2

Training and Education Support

Industry Skills Unit

Meadowbank

Product Code: 5566

HLTEN506B Apply principles of

wound management in the clinical environment

SAMPLE

HLTEN506B Apply principles of wound management in the clinical environment

© TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank) 2012

Acknowledgments

The TAFE NSW Training and Education Support Industry Skills Unit, Meadowbank

would like to acknowledge the support and assistance of the following people in the

production of this Facilitator resource guide:

Writers:

Michelle Barakat-Johnson

TAFE NSW

Reviewers:

Beryl Grant Kathryn Austin

Rhonda Albani Michael Shea

Amanda Culver Cheryl Bradshaw

Sherryl Dismorr Merja Debsia

TAFE NSW

Project Manager:

Di Dawbin

Education Programs Manager

Training and Education Support, Industry Skills Unit, Meadowbank

TAFE NSW

Acknowledgements are also given to all Facilitators of the Enrolled Nurse Education

Program.

Enquiries

Enquiries about this and other publications can be made to:

Training and Education Support Industry Skills Unit, Meadowbank

Meadowbank TAFE

Level 3, Building J,

See Street,

MEADOWBANK NSW 2114

Tel: 02-9942 3200 Fax: 02-9942 3257

ISBN 978-1-74236-303-5

© TAFE NSW (Training and Education Support, Industry Skills Unit

Meadowbank) 2012

Copyright of this material is reserved to TAFE NSW Training and Education

Support, Industry Skills Unit Meadowbank. Reproduction or transmittal in

whole or in part, other than subject to the provisions of the Copyright Act, is

prohibited without the written authority of TAFE NSW Training and Education

Support, Industry Skills Unit Meadowbank.

SAMPLE


© TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank) 2012

Table of contents

Introduction ...................................................................................... 7

1. General introduction ............................................................................. 7

2. Using this Facilitator guide ..................................................................... 8

3. Prior knowledge and experience ........................................................... 10

4. Unit of competency overview ............................................................... 10

5. Assessment ....................................................................................... 12

Section 1 Aseptic technique/infection prevention strategies .........15

Section 2 Physiology of wounds and wound healing ......................17

Section 3 Types of wounds .............................................................23

Section 4 Wound assessment .........................................................25

Section 5 Management of wounds ..................................................27

Section 6 Current products for wound management ......................31

Section 7 Evidence based practice .................................................39

Section 8 Skills in wound care ........................................................45

Section 10 Evaluation ......................................................................55

Section 11 Client education/health promotion on wound management strategies ..................................................61

Section 12 Complex or challenging wounds .....................................63

Reference list ...................................................................................73

Resource Evaluation Form ................................................................77

SAMPLE


© TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank) 2012 Page 15 of 80

Section 1 Aseptic technique/infection

prevention strategies

Aseptic technique provides a method for preventing microorganisms from entering a

susceptible site by using sterile equipment and avoiding direct contact with the

wound and its discharge.

For nurses working in operating theatres and acute surgical units it is necessary to

have knowledge of aseptic technique. In recent years however, studies have shown

the use of a clean technique using tap water and clean equipment (particularly for

shallow leg ulcers) is just as effective as the aseptic technique in terms of healing of

wounds. The Clean technique is discussed later in this unit and the conclusions are

that nurses need to be capable of problem-solving in order to meet the needs of each

specific client in various environments.

Nurses should utilise evidence based practice (EBP) as a means of determining the

care to be implemented for the client with a wound. The importance of consistency of

technique and communication between the members of the wound management

team cannot be stressed enough. Economic consideration must be kept in mind when

clinical decisions are being made in relation to wound management and the use of

wound care products.

A useful website to explore is www.awma.com.au

SAMPLE

http://www.awma.com.au/



Section 2 Physiology of wounds and wound

healing

TYPES OF WOUND HEALING

1. Primary intention:

full thickness wound edges are approximated shortly after the primary wound

has been created e.g. surgical wounds with nil tissue loss

epithelialisation and wound contraction has little to do with healing (healing occurs by the formation of connective tissue)

within 24-48 hours the wound is sealed from bacterial contamination.

Delayed primary closure: closure of grossly contaminated incisions should be

delayed allowing time for host inflammatory and immune responses to control

contamination e.g. contaminated wounds with nil tissue loss - colorectal surgery.

2. Secondary intention:

wound healing occurs by the formation of granulation tissue (without surgical

intervention)

contraction is the most important phenomenon in the spontaneous closure of

large open wounds e.g. dehiscence of primary healing wounds, tissue loss due

to trauma, chronic ulceration due to various causes i.e. arterial, venous,

pressure necrosis

3. Partial thickness wounds:

injury to the epidermis/dermis

repair involves epithelialisation (approximately 12 days) e.g. abrasions, skin

grafts.

Activity 1

You are required to visit internet sites in order to gain additional knowledge relating to

wound care.

SAMPLE


Page 18 of 80 © TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank) 2012

CLASSIFICATION OF WOUNDS

1. Acute wounds

An acute wound occurs as a result of injury or surgical intervention e.g. surgical

incisions, crushing wounds, shearing wounds or burns. They heal within a

reasonable period of time.

2. Chronic wounds

Chronic wounds do not heal easily, some never heal. They are the result of a

predisposing condition, which impairs the tissue‟s ability to maintain its integrity

or to heal e.g. venous and arterial ulcers, diabetic ulcers, pressure ulcers.

Later resources will discuss other classifications under Types of Wounds.

3Rs OF WOUND HEALING

(Note: The stages of healing overlap.)

1. Reaction (inflammation) injury to 3 days:

vasoconstriction – to control haemorrhage

clot formation

In the next 24 hours there is an acute inflammatory response at the wound

margins and the formation of exudate.

vasodilatation leads to:

- the formation of serosanguinous exudate in the wound and:

-

* redness (erythema)

* heat

* swelling (oedema)

* pain

* loss of function.

INFLAMMATION

(this is a normal process

of healing)

debridement – the neutrophils and macrophages in the exudate remove dead

cells and debris.

2. Regeneration (proliferation and contraction) 1-24 days

capillaries bud to form new vessels and collagen forms new tissue

granulation tissue forms

Granulation moves inward from the wound margin. The epithelial cells at the skin

margin begin to grow and in the next 36 to 72 hours the epithelium begins to

cover the wound below the eschar (scab). The regenerating epithelium uses the granulation tissue beneath the scab as a base upon which to grow.

Eventually the wound heals, with scar tissue closing the defect and regeneration

of the epithelium. Once the epithelium covers the wound the scab drops off. Skin

appendages such as hair follicles and sweat glands are unable to regenerate, and this scarred area will not contain these.

SAMPLE



3. Remodelling (maturation) 24 days to 1-2 years

activity within the wound decreases

no new granulation tissue

collagen reorganises scar tissue flattens and softens. Scar colour changes

from pink to white.

TYPES OF WOUND EXUDATE (DISCHARGE)

Wound exudate has been demonstrated to contain anti microbial substances that

offer protection, cleanse the wound and provide a moist environment that is

conducive to healing. However, excessive exudate will macerate the surrounding skin

as well as provide an environment for microorganisms to flourish and thus traumatise

the wound.

Activity 2

Describe the following types of wound discharge using the internet or relevant

text.

1. Serous:

_________________________________________________________________

_________________________________________________________________

2. Purulent:

_________________________________________________________________

_________________________________________________________________

3. Sanguineous/haemorrhagic:

_________________________________________________________________

_________________________________________________________________

4. Haemoserous/serosanguineous:

_________________________________________________________________

_________________________________________________________________

SAMPLE



MAJOR COMPLICATIONS OF WOUND HEALING

1. Wound dehiscence

a bursting open of the wound.

2. Wound infection

Wound infection prolongs the inflammatory stage of healing. Most wounds are

colonised by some microorganism, however acute infections require appropriate

treatment.

Clinical signs of infection:

inflammation, localised pain, heat and erythema

oedema around the wound margin

increased exudate

copious pus - green, yellow or grey

offensive odour

pyrexia

tachycardia

granulation tissue that bleeds easily.

3. Haemorrhage

persistent bleeding due to dislodged clot, slipped ligature or erosion of a blood

vessel.

SAMPLE



Activity 3

How can the following factors affect healing?

(i) Infection:

_________________________________________________________________

_________________________________________________________________

(ii) Hypoxia:

_________________________________________________________________

_________________________________________________________________

(iii) Haematoma:

_________________________________________________________________

_________________________________________________________________

(iv) Foreign bodies:

_________________________________________________________________

_________________________________________________________________

(v) Age:

_________________________________________________________________

_________________________________________________________________

(vi) Poor nutritional state:

_________________________________________________________________

_________________________________________________________________

(vii) Degree of injury:

_________________________________________________________________

_________________________________________________________________

(viii) Location of wound:

_________________________________________________________________

_________________________________________________________________

SAMPLE



Activity 3 (continued)

(ix) Stress:

_________________________________________________________________

_________________________________________________________________

(x) Steroid therapy:

_________________________________________________________________

_________________________________________________________________

(xi) Wound care:

_________________________________________________________________

_________________________________________________________________

(xii) Chemotherapy:

_________________________________________________________________

_________________________________________________________________

(xiii) General health:

_________________________________________________________________

_________________________________________________________________

(xiv) Immobility:

_________________________________________________________________

_________________________________________________________________

Activity 4

Can you think of any other examples of factors which could affect wound healing?

________________________________________________________________

________________________________________________________________

________________________________________________________________

SAMPLE



Section 3 Types of wounds

Wounds may be classified in a number of ways. As mentioned previously the terms

„acute‟ and „chronic‟ are used to describe wounds in terms of onset and duration.

Types of wounds include:

1. Surgical incision 5. Avulsions

2. Traumatic/lacerations/punctures 6. Abrasions/skin tears

3. Ulcers 7. Amputations

4. Burns 8. Graft and donor sites

Activity 1

Describe the following types of wounds, using relevant text or the internet.

1. Surgical incisions:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

2. Traumatic injuries:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

3. Ulcers:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

SAMPLE

hlten506b apply principles of wound management in …€¦ · · 2012-04-23delayed primary...

Documents