Reference no: EM133044042

HLTENN006 - Apply principles of wound management in the clinical environment

Simulation Based Assessment Task 1:
Mr Anderson is admitted in your health care facility following an abdominal surgery. The surgical wound is 5 cm long with 7 surgical staples. Two surgical staples were removed from one side yesterday and steri-strips were applied in that area as reinforcement for the surgical wounds after early staple removal. The wound chart is updated with the information that these steri-strips are not to be disturbed when providing wound care management until the next review by the wound nurse.

You are required to undertake the following activities:
• Address the comfort requirements of Mr Anderson including pain relief.
• Gather appropriate wound care resources from the equipment room.
• Perform wound assessment.
• Remove four staples from the other side of the wound.
• Apply Primapore as primary dressing.
• Apply OpSite Flexigrid as secondary dressing.
• Apply barrier cream on the surrounding skin.
• Report your activities and findings to the registered nurse.
• Complete required documentation.

You must demonstrate appropriate skills on the wound manikin in the simulated nursing environment.

Simulation Based Assessment Task 2:

The underwater seal drainage (UWSD) chamber/container for your client is full and the registered nurse asked you to replace the chamber with a new one. The UWSD is applied on the patient to help with the drainage of pleural blood to allow re-expansion of lungs.
You are required to:
• Collect a drainage specimen for culture.
• Perform assessments relevant to the situation.
• Replace the chamber with a new one.
• Complete required documentation.

You must demonstrate appropriate skills on the wound manikin in the simulated nursing environment.

Simulation Based Assessment Task 3:
A Redivac drain tube is inserted in a person following his abdominal surgery. The drain tube is sutured to the person's skin. The registered nurse asked you to remove the drain and send the tip of the drain tube for microbiology.
You should undertake the following activities as part of this task:
• Remove the Redivac drain carefully removing the suture.
• Send the tip of the drain tube for microbiology.
• Perform assessments relevant to the situation.
• Apply an appropriate dressing to the drain site after the removal of the drain tube.
• Complete required documentation.

You must demonstrate appropriate skills on the wound manikin in the simulated nursing environment.

Simulation Based Assessment Task 4:
You are asked to provide home care to Mr Freemantle, 78 years old, suffering from quadriplegia secondary to a recent stroke. Mr Freemantle's daughter and a community support worker were available to provide assistance to him with positioning and personal care.
You identified a shiny and shallow dry ulcer with a red pink wound bed on the lower back (sacrum) of the person when providing personal care with the community care worker. An area of redness was also observed on the left shoulder of the person.
Mr Freemantle believed that his mobility may improve and that he could return to his normal routine through physiotherapy before getting discharged from the hospital. He appeared upset as you identified the wound and had concerns whether his condition might get worse and he might be bed-ridden for a longer period.

Undertake the following activities:
• Assess the affected area and identify the stage of the pressure injury.
• Perform a holistic wound assessment as per the wound assessment and management chart, including:
o Wound measurement
o Wound tracing
o Wound photography
o Skin assessment
• Identify and discuss common problems and complications of pressure injury.
• Consider and discuss factors that impact on wound healing.
• Identify and discuss the psychosocial impact of a wound on the person's daily living activities.
• Use the Braden Risk Assessment Tool and undertake a pressure injury risk assessment for this person.
• Discuss your findings with the registered nurse and seek assistance in decision-making for wound care management for this person.
• Use appropriate medical terminology in your communication and documentation.
• Use appropriate infection prevention and control strategies, e.g. use of PPE, demonstration of ANTT techniques.
• Provide appropriate wound dressing.
• Make the person comfortable by providing pressure support using appropriate pressure relieving resources and equipment available.
• Set appropriate goals and decide on cleansing methods, primary dressing and secondary dressing products for pressure injuries on this person in collaboration with the patient and the wound nurse.
• Complete all sections of the Braden Pressure Ulcer Risk Assessment Tool and wound chart, under supervision, to comply with your organisational policies and procedures on wound management.
• Discuss what the community care worker, the daughter and the person could do to prevent pressure injuries related to the current health status and immobility.
• Discuss infection development and modes of transmission of infection with the community care worker, the daughter and the person after applying the wound dressing.

You should request your classmate to play the role of the community support worker.
You must demonstrate appropriate skills on the wound manikin in the simulated nursing environment. Your assessor will provide voice over for the patient and also play the role of the registered nurse who is a wound care expert, where appropriate.
You must submit the completed Braden Pressure Ulcer Risk Assessment Tool and wound chart as additional evidence. Separate wound chart must be completed for each pressure injury.
Time allocated for this task is thirty minutes.

Simulation Based Assessment Task 5:

Mr Smith, 75 years old, is brought to your clinical setting for wound evaluation and dressing. You are asked to provide nursing care to Mr Smith who has presented with a deep and narrow post-infection soft tissue gangrene on his lateral right thigh. A surgical debridement of the wound was undertaken seven days ago. The wound measured 3cm in length, 2 cm in breadth and 0.8cm depth after the surgical debridement.
The wound had a serosanguineous exudate in large quantity and a bad odour as per the wound chart last week.
There is another dressing on his right knee which must be kept un-disturbed for another three days as per the wound chart.
You are asked to perform wound care for this person. You must undertake the following activities as part of this task:
• Liaise with the wound nurse and perform a wound assessment.
• Collect a specimen required for microbiology.
• Identify the wound healing stage for this wound.
• Evaluate outcomes of nursing actions and wound care management with the person and the wound nurse.
• Identify and discuss common problems and complications of a post-infection soft tissue gangrene with Mr Smith outlining why utmost care needs to be taken.
• Perform assessments relevant to the situation.
• Perform appropriate wound management.
• Complete required documentation.