Question 176

Question Answered step-by-step Carol Mitchell, aged 64 was admitted to the burns unit after… Carol Mitchell, aged 64 was admitted to the burns unit after sustaining burns to the front and back of her left lower leg and foot. Carol had been cooking in her kitchen, when she accidently knocked a saucepan full of hot oil over herself. Carol’s husband drove her to the nearest medical centre where Carol’s burn was treated and then she was transported by ambulance to the hospital for further assessment. In the emergency room, Carol was conscious and in evident distress. Her admission notes were: areas of variable depth of injury over her posterior lower leg and foot only; dark pink discoloration with sluggish capillary refill, blistering is evident; an area on her inner left ankle has an area of blotchy red/white with sluggish to absent capillary refill, patient is complaining of pain on her lower leg, but states that her ankle is somewhat pain free. After consultation with the Burns team, the burns are to be surgically debrided and a small skin graft will be applied to her inner ankle injury.1.Skin Assessment – outline the steps of the skin assessment for Carol’s burn that would be carried out immediately on admission to the emergency department.  2.It was noted in the case study for Carol that she required “surgical debridement” to her burns Explain what surgical wound debridement is and why is it done?  3.Describe how the skin heals with the assistance of a skin graft. 4.When assessing a patient’s wound discuss 2 common problems / complications you may encounter 5.As stated in the case study, Carol is complaining of pain Which of the following strategies may be utilised to provide comfort to Carol? (There is more than one) ¨  Provide pain relief¨  Provide distraction therapy¨  Elevate Carol’s foot above heart level¨  Ensure bed comfort ¨  Assess stress / anxiety levels and look at reducing these .. Inform Carol that pain is a normal aspect of a burn and there is not much that can be done to reduce all pain6.Provide a description for each of the classifications in the table below a.Superficial b.Partial thickness c.Full thickness7.The wound healing process commences when any damage to the skin has occurred. Once the skin is impaired and a wound is created the healing process begins. This is a dynamic and complex process. It consists of four stagesMatch the stage with the physiological and biochemical processes-          haemostasis – stage 1 –          inflammation phase – stage 2 –          proliferation or reconstruction phase – stage 3 –          maturation phase – stage 4   Stage Physiological and Biochemical Processes   ___________________During this phase tissue is temporarily replaced and the area is cleaned up by macrophages which digest the dead bacteria and debris. New blood capillaries are developed and granulation tissue (mainly collagen) is laid down. As granulation tissue continues to be laid the epithelium thickens to 4 to 5 layers forming the epidermis. The wound contracts and becomes smaller. This stage can take from 2 to 24 days   __________________Process of the wound being closed by clotting. Starts when blood leaks out of the body. The first step is when blood vessels constrict to restrict the blood flow. Next, platelets stick together in order to seal the break in the wall of the blood vessel. Finally, coagulation occurs and reinforces the platelet plug with threads of fibrin which are like a molecular binding agent, this stage happens very quickly   __________________Vasodilation of surrounding tissues occurs due to the release of histamine and other vasoactive chemicals. This increases blood flow to the surrounding areas which leads erythema, swelling, heat and pain. White blood cells descend into the area as a defense response. This phase lasts approximately three days   __________________The wound and surrounding tissue is gradually remodeled and the collagen cells laid down are strengthened. This stage can last from 24 days to approximately one year. During this stage the wound is still at risk and should be protected.8.Part of the assessment (here is a clue for the above question) is burn size. tick the correct estimate of the size of Carol’s burn using the information in the scenario¨  Burn percentage 20% approx.¨  Burn percentage 9% approx.¨  Burn percentage 27% approx.¨  Burn percentage 0.7% approx.  John James is an 82-year-old male who has been a resident in the high care ward of a local aged care facility for the past 2 years. His mobility has been decreasing since admission and he now requires 2 hourly turns when in bed and is reliant on a hoist and wheelchair. John is incontinent of both urine and faeces and has a poor dietary intake. John’s skin is paper thin and the pressure ulcer on his sacrum, below has increased in diameter by 2cms over the last 2 weeks. John was recently transferred into your hospital ward with chronic bronchitis.9.You have been asked to attend to the dressing of John’s wound. What would be a suitable dressing to use on John’s wound? (you must give a rationale for your choice). 10.Explain the goal of this treatment as per Q1a – what are you trying to achieve by maintaining a moist wound environment 11.Explain whether John required a primary or secondary dressing, or both, and provide a rationale for your choice 12.Most infections agents are micro-organisms, these include: – (choose one answer) ¨  Bacteria, viruses, Soil, protozoa and prions¨  Bacteria, Candida, fungi, protozoa and prions¨  Bacteria, viruses, fungi, protozoa and prions¨  Bacteria, viruses, fungi, protozoa and dust13.Match the common fungal infections with their major reservoir Common fungal infection: Candida albicans, Aspergillus organismsCommon fungal infection Major Reservior _____________________________ Soil, dust, mouth, skin, colon, genital tract  _____________________________ Mouth, skin, colon, genital tract14.Match the common viral infections with their major reservoirCommon viral infections Viral infection, Hepatitis A virus, Hepatitis B virus, Hepatitis C virus, Human immunodeficiency virus (HIV), Herpes simplex virus (type I) Common viral infection Major reservoir   _________________________ Reservoir   _________________________ Faeces   ________________________ Blood and body fluids   ________________________ Blood   ________________ Blood, semen, vaginal secretions (also isolated in saliva, tears, urine and breast milk, but not proved to be sources of transmission)   ________________________ Lesions of mouth or skin, saliva, genitalia plus herpes zoster (shingles) or viral warts or herpangina (oral ulcers) 15.Discuss 4 pressure relieving devices that may be used for John either in hospital or when he goes back to the aged care facility.16.Match the Ulcer type with their specific characteristic Ulcer type: Venous ulcers, Diabetic ulcers, Arterial ulcers, Pressure ulcer:Ulcer type Characteristic _____________________ Caused by ischemia; related to the presence of arterial occlusive disease; symptoms include pain and tissue loss _____________________ Local losses of epidermis and various levels of dermis and subcutaneous tissue, occurring over or near the malleoli at the distal lower extremities; caused by edema and other sequalae of impaired venous return._____________________ Caused by trauma or pressure secondary to neuropathy or vascular disease related to diabetes mellitus._____________________ Caused by pressure which destroys soft tissue17.As John is quite elderly and his mobility has decreased, outline 3 risk assessments you can do, and using your research state 2 common risk assessment tools used in Australia.18.There are four stages of pressure ulcer formation and each stage has its noted characteristics. Match the stage with the presentation.Stage: Stage 1, stage 2, stage 3, stage 4. Stage Presentation  _______________ pressure injuries present as shiny or dry shallow ulcers without any bruising present_______________ Pressure injuries are the most severe and represent full-thickness tissue loss with exposed bone, tendon or muscle_______________ pressure injuries present as areas of persistent, non-blanch able redness when compared with the surrounding skin_______________ Pressure injuries represent full-thickness skin loss. Subcutaneous fat may be visible, but bone, tendons or muscle are not exposed.  19.Give a rationale to support which stage you think John’s pressure ulcer is at 20.When the nurse is assessing Johns wound, he/she documents what it looks like using a variety of methods.Choose from the following words and fill in the blanks with words that match them to the sentences.Probe, marking pen, wound tracing, a ruler, written consent, transparent acetate grid, clinical wound photography, wound measurement.  ……………………………….  provides the most accurate and objective means of assessment and evaluation of wound treatments………………………………..  can be used to provide an accurate measurement of the length and width of a wound Assessment of the depth or length of a wound can be performed using a   ………………………………………………………………………………………….  Using a two-dimensional method, such as by tracing the margins of the wound, can be assessed using a …………………………………………….  and ………………………………………………………..  It is essential that ……………………………………………….  is obtained from the patient/relative or carer prior to taking photographs21.Johns doctor has ordered a Doppler ultrasound, explain what this means and how it is performed? 22.Identify and discuss two effects on wound healing in regards to complex and challenging wounds Factor Effect on wound healing   23.Many factors affect the wound-healing process. Therefore, wound management strategies must be tailored to meet the individual holistic needs of the patient, their wound and their environment.Tick the sentence that best outlines the principles of wound management ¨  Assess and correct cause of tissue damage¨  Assess wound history and characteristics¨  Ensure adequate tissue perfusion¨  Wound-bed preparation¨  Wound cleansing¨  Wound-cleansing solutions and techniques¨  All of the above   Health Science Science Nursing HBM HNBM Share QuestionEmailCopy link Comments (0)

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