Sample assessment tool -- Observation and demonstration checklist Required resources · Computer with internet connection to access online resources. · Log in credentials to access the Moodle platform....

Sample assessment tool -- Observation and demonstration checklist
Required resources

· Computer with internet connection to access online resources.
· Log in credentials to access the Moodle platform.
· Textbook reference:
· Coleman, K. (2016). Chapter 29: Maintaining and promoting skin integrity and wound care. In Koutoukidis, G, Stainton, K & Hughson, J. Tabbner's nursing care. (7th ed.). Elsevier, China.
· Lewis., T. (2016). Chapter 22 – Infection prevention and control. In Koutoukidis, K. Stainton, & J. Hughson. Tabbner's nursing care. (7th ed.). Elsevier, China.
· Tollefson, J., Watson, G., Jelly, E. and Tambree, K. (2019). Essential Clinical Skills: Enrolled Nurses. 4th ed. Cengage, China.

· Website reference:
· Australian Commission on Safety and Quality in Health Care (2012). NSQHS Standards fact sheet – Standard 8: Preventing and managing pressure injuries. Retrieved from https://www.safetyandquality.gov.au/publications/nsqhs-standards-fact-sheet-standard-8preventing-and-managing-pressure-injuries/
· Daunton, C., Kothari, S., Smith, L. & Steele, D. (2012). A history of materials and practices for wound management. Wound Practice and Research. 20 (4). pp. 174-186. Retrieved from https://www.researchgate.net/publication/256492792_A_history_of_materials_and_practices_f or_wound_management
· Shah, J. B. (2011). The history of wound care. The Journal of the American College of
Certified Wound Specialists. 3 (3), pp. 65–66. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3601883/
· Wounds Australia (2017). Welcome to Wounds Australia. Retrieved from http://www.woundsaustralia.com.au/home/ ▪ Wound Innovations ▪ Etcetera.

Knowledge questions

1. Define the following wound management terminologies in your own words (in at least a sentence each):

    Acute wound
    As the name suggests, a puncture wound develops abruptly rather than over the course of several days or weeks.
    Chronic wound
    In contrast to most wounds, chronic wounds do not heal in a logical sequence of phases or over a predicted span of time.
    Dermis
    The second of the skin's two major layers is the inner layer. The dermis includes hair follicles, nerves, sweat glands, blood vessels, and the connective tissue,
    Exudate
    A protein- and cellular-rich fluid, which leaks from inflamed blood arteries and deposits itself in surrounding tissues, is called exudate.
    Purulent
    Fluid known as purulent discharge is exuded from a wound. It is nearly usually an indication of infection, and it has often characterised as "milky" in appearance.
    Epithelialisation
    A procedure for growing new epithelial tissue on denuded tissue.
    Granulation
    Granulation is the process in which the primary powder particles are made to adhere to form large, multiparticle entities called granules.
    Erythema
    Capillary congestion causes skin to become red. For instance, sunburn and medication allergies can cause erythema.
    Macerated
    When skin is exposed to moisture for an excessive amount of time, maceration develops.
    Cellulitis
    Infections of the epidermis and soft tissues under the skin are known as cellulitis. It occurs when germs enter and spread through a skin breach.

2. Explore and briefly describe the historical development of contemporary wound management strategies in your own words.
Clay tablets from Mesopotamia dating back to around 2500 BCE include the oldest documented descriptions of wound care. People believed that wound care evolved by trial and error, with ancient societies using tried-and-true methods. We will look at how wounds heal biochemically in both acute and chronic situations, and we will talk about different materials that can help with healing and prevent infection. Before applying honey or resin to wounds, ancient Mesopotamians cleansed them with milk or water.
Hippocrates, an ancient Greek physician, recommended cleaning wounds with wine or vinegar, then using honey, oil, and wine to soothe them. During Galen's career as a surgeon to the gladiators at Pergamos, he learned about the use of styptics that included antibiotic-like components. Galen was the physician to the Greek Emperor Marcus Aurelius (131–201 AD). A growing need arose as medicine transitioned from being mostly spiritual to being predominantly scientific.



    

3. Explore and describe in your own words the National Safety and Quality Health Service (NSQHS) Standard relevant to wound management. How can compliance with this Standard be ensured and monitored?
Pressure injury prevention and wound care systems and processes must be compatible with best-practice standards for health service organisations implementing the National Safety and Quality Health Service (NSQHS) Standards.
Standard 1 - Conduct a background check
Perform a pressure injury screening on all new patients as soon as feasible after they are admitted. Using the results of screening, identifying individuals who are at danger, and then implementing measures to protect them risk assessment for pressure injury in its entirety.
Standard 2- Conduct a risk and skin evaluation.
Circulation and sensory assessments may need the use of devices. Prepare a comprehensive treatment plan based on known pressure injury risks.
Standard 3 - Put preventive plans into action
Work with the patient, their family, and caregivers to develop and implement a personalised, risk-based Pressure Injury Prevention Strategy.
Standard 4 – Examine any pressure sores that already appear.
Injuries caused by pressure are excruciatingly unpleasant, so make sure to do pain evaluations and address your patients' pain first. Some people are more likely in comparison to others to suffer pressure damage, infection, and biofilm.
Standard 5 - Address any current pressure injuries.
Existing pressure injuries require immediate attention to the wound and management of pain. Care for a wound includes Tissue management, Infection and inflammation control, Moisture balance, Advancement of the epithelial edge, Repair and regeneration factors, and Social and individual variables.
Standard 6 – Document monitoring
In the patient's medical record, all evaluations, management, treatments, and results must be noted. This covers the frequency and prevalence of pressure injury.

4. Discuss various causes of internal and external wounds in your own words.
Internal wound
Irritation results from wounds when the body's many regulatory mechanisms are disrupted. Ischemia or stasis, caused by a decrease in blood flow or a disruption in circulation, can cause this. Ischemia is a condition in which the blood arteries are narrowed or blocked, resulting in inadequate circulation.
External wound
The skin and underlying tissue are damaged when wounds are closed, but they are not exposed to the outside environment. Cuts made with a scalpel or knife is the most frequent cause of incisions. Surgery or skin incisions are the most common. Penetrating wounds are dangerous and can result in significant damage.
5. Discuss the pathophysiology and management of fungal infections.
Your answer should include:
· What it is
The interaction between fungal virulence factors and host immune responses is the key to development of fungal illness.
· How it is detected
A fungal infection can be determined by microscopic analysis of the material utilising procedures like KOH pre-treatment and calcofluor white stain.
· How it is managed – consider PPE, medications, wound dressing etcetera.
Folliculitis and furuncles are the most frequent bacterial skin diseases associated with PPE. In hot and humid climates, intact skin is more susceptible to fungal diseases. Antifungal cream and 3 % boric acid solution are also options for top-down therapy. Oral itraconazole is an option for treating onychomycosis or a widespread fungal infection.
· List three (3) different types of fungal infection.
1. Athlete's foot
2. Jock itch
3. Ringworm of the scalp






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6. Discuss the pathophysiology and management of viruses, which cause wound infections. Your answer should include:
· what it is
An infected wound is a localized defect or excavation of the skin or underlying soft tissue in which pathogenic organisms have invaded into viable tissue surrounding the wound.
· how it is detected
The common cold, which is mostly caused by rhinoviruses, coronaviruses, and adenoviruses, can be diagnosed as a viral infection by the following symptoms. Enteroviruses and the herpes simplex virus (HSV) cause encephalitis and meningitis, as well as West Nile Virus warts and skin infections. HPV and HSV are also responsible for West Nile Virus warts and skin infections.
· how it is managed
Some viruses' symptoms can be relieved temporarily by antiviral medicines. They can either inhibit the virus from replicating or strengthen the host's immune system to counteract the infection's effects. These medications won't stop the infection from spreading, and their usage raises the danger of antibiotic resistance. The majority of treatment focuses on symptom relief while the body’s own immune system deals with the virus on its own.
· list two (2) different types of viral infections
1. Zika virus
2. HIV

7. Discuss the pathophysiology and management of two (2) bacteria, which may be able to cause wound infections.
Your answer should include:
· what it is
A bacterium is a microscopic single-celled creature. Because of their adaptability, they can survive in conditions ranging from scorching heat to bitter cold. Few of the billions of bacterial strains that exist cause illness in humans. Some of these microorganisms are harmless to humans since they reside in places like the gut or airways.
· how it is detected
In one step, mass spectrometry is utilised to detect the different types of bacteria found in a wound sample that has been grown. It takes less than an hour to identify a species using MALDI-TOF mass spectrometry, which uses matrix aided laser desorption ionisation time of flight.
· how it is managed
Antibiotics are drugs that a doctor uses to treat bacterial illnesses. Some strains, on the other hand, develop a resistance to the treatment and survive it.
· list two (2) different types of bacterial infections
1. bacterial meningitis
2. otitis media
8. What are the classifications of surgical wound? Provide two (2) examples of each of the classifications of surgical wound (Class I - IV).
1. Class I/Clean - This category should include operative incisional wounds that are the result of blunt trauma (not penetrating). An illustration of this is an abdominal incision resulting from the main closure of exploratory surgery to treat a splenic laceration caused by physical trauma. Uninfected surgical wounds are those that have not been inflamed and have not invaded the respiratory, alimentary, or vaginal tracts.
2. Class II/Clean-Contaminated - There is no indication of infection or substantial breach in sterile procedure found in operations involving the biliary system or oropharynx if any of these are performed. This category comprises procedures in which the respiratory, gastrointestinal, vaginal, or urinary tracts are accessed under strict supervision and without the risk of unexpected contamination.
3. Class III/Contaminated - This also includes open traumatic wounds that have been open for more than 12–24 hours. This category covers surgeries involving severe lapses in sterile technique (e.g., open heart massage) or extensive gastrointestinal leakage, as well as incisions with acute, non-purulent inflammation.
4. Class IV/Dirty-Infected - According to this definition, post-operative infection is caused by organisms that were present in the surgical field prior to the procedure, such as peritonitis from gross faecal contamination (e.g., emergency surgery for peritonitis due to gross visceral perforation).

9. Identify and briefly describe the stages of pressure ulcers.
According to the extent of tissue injury, pressure ulcers progress in four phases. These phases assist medical professionals in determining the most effective treatment for a quick recovery. These sores can cure in a couple of days if they are discovered and treated quickly.
Stage 1 - It changes the colour of the epidermis, usually to a reddish tint. Although the afflicted region may be sensitive to the touch, there are no surface breaks or rips. In addition, the growing sore will probably have a distinct texture and warmth from surrounding healthy tissue.
Stage 2 - An ulcer begins with a rupture in the skin that leaves a small, open lesion with no signs of healing. In the second stage of an ulcer, a blister filled with serum (a clear to yellowish fluid) may or may not have broken. Swollen, painful, or redness around the affected region of the skin may suggest tissue death or injury.
Stage 3 - Infected areas of the skin that have progressed through two layers of skin and are now infected with a secondary infection. At this point, an ulcer may resemble a crater, smell terrible, and appear as if it has erupted.
Stage 4 - Ulcers in the fourth stage are the most severe, and they can spread to the bones and cartilage of your body. In addition to drainage, you may also find dead skin tissue, muscles, and even bone in these faeces. The sore may turn black, show indications of infection, and have a hard, dark material called eschar (hardened dead wound tissue) on it.

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