To complete Assessment 1, Part B, you must respond to the questions in both section 1 and section 2. Section 1 is based on the case scenario below. In this section, you are also required to complete a...

Assignment Question
To complete Assessment 1, Part B, you must respond to the questions in both section 1 and section 2. Section 1 is based on the case scenario below. In this section, you are also required to complete a wound care assessment, develop a plan of care for the client and document using a clinical record on the assessment response template provided. These questions must be answered in full. When responding to the questions, please pay attention to the entire question being asked, as well as the prescribed word count, if provided. Use the correct medical terminology when assessing, reporting and recording data while answering all questions. Your answers should be reflective, analytical and based on critical assessments and the Enrolled Nurse standards for practice and Codes of Ethics for Nursing. Section 2 contains two questions, which must be answered but are not related to the case study.
You will be assessed on the responses to the questions and will be deemed as either satisfactory or not satisfactory. ALL of the responses must be marked as satisfactory in order to pass the assessment. If your assessment is not deemed satisfactory, you will be re-assessed as per the THINK Education Assessment Policy for Vocational Education and Training (VET), before being awarded a Non-Satisfactory mark for the assessment.
Case Scenario:
Mr George McFarlane is a 53-year-old Caucasian Male, admitted to hospital after seeing his General Practitioner (GP) for an infected Left (L) toe, caused by a blister/ lesion, possibly from ill-fitting shoes. When Mr McFarlane realised there was a lesion present, he initially did not consider it serious and did not seek medical treatment straight away. After a week, the smell disturbed him and he sought advice from his General Practitioner (GP) who prescribed oral antibiotics and stressed the importance of cleansing and changing the dressing on his wound regularly. Due to Mr McFarlane’s job which required being on the road for long hours at a time, these regular dressing changes did not occur. Subsequently, due to irregular dressing changes, Mr McFarlane’s Methicillin-resistant Staphylococcus Aureus (MRSA) positive status and Type II diabetes, and the lesion failed to heal and became larger and deeper. Mr McFarlane returned to his GP five (5) weeks later. The GP immediately referred him to a specialist wound clinic. Investigations included a full blood count (FBC). The white blood cell (WBC) count was 17x 10⁹/L, predominantly neutrophils. The erythrocyte sedimentation rate (ESR) was 75mm/hr. An x-ray showed changes consistent with osteomyelitis.
Mr George McFarlane was admitted to hospital for surgical debridement of his wound. A large amount of tissue was excised from his left foot, which resulted in amputation of all 5 toes. The wound was packed and placed on a suction wound dressing (negative-pressure wound therapy), to minimise the exudate at the wound surface and promote healing by granulation. Post-operatively, he initially did well. However, on the seventh day after surgery, he developed pyrexia and his diabetic control deteriorated. His left foot had swollen above the bandaging. The dressing was removed and there was tissue engorgement and cellulitis surrounding the wound and evidence of necrosis (as shown in the photograph below).
Mr McFarlane has a Past Medical History (PMHx):
· Type ll Diabetes needing close management
· Osteoarthritis in L) Knee
· Peripheral Vascular Disease (PVD)
· Chronic Obstructive Pulmonary Disease (COPD)
· Methicillin-resistant Staphylococcus Aureus (MRSA) positive
· Peripheral neuropathy
Social History (SHx):
· Second marriage
· Occupation - Long Haul truck driver
· ETOH (Alcohol) usage on a regular basis
· Smoker, averages 15/20 cigarettes per day
· Often consumes take away/ fast food diet as away from home regularly
Mr McFarlane’s current assessment consists of the following:
· BP 135/85
· RR 18
· SpO2 92% Room Air (RA)
· HR 89
· Temp 38.2oC
· BGL 13.8mmol
· U/A (Glucose ++, ketones+, protein +, SG 1010, PH 5)
· Pain score 7 at rest
· GCS 15
· Water low score of 15 (High Risk)
Reference:
https://www.gettyimages.com.au/detail/news-photo/amputation-due-to-diabetes-news-photo/151032672?adppopup=true
    Section 1
This section relates to Mr McFarlane’s case study
    TASK
    Assessment Criteria
    Question 1
    Discuss the four stages of normal wound healing. Include, in your answer, factors that impact wound healing.
References required
(word limit 300-400 words)
    Response:
The four stages of normal wound healing are haemostasis, inflammation, proliferation, and maturation. Each stage can be identified by the display of the wound. As mentioned by, Ellis, Lin and Tartar (2018), the stages focus on the immune pathways of a human body, which considers the time for its healing. The haemostasis includes the process of stopping the flow of blood from the wound, inflammation deals with the reddening and swelling of the wounded site due to the accumulation of immune cells in the area. Proliferation causes the rapid growth of the granulating tissues to rebuild the skin of the area and maturation refers to the remodelling stage of wound healing where the collagen is repaired from type III to type I and the surface of the wound is closed. Hence, the maturation stage can be further divided into two phases: collagen degradation and collagen remodelling.
The factors that impact wound healing are age of the patient, type of infection, the type of wound, any disease such as diabetes or other long-term diseases, poor blood circulation, poor nutrition, oedema, poor hydration, medication and addiction to any toxic substances. As mentioned by Guo and DiPietro (2010), the process of wound healing requires energy production in the form of ATP, which is reduces with age and hence the healing process in slower in older people than the younger ones. Moreover, if infection persists, the inflammation phase is hampered by the manifestation of the microorganisms, which showers the process of the immune cells to act together. Chronic diseases such as diabetes reduces the capability of wound healing by several factors such as defective T-cell immunity, defects in leukocyte chemotaxis, phagocytosis, and bactericidal capacity, and dysfunctions of fibroblasts and epidermal cells. This thing results in improper bacterial clearance and a delayed wound healing. According to Beyene, Derryberry and Barbul (2020), the glycation of collagen and other recovery proteins extends the wound healing process. The foot ulcers in diabetic patients are an increased issue, which often results in foot amputation as it lacks to perform the healing process.
References:
Beyene, R. T., Derryberry, S. L., & Barbul, A. (2020). The effect of comorbidities on wound healing. Surgical Clinics, 100(4), 695-705
Ellis, S., Lin, E. J., & Tartar, D. (2018). Immunology of wound healing. Current dermatology reports, 7(4), 350-358
Guo, S. A., & DiPietro, L. A. (2010). Factors affecting wound healing. Journal of dental research, 89(3), 219-229
    TASK
    Assessment Criteria
    Question 2
    Discuss the nursing strategies required to minimise cross infection whilst conducting a wound assessment and implementation of a wound dressing.
Discuss in your answer:
a) The relevance of the client’s MRSA status, universal precautions and appropriate PPE to be considered for the client’s protection
b) Compliance with infection control practices and correct disposal of wound care products, including how hazardous waste are to be discussed.
c) How Aseptic Non-Touch Technique (ANTT) and Hand Hygiene practices can prevent the introduction of new bacteria to the client.
References required
(word limit 300 words)
    Response:
The nursing strategies required to minimise cross infection whilst conducting a wound assessment and implementation of a wound dressing are thinking critically and analysing the type of the wound first. Then it requires cleansing the wound to remove the necrotic debris, aseptically handling the wound with moist environment and reducing the chance of further injuries, providing proper nutrition to the patient for proper healing of the wound (Nursing and Midwifery Board, 2022).
The patient is Methicillin-resistant Staphylococcus Aureus (MRSA) positive due to irregular change in dressing and it the cause of hospital-acquired infection. As mentioned by Kourtis et al. (2019), the hospital acquired infection chance is relevantly higher in the MRSA positive patients. Hence, such patients must be treated accordingly to the standards of nursing with the use of appropriate PPE kit and universal precautions such as not handling the wound with bare hands and proper usage of facemask, eyeglass, head cap, hand glove, and foot cover.
Infection control practices such as hand hygiene, using of personal protection, maintaining cough etiquettes and disposal of medical dressing wastes such as cotton, gauge and all the components included in the dressing activity must be disposed in a proper way maintaining the biomedical waste disposal rules of segregating the body waste such as blood and tissues from the other wastes. According to the registered nursing standards, the nurses must provide a safe and quality nursing which requires the proper practices to reduce Hospital Acquired Infections (Nursing and Midwifery Board, 2022).
The Aseptic non-touch technique (ANTT) helps in quicker wound healing and reduces the spread of infection as it contains the use of forceps and medical equipment to handle a wound. As mentioned by Clare and Rowley (2018), the ANTT indicates the touching of the non-key parts without contaminating the key parts of dressing material, the cleaning of the wound and dressing must be done maintaining an aseptic environment with the primary step of washing the hands properly and sanitising them carefully.
References:
Clare, S., & Rowley, S. (2018). Implementing the Aseptic Non Touch Technique (ANTT®) clinical practice framework for aseptic technique: a pragmatic evaluation using a mixed methods approach in two London hospitals. Journal of infection prevention, 19(1), 6-15
Kourtis, A. P., Hatfield, K., Baggs, J., Mu, Y., See, I., Epson, E., ... & Cardo, D. (2019). Vital signs: epidemiology and recent trends in methicillin-resistant and in methicillin-susceptible Staphylococcus aureus bloodstream infections—United States. Morbidity and Mortality Weekly Report, 68(9), 214
Nursing and Midwifery Board, 2022 Registered nurse standards for practice Retrieved from https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx
    TASK
    Assessment Criteria
    Question 3
    Discuss how Mr McFarlane’s chronic illnesses could impact on wound healing and the cause of his wound.
· Include, in your answer, how the pathophysiology of Type II Diabetes, Peripheral Vascular Disease and peripheral neuropathy could delay/ hinder wound healing.
· Discuss the differences in pathological terms between a venous ulcer, an arterial ulcer, a diabetic ulcer and a neuropathic ulcer.
· What type of ulcers may be treated with compression therapy, and what piece of equipment could you use to determine a pulse in a limb if you could not feel one?
References required
(word limit 400-500 words)
    Response:
Mr McFarlane’s is suffering from diabetes, and this could lay impact on wound healing and the cause of his wound. The people with diabetes experiences poor blood circulation ad this slows down the process of wound healing. The diabetic population is prone to develop a chronic non-healing foot ulcer due to the pathophysiological mechanism. As mentioned by, Beyene, Derryberry and Barbul (2020), patients with diabetes show hormonal dysregulation, decreased neuropeptide release, delayed platelet activation, and irregular molecular signalling and release in the haemostatic phase.
Improper cell migration in the inflammatory phase, collagen deposition and granulation is altered in the proliferation phase and the maturation phase increases the matrix metalloproteases activity and alterations in collagen turnover. Diabetes causes peripheral vascular disease, which affects the lining around the cell of the blood vessels. This hinders the smooth blood flow and delays the healing process.
As mentioned by Hinchliffe et al. (2019), peripheral vascular disease and peripheral neuropathy increases the time for wound healing. This is because in diabetic patients, the blood circulation is poor due to the vascular lining and the flow of blood to the foot is much less which increases the time for healing by reducing the number of infection-fighting cells. The peripheral vascular disease and the peripheral neuropathy together affects the wound healing time as thickened blood vessels obstructs the flow of the blood to the lower parts of the body and blood takes a longer time to reach to the legs. Hence, people with diabetes are at a high risk of suffering from surgical foot ulcers, which often causes amputation of the foot.
Venous ulcer commonly occurs on the lateral malleoli and produces a dull achy pain whereas arterial ulcers are extremely painful occurring in the shin of toes due to lack of arterial blood flow. Vascular ulcer can be treated with compression therapy. As stated by Eastman and Dreyer (2020), Diabetic ulcers are associated with peripheral neuropathy with pin-and-needles type pain. It occurs mainly on the leg where the blood circulation is poor due to vascular peripheral disease and the infection fighting T-cells are unable to reach at a sufficient amount to heal the wound on time often, causing necrosis and foot amputation.
Neuropathic ulcer occurs in the patients suffering from neural disorder with poor functioning of peripheral nervous system. This type of ulcer mainly occurs in the foot rather than other body parts and often forms a gangrene. The venous ulcer can be treated with compression therapy where the wound is compressed with a dressing. As mentioned by Mościcka, Szewczyk, Cwajda-Białasik and Jawień (2019), the pressure created with the dressing helps to heal the veins quickly.
The instrument, which helps to determine the pulse in a limb when it cannot be felt is the pulse oximeter, which shows the pulse rate and the oxygen level of the body. The pulse oximeter shows the vitals of respiratory rate, pulse rate, oxygen level in the body. It gives a quicker result in the times of emergency, which helps to decide about the primary treatment required to be provided to the patient.
References:
Beyene, R. T., Derryberry, S. L., & Barbul, A. (2020). The effect of comorbidities on wound healing. Surgical Clinics, 100(4), 695-705
Eastman, D. M., & Dreyer, M. A. (2020). Neuropathic Ulcer
Hinchliffe, R. J., Forsythe, R. O., Apelqvist, J., Boyko, E. J., Fitridge, R., Hong, J. P., ... & International Working Group on the Diabetic Foot (IWGDF). (2020). Guidelines on diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update). Diabetes/metabolism research and reviews, 36, e3276
Mościcka, P., Szewczyk, M. T., Cwajda-Białasik, J., & Jawień, A. (2019). The role of compression therapy in the treatment of venous leg ulcers. Advances in Clinical and Experimental Medicine, 28(6), 847-852
    TASK
    Assessment Criteria
    Question 4
    A. Explain the differences between a simple, complex and surgical wound. In your response, consider the complications of healing with each type of wound.
B. Which wounds may need debridement?
C. How has the historical development of contemporary wound management strategies changed over time?
D. Discuss the reason why some wounds are left undisturbed for a longer span of time.
References required
(word limit 200-300 words)
    Response:
A.
Simple wound is the break in the continuation of the skin, which is not much deeper than the sub-cutaneous fatty tissue and does not affect the underlying muscles and bones or tissues. On the other hand, a complex wound is a difficult wound, which creates a challenge for the nursing team to cure with just dressing therapy.
A surgical wound is a wound created by an incision or a cut on the skin during surgery, which may be closed with sutures or left open to heal. As mentioned by McCosker et al. (2019), the most common complication in wound healing is the occurrence of infection, which increases the time of healing. Other complications include tissue necrosis, osteomyelitis, gangrene, oedema and hematomas.
    B.
The wound, which are chronic and does not respond to the immune system, requires debridement. As mentioned by Nube et al. (2021), diabetic leg ulcers require debridement for healing. Severe burns also require debridement. The debridement gives a covering to the open wound and protects it from any further microbial...