HLTEN506B Apply Principles Of Wound Management In The Clinical Environment

Wound Healing In Philomena’s Case Study
Wound Assessment


Don’t use plagiarized sources. Get Your Custom Essay on
HLTEN506B Apply Principles Of Wound Management In The Clinical Environment
Just from $8/Page
Order Essay


Patient’s: Name; Age; Address; marital status  

Philomena McCarthy , 78 years, 17/247 Basildon Road BROADMEADOWS NWS, Single

Wound Date Onset



Wound Type/Etiology


Arterial Lower leg wound:

The wound is arterial ulcer type which has been as a  result of peripheral vascular disease


Pressure Ulcer Stage

Stage X Unstageable:

 Evidently, the  slough or eschar ( necrotic tissue) is covering the bed of the wound as so not possible to determine the depth of  bed of the wound



Wound Location

Lower Left foot

Wound Bed

Granulation: Red, moist

Slough: Yellow to brown dead tissue

Eschar: black, dry

Foreign body:  mesh present

Underlying structures: tendon

Exudate Amount

ü Large/copious

Exudate Type

ü Purulent ( Thick cloudy fluid)

ü Suregenous Also, it is noticeable that there is a bloody fluid exudating from Philomena’s wound)

ü Serous ( There is a thin yellowish fluid exudate from the wound of Philomena)


ü Odour present

Wound Edge

ü Rolled edge

ü Epithelisation

Peri-Wound Skin

ü Erythma (Dark red)

ü Excoriated ( Signs of loss of tissue)

ü Fragile: The skins look loosely attached and at the risk of failing off

ü Calloused (Hyperkeratosis)

ü Indurated ( it is noticeable that the skin around the wound in Philomena’s case has abnormal firmness of tissues with margins being palpable)

Wound Pain

ü Excruciating pain. Rated at 9 on the Visual Analogue Scale of 0-10.

2. Physiologic process of wound Healing in relation to Philomena’s present wound

The physiological processes of wound healing occur in phases that include; inflammation, proliferation and maturation. In Philomena’s present state, it is evident that the wound has already progressed from inflammatory phase that often involves natural response where by the blood vessels at the bed of the wound contract forming a clot in the process (Hunt,  Hopf, & Hussain 2000). Also, in this physiological process of wound healing, the blood vessels often dilate and in the event, antibodies, white blood cells and essential cells are allowed into the wounded area to facilitate wound healing.

Proliferation phase: The second physiological wound healing process in Philomena’s case is proliferation(Hunt,  Hopf, & Hussain 2000). In this phase, the wound is rebuilt with new granulation tissue that is composed of extracellular matrix as well as collagen. This granulation tissue, through the process known as angiogenesis, provides a surface into which a new network of blood vessels forms(Hunt,  Hopf, & Hussain 2000). After the granulation, through a process called epithelialisation, epithelial cells resurface the wound. Notably, granulation tissue can either be healthy or unhealthy, indicated by its color. For example, healthy granulation tissue manifests as pink or red in color, uneven in texture, no bleeding and granular. Unhealthy granulation is indicated by dark pigmentation. Since the granulation tissue in Philomena’s case is dark, it is indicative of poor perfusion, ischaemia and infection.

Maturation phase: Maturation is the last stage of physiological process (Principles of regenerative medicine 2008; Hunt,  Hopf, & Hussain 2000). As per the state of Philomena’s wound, this process will involve remodeling of collagen from type I and type II.  In addition there will be a reduction in cellular activity and regression of the number of blood vessels in the wound.

3. Four Factors that impact on the healing process of Philomena’s wound

Age: Age is one of the most important factors that come into play during the process of wound healing. In essence, age massively influences how one recovers. As one gets older, there are physiological changes that put one at the risk of poor wound healing. These changes include reduced skin elasticity, slower replacement of collagen and age related diseases. Based on these, it is evident that, due to her old age, Philomena is likely to experience poor wound healing process.
Hygiene: Hygiene is another important factor that will influence the wound healing process for Philomena. Basically, for the wound healing process to progress fact, the patient must observe good hygiene. Poor hygiene slows the process of wound healing since the wound acquires many extrinsic infections that strains on the blood cells that are involved in wound healing process. Since Philomena observes poor hygiene, her wound healing process would take longer.
Alcoholism:  Alcoholism significantly influences the process of wound healing for Philomena through increasing the risk of wound infections. Alcoholism increases the risk of wound infection by way of diminishing the resistance of the body to harmful elements including bacteria.
Smoking: Smoking has been known to interfere with the process of wound healing to a greater extent. Since Philomena is a smoker, her wound healing process will be delayed. In  influencing the process of wound healing, smoking interferes with the immune system of the body
4.  Wound Management products for Philomena
Antiseptics(Ammonia Solution 30%): This antiseptic is needed to kill any germs that may invade the wound to slow the healing process. I choose ammonia solution to other antiseptics because it is easy to prepare and has no scorching effects on the patient’s skin.
Foam Dressing: Since Philomena’s wound is unhealthy, there is high probability that the wound stinks. As such, it is recommended to do foam dressing using pads soft absorbent foam pads that have a gentle silicone adhesive and with bacteria barrier.  This will not only put off the bad odor from the wound, but also comfortable to the patient.
§ Hydrating Dermal Wound Dressing Gel with Alginate: This product is essential for Debridement of Philomena’s wound. Debridement is the process that involves removing the damaged, dead or the infected tissues which may potentially impair wound healing. The product aforementioned is appropriate for acute or chronic wounds and that is the reason to use on Philomena’s case.

5. Nursing Care Plan for Philomena





Patient Label, Name , Age,

 Philomena McCarthy, 78 Years old/ Single, 17/247 Basildon Road BROADMEADOWS NWS








Objective Data: Philomena infected on left foot;  Open wound,; Grimacing

Subjective Data:  The patient complains of pain on turning and ambulating

Medical Diagnoses

ü Arterial ulcers on left foot



Nursing Diagnosis


ü Impaired tissue integrity r/t wound, presence of infection.






Nursing Goals


1. To alter sensation or pain at site of tissue impairment

2. To maintain the wound and protect it from entry of germs

3. To manage/ Monitor wound (Increase wound granulation)

4. . Achieve functional pain goal of zero per patient’s verbalizations

5. To heal tissue and prevent injury




Nursing Actions




1. Monitor the edema, color, temperature, skin appearance around the wound and moisture.

2. Closely examine the site of the impaired tissue daily for infections. Determine if the patient experiences changes in pain or sensation

3. Keeps an eye on the status of skin surrounding the wound.  Also, examine the care practices that the patient uses including cleansing agents

4. Choose a topical treatment that has the ability to maintain the wound in moist condition

5. Make sure you check the nutritional status of the patient. If need be, order nutritional consults.










1. It is recommended that regular check up is done. The essence of the check is to ascertain that  any possible problem as regards the early areas in infection is identified

2. The pain that come as a result of the dressing change can be effectively monitored and hence managed by application of interventions that mainly focus on reducing the trauma and possible other sources of wound pain.

3. It is critical to customize each care of plan to a particular patient in question based on the patient’s skin condition preferences and needs at large. As such, it is important care practices that include harsh agents of cleansing, extreme force or friction, hot water and too recurrent cleaning

4. It is imperative to choose dressings that essentially provide an environment that is moist. Also, it is advisable to keep the skin that surrounds the wound dry and also eliminate dead space  in addition to controlling exudate

5. The healing of the wound is largely contributed by the nutritional status of the patient. Arguably, a good diet composed of vitamins and nutritional foods largely promotes the faster wound healing process  

Primary care providers/ services to prevent the ulcer from initially occurring

Primary care provider/service


1. Cessation of smoking

Smoking weakness the body’s immune system. As such, quitting smoking helps improve body immune system that in turn increases body’s resistance to infections

2. Examination of feet on daily bases

One should examine plantar surface of the foot to detect any fungal infections in time and seek immediate medical intervention

3. Foot hygiene (Washing and drying feet at least once a day)

Foot hygiene is important as it eliminate the microorganisms like fungi that may cause infections including arterial ulcers

4. Apply lubricants containing urea or salicylates

This helps in the softening of the dry skin and preventing the cracking that my facilitate entrance of microorganisms thus foot infections

5. Lifestyle Modification

A good lifestyle that includes eating a balanced diet is essential as it improves the body’s immune system thus prevents the ulcers


Hunt, T.K., Hopf, H. and Hussain, Z., 2000. Physiology of wound healing. Advances in skin & wound care, 13, p.6.

Principles of regenerative medicine, 2008.  Amsterdam: Elsevier/Acade