DRAFT: This module has unpublished changes.

Deliberate Repetitive Practice Lesson Plan: Wound Assessment

Vanessa VanDomelen

Boise State University

 

The top 5 skills students in our wound and ostomy program, a student nurse should be able to perform competently by the end of the orientation are the following:

Pressure injury prevention

Wound Assessment

Pouch change

Support surface identification

Negative pressure wound therapy application

The Identified skill:  Wound assessment skill competency

Lesson Objectives: By the end of this DRP session, students will demonstrate mastery of wound assessment and vocabulary, wound dressing application, and documentation of wound assessment.

The equipment required for the facilitation of the DRP session are the following items:

Personal protective gear

Measuring guide

Cotton-tipped applicators

4x4 gauze pack

Wound cleanser to irrigate skin tears

Scissors and tweezers

Name, medical record, and birthdate sticker identifier

Black felt tip marker for marking the date on the dressing

Dressing change supplies, including nonadherent topical antimicrobial dressing, soft

Silicone dressing

Method for recording measurements

Method for photo recording

Red container for disposal of dressings

            DRP Scenario: Charles White is an 84-year-old male with multiple comorbid conditions, including hypertension, congestive heart failure, coronary artery disease, arthritis, chronic obstructive pulmonary disease, anemia, and was admitted through the ED due to the trauma the client experienced falling off his electric scooter.  The admitting physician documented skin sores on admit in the medical record but did not note the severity or location.  A nurse in the emergency room covered the total flap loss skin tears with dry gauze dressings.  Even with saline soaks, the removal of the dressings caused further trauma.  The client described the skin tears as painful.

The following morning the RN caring for the client could determine the electric scooter accident happened twenty-four hours prior to the patient coming to the emergency room.  The first tear to the right elbow measures 5.0x3.0x0.2 cm.  The second skin tear on the right forearm measured 6.0x4.0x0.2cm.  Both skin tears were type three tears, as identified by the International Skin Tear Advisory Panel (ISTAP), indicating total flap loss that exposed the entire wound bed.  The bleeding was profuse, most likely exacerbated by the client’s anticoagulant medication taken for his coronary artery disease.  The patient continues to take the prescribed anticoagulant during his hospital stay.  Due to the bleeding, by day three of his hospital stay, the client’s hemoglobin had dropped to 8g/dl, requiring a blood transfusion. Orders from the Wound and Ostomy nurse (WOCN) include treating the skin tears with a nonadherent topical antimicrobial dressing and a soft silicone dressing daily due to the potential for infection and amount of drainage.  Since the client had been vaccinated with tetanus toxoid within the past ten years, no tetanus prophylaxis was given.

 

     DRP Checklist: Create a checklist of critical student actions for faculty to evaluate student performance.

  • ·       Wound assessment competency criteria actions for evaluation:
  • ·       Identifies etiology (type) of skin break
  • ·       Pre-activity: assigned wound vocabulary with passport stamp
  • ·       Pre-activity: wound care supply treasure hunt with passport stamp
  • ·       Pre-activity: Review International Skin Tear Advisory Panel   classification system
  • ·       Identifies self and explains procedure to client
  • ·       Washes hands
  • ·       Applies personal protective gear as needed for contact precautions
  • ·       Gathers necessary supplies prior to beginning the procedure
  • ·       Follows infection control guidelines for discarding dressings into the red container
  • ·       Cleanse wounds prior to assessment using appropriate infection control technique
  • ·       Identifies correct anatomical location of wound
  • ·       Measures the wound’s (in cm) height, width, depth, tunneling, an undermining
  • ·       Notes tissue type (red, granular, yellow, necrotic)
  • ·       Notes condition of peri wound skin
  • ·       Notes presence or absence of signs of infection
  • ·       Explains purpose of the dressing, the intended outcome
  • ·       Applies new dressing according to step-by-step instructions
  • ·       Documents accurate wound assessment in the electronic record

 

 

References

Baranoski, S., LeBlanc, K., & Gloeckner, M. (2016). Preventing, assessing, and managing skin tears: A clinical review. American Journal of Nursing, 116(11), 24-31.

Bryant, R. A., & Nix, D. P. (2012). Acute and chronic wounds current management concepts (4th ed.). Minneapolis, Minnesota: Elsevier Mosby.

DRAFT: This module has unpublished changes.