Quick Wound Assessment

Evidence suggests that pressure ulcers greatly increase mortality rates in both hospitals and nursing homes (Thomas, 2001). Patients who develop a pressure ulcer within six weeks of admission to an acute-care facility are three times more likely to die than patients who do not develop pressure ulcers (Thomas, 2001). Moreover, patients who develop a pressure ulcer within three months of admission to a long-term care facility are associated with a 92% mortality rate compared with a 4% mortality rate for patients who do not develop them (Thomas, 2001). This evidence alone shows how significant this problem is to the overall health status of patients. In my personal nursing experience, I have heard many complaints voiced from patients and their family members concerning the development of new pressure ulcers. Patients and family members have expressed dissatisfaction because of the increased stress and prolonged hospital stay often associated with the treatment of pressure ulcers.

Outline and discuss a clinical audit that you have undertook into one aspect of care delivery and reflect upon the experience using Driscoll’s model of structured reflection. Word Count (2197)

Although the situation was quite challenging, it provided me with some useful experiences for the future practice. I understand that all institutions should have a policy for documenting the assessment of patients, including pressure ulcers (Morison 2001). I have come to be familiar with the homes assessment policy using the Sterling Pressure Sore Severity Scale and most importantly I have learned that by using a universal assessment tool it supports a systemic and consistent approach to pressure ulcer evaluation. This therefore supporting continuity of care.

Pressure ulcers are one of the most common problems health care facilities often face which causes pain and discomfort for the patient, cost effective to manage and impacts negatively on the hospital (Pieper, Langemo, & Cuddigan, 2009; Padula et al., 2011). The development of pressure ulcers occur when there is injury to the skin or tissue usually over bony prominences such as the coccyx, sacrum or heels from the increase of pressure and shear. This injury will compromise blood flow and result in ischemia due to lack of oxygen being delivered (Gyawali et al., 2011). Patients such as those who are critically ill or bed bounded are at high risk of developing pressure ulcers (O'Brien et

An interdisciplinary team of professional staff is a necessity to overcome the issue of pressure ulcer development among patients. Relevant stakeholders would include a nurse, nurse aide, dietitian, and a hospitalist. The primary responsibilities of the nurse consist of completing and documenting skin and risk assessments, monitor progress and/or changes in medical/skin conditions, report patient problems to the hospitalist, and work with the wound team

• Nutrition- Mani (2003) claims that nutrition is a fundamental role that must be adopted in the treatment and healing process of pressure ulcers. A balanced diet with adequate nutrients should be key for all patients deemed to be at risk of pressure ulcers. Both nutrition and hydration are the basic components in promoting wound healing and maintaining normal tissue integrity. Patients at risk of pressure ulcers should be nutritionally assessed at regular intervals (Shepard. 2003). This could have been adopted by the use of assessment tools such as, The Nutritional Screening initiative. This tool includes nutritional screening at regular intervals and a comprehensive assessment that includes nutritional assessment, functional assessment and evaluation for depression. This comprehensive approach allows the nurse to quantify the nutritional problems and initiate the appropriate resources that will meet with the individual needs (Bryant, 2000). Another optional tool is the Malnutrition Universal Screening Tool or MUST. This has been designed by the Malnutrition Advisory Group (MAG) of the British

While nurses encounter patients with pressure ulcers in home care and acute care settings, they are mainly a problem with elderly adults in long term care facilities. This is because of decreased sensory perception, decreased activity and mobility, skin moisture from incontinence, poor nutritional intake, and friction and shear (Stotts and Gunningberg, 2007).

Dale Gordon has been a patient in the ICU for 6 days after developing complications after open heart surgery. He is an 82-year-old African American who is disoriented to place and time. He lives with his daughter Claudia in her home. Claudia and her two brothers visit Mr. Gordon daily since he has been hospitalized. Mr. Gordon has not been eating well since the surgery and has lost 3 pounds. Mr. Gordon has type 2 diabetes and is on oral antihyperglycemic medication. Before he came to the hospital, Mr. Gordon was able to only ambulate for short distances. He has orders to get up in a chair twice a day. Joan, a student nurse, is caring for Mr. Gordon this morning. She has reviewed his medical record and is now ready to start caring for him.

The process of wound assessment requires accurate and appropriate interventions while dealing with the patients. There are some major components which the operator must consider to effectively access an infection, and they require a range of skills and knowledge. These factors are the knowledge of relevant anatomy and physiology, the understanding of the various factors that accelerate wound growth, and the ability to listen and understand the patient’s needs. In wound accessing, the doctor should have an idea concerning the number and location of wounds, the required treatments depending on the type of infection, the type of wound in accordance to various grading given, and the procedures to follow to achieve the treatment

Despite advancement of technology, pressure ulcer continues to be a primordial in the health care system. Prevention of pressure ulcer remains an important issue in the health care facility. The critically ill ICU patient is the main target of this disease. Prevention remains the key for this problem. Some facility have standard policy for the eradication of pressure ulcer However the question is will the sacrum pressure ulcer formation be reduced in adult critically ill clients

Donnelly, Winder, Kernohan and Stevenson used a Randomized control trial (RCT), to try and establish a difference between offloading and standard care in relation to the number and severity of pressure ulcers (PU’s) on the heel of patients who were admitted with fractured hips, while also examining the number and severity of PU’s that occurred in other areas of the body. This study took place in the fracture trauma unit of a major tertiary referral center in Belfast, with 119 patients being allocated the control group and 120 in the intervention group. The patients were aged 65 years and over and could not already have existing heel damage. The research design chosen, randomized control trail, allows for patients to be randomly allocated to

5. Patients with leg wound ulcers usually complaint of moderate to severe pain (Stevens et al.,2008). However, a survey carried out by Roe (2005) found out that 55% of district nurses were interested in healing the wound rather than minimising the pain. According to Tobon (2010), if a patients wound begins to reduce in size and yet still complaints of same amount of pain, other comorbidities should be discussed.

In various literature content of method of wound assessment many authors had a survey and defined different solutions

However, the blister was not noted on the first wound care assessment that was done on 09/30/2016 “Patient evaluated for pressure related injury, No evidence of pressure related skin damage at present. On the center of back, skin fold, and left buttock, 1 cm, re-epithealizied, pink tissue was noted”. The patient’s initial Braden score was 9 that indicated the patient’s high risk for pressure-related skin damage. On the following skin evaluation sessions by wound care, Stage II pressure ulcers were assessed on the right buttock, induration of the left upper leg, dark discoloration from mid inner thigh to the medial aspect. Intertriginous Dermatitis (ITD) was noted in right inguinal area and had purulent drainage present. Also, several small areas of partial thickness skin loss were assessed due to moisture, pressure and sheer. Nevertheless, it was documented that overall skin wounds were resolving. On the other hand, two Stage IV pressure ulcers sites were documented on 11/11/2016: (1) left ankle distal area that was open, red, bleeding, and raw, and the medial area of the ankle that had black scab; and (2) posterior head (occiput) had a large, formerly fluid-filled blister that split open. There was purulent drainage, tunneling, and circumferential undermining that

Abstract- Diabetic foot ulcers speak to a critical medical problem. Right now, clinicians and medical caretakers primarily construct their injury evaluation in light of visual examination of wound size and mending status, while the patients themselves rarely have a chance to play a dynamic part. Henceforth, love quantitative and practical examination technique that empowers the patients and their parental figures to take a more dynamic part in every day wound care