Wound Assessment

Wound management is one of the cornerstones for nursing care however, effective wound care extends far beyond the application of the wound itself. Nurses may be required to assess, plan, implement, and evaluate wound care; therefore, order to fill these roles it’s critical to have an understanding of the several different areas of wound care such as, integumentary system, classification of wounds, wound procedures, and documentation. Knowledge in each of these areas will allow nurses to make well informed decisions about wound care, and as a result play an active part in wound healing.

The community nurses decided that they needed to talk to Mrs. Smith about the odour and involve her in selecting a dressing product that was designed to alleviate or reduce the problem. The assessment identified that the wound was infected with beta-haemolytic streptococci and Staphylococcus aureus and a two-week course of systemic antibiotics was prescribed.

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)

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

The aim of treatment of wound management in Mr BW was to safely allow the exudation of pus to drain freely from the wound in order to expedite wound healing. At the same time, to consider the level of comfort, prevent further infection, increased mobility and ensure nutritional

In this paper we will present critical analysis on the different views on nursing the wound dressing focusing primarily on the possible infections ranging from technique to use of silver to the overall impact made by these choices.

I observed the documentation process from week -2 in my clinical setting and through reading the related documents I gained theoretical knowledge of documentation . I week -4 I did the the return demonstration of documentation with my instructor successfully and started the documentation process in clinical and developed my communication skill . I think my learning plan helped me to achieve this goal . When I started this semester I wanted to learn about the wound care . To achieve this goal I observed the techniques of wound care in week -10 demonstrated by my instructor and reviewed the related resources of wound care . In week -11 I was successful in return demonstration of wound care and evaluated by my instructor . The plan I made

On assessment, the wound was slightly exudates, odour, sloughs and dry skin patches on the surroundings. Sprakes (2010) state that, holistic assessment of patient and the wound are essential in order to facilitate the wound healing process. Ousey and McIntosh (2010) points out that, chronic wounds are exacerbated by a sequence of misdiagnosis, neglect, incompetence or inappropriate treatment strategies. I observed that, M’s wound was with exudates and sloughs; this

This paper will discuss the PICO question of does applying a CHG tegaderm versus a regular tegaderm dressing decrease the rate of infection in patients with invasive lines? There are a high number of invasive line infections and it is important to know if a product can decrease a patient’s rate of infection. This paper will analyze the information found and explore how evidence based practice is useful to nurses.

Throughout the procedure, I was able to interact with the patient and communicate effectively with him, discussing his pertinent health history as well as his experience in dealing with his chronic wound. Such communication and patient interactions bring an abundance of positive feelings to any clinical situation. I also felt positively about the decision of the nurse and healthcare provider in the use of barrier cream to prevent further maceration of the peri-wound skin,

A full assessment of the wound should be carried out prior to selection of dressings. Any allergies should also be noted. The wound should be traced, photographed and measured providing data for comparison throughout the treatment. Consent should be gained prior to photographing the wound and the patient should not be identifiable from the photograph (Benbow 2004). All information should be documented in patients’ records, using the wound assessment tool. The pressure sore was identified as grade two

DOI: 8/27/2014. The patient is a 45-year-old male laborer who sustained a work-related injury when he stepped on a sharp foreign object which pierced his skin. As per OMNI, he was diagnosed with open wound on the foot.

The wounds that were located in the left sacrum and left hip had been present for more than 41 days and had serous exudate. The wound in the right hip had been present for more than 35 days and also had serous exudate. The provider cauterized the wound in the left sacrum after administering a local anesthetic and applied a special dressing to all 3 wounds. The plan was to follow-up “within 7 days.”

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