Wound care assessment
General
Instructed patient unlike gauze bandages that merely cover a wound, V.A.C. therapy actively works to help the wound healing process. The V.A.C.therapy system helps: promote wound healing, provide a moist wound healing environment, draw wound edges together, remove fluid and infectious materials, reduce wound odor, reduce the need for daily dressing changes.
Instructed patient when should I call my clinician when on V.A.C. Therapy: immediately report to your clinician if you have any of these symptoms: fever over 102°, diarrhea, headache, sore throat, confusion, sick to your stomach or throwing up, dizziness or feel faint when you stand up, redness around the wound, skin itches or rash present, wound is sore, red or swollen, pus or bad smell from the wound, area in or around wound feels very warm.
Skilled nurse developed patient plan of care with patient/caregiver involvement to be countersigned by physician. SN to perform complete physical assessment each visit with emphasis on disease process. SN to assess other co-morbidities including list diseases and other conditions that present themselves during this episode of care. SN to recognize and intervene to minimize complications; notify physician immediately of any potential problems that impede completion of patient recovery and desired goals.
SN instructed the patient on good diabetic foot care and assessment as follows: using a handheld mirror if needed assess feet daily to include in between toes. Never cut toenails or file down calluses. Only a podiatrist should do this. Report any blisters, cracks, wounds or any other concerns to your podiatrist immediately. Wash and lotion feet very well daily. Do not lotion between toes as this may cause maceration and cause skin breakdown. Recommended wearing diabetic socks. Always wear good fitting shoes. Preferably tailor-made for the patient. Never walk around barefoot.
Instructed patient about vacuum assisted closure ( VAC ) therapy the length of time to heal a wound is different for every patient. General conditions, size and location of the wound, and nutritional status can affect the time it takes for a wound to heal. Your clinician will discuss when and why V.A.C. therapy may begin and end.
SN instructed pt on hygiene r/t woundcare. It is very important to maintain a clean environment as well as clean , dry skin. Do not pick at wounds, or at other areas of the skin. Our fingernails harbor bacteria under them, wash hands throughly and often throughout the the day with soap and water, hand sanitizer can be used in between but are not a substitute for proper hand washing.
SN assessment done on all body systems. Checked blood sugar daily monitoring on patient's log book, hydration, dietary, and medication compliance. Instructed patient on keeping blood glucose within normal range and preventing the development of long-term complication. Careful monitoring of diet, exercise and blood sugar levels are as important as the use of oral medications in preventing complications of diabetes. Also taught infection control, safety/fall precautions and preventions, and to contact MD for any emergency and/or medical concerns and changes.
SN complete assessment done on all body systems, checked vital signs, blood sugar monitoring, hydration, nutrition intake, and medication compliance. SN refilled patient’s medication box for daily routine. Taught patient to carefully manage her blood sugar with diet, physical activity, and medication to prevent diabetes complication and avoid hypo/hyperglycemia.
SN completed patient cardiovascular and pulmonary assessment. Medication reviewed and administered. Educated staff on monitoring patient for mood changes, aggressive episodes, anxiety, and agitation related to medication SEs. Staff instructed to monitor environmental hazards to prevent falls and injuries. Staff was also encourages to encourage patient to rise slowly to prevent syncope and dizziness.
SN completed patient cardiovascular and pulmonary assessment. Educated staff on monitoring patient for dizziness, syncope, cardiovascular status, anxiety, and agitation related to medication SEs. Staff to encourage patient to rise slowly to prevent syncope and dizziness. Staff instructed to monitor environmental hazards to prevent falls and injuries in addition to monitoring skin for breakdown due to episodes of bowel and bladder incontinence.