skin care
Wound Care
Instructed patient to report to nurse or MD at the first sign or symptom of pressure ulcer formation, for example: redness that remains half an hour after pressure has been removed from area.
Patient was instructed on the risk and factors that contribute to the development of pressure ulcers, such as malnutrition, dehydration, impaired mobility, chronic conditions, impaired sensation, infection, advance age and pressure ulcer present.
Patient was instructed on how to manage pressure that is necessary to avoid future complications. Provide appropriate support surface, repositioning every two hours in bed, off-load heel using pillows or positioning boot, use pillow between legs for side lying.
Patient was instructed how to reduce friction and shear. Use draw sheet for repositioning, encourage use of trapeze if possible, keep head of bed elevated (if tolerated), elevate foot of bed slightly (if condition permits), use pillow or wedge to support hip (side lying, lateral position), utilize lifts and transfer devices.
Patient was instructed on eliminate or minimize pain of wound. Address the cause (remove the source if external, treat the infection or medicate based on physiological stimulus), pharmacological strategies
Patient was instructed on pain caused by pressure ulcers. Pain can be classified as acute or chronic. Cyclic acute pain, which is periodic and corresponds to the pain experienced during repeated management, such as dressing changes or patient repositioning and non-cyclic acute pain, which is accidental, including pain experienced during occasional procedures such as debridement or drain removal.
Patient was instructed on wounds contributing facts. In addition to poor circulation, neuropathy, and difficulty moving, factors that contribute to chronic wounds include systemic illness, age and repeated trauma.
Patient was instructed on factors that contribute in chronic wounds as repeated trauma. Repeated physical trauma plays a role in chronic wound formation by continually initiating the inflammatory cascade. The trauma occurs by accident, for example when a leg is repeatedly bumped against a wheelchair rest, or it may be due to intentional acts.
Patient was instructed on treating painful wounds. Persistent pain associated with non-healing wounds is caused by tissue or nerve damage and is influenced by dressing changes and chronic inflammation. Chronic wounds take long time to heal and patients can suffer from chronic wounds for many years.
Patient was instructed on chronic wound healing. That may be compromised by coexisting underlying conditions, such as, venous valve backflow, peripheral vascular disease, uncontrolled edema and diabetes mellitus. It is important to remember that increased wound pain may be an indicator of wound complications that need treatment, and therefore practitioners may be constantly reassess the wound as well as the associated pain.