Wound care assessment
Diseases Process
The patient was instructed in diverticulosis and diverticulitis obtaining appropriate supplies, such as sterile dressings or ostomy devices. The patient was taught in proper woundcare or stoma management and dressing changes, procedure, frequency, and wound stoma or stoma inspection. The patient was advised to take hydrophilic colloid laxatives. The patient was instructed that baths or showers may be taken when drains or sutures are removed.
Instructed caregiver that treatment includes proper positioning, always avoid placing any weight
or pressure on the wound site.
SN instructed patient to always assess wound dry sterile dressing when removed for any symptoms / signs of infection, such as increase drainage amount, any odor, drainage color, etc . Check your temperature once or twice a day. Report any fever or increase pain.
SN instructed patient to eat a balanced diet and drink fluids, eat protein like red and white meat, eggs, beans and take vitamins from vegetables/fruits , to promote wound healing.
Instructed patient through the use of negative pressure wound therapy, a standard surgical drain, and optimized nutrition, fistula drainage was redirected and the abdominal wound healed, leaving a drain controlled enterocutaneous fistula. Patient control of fistula drainage and protection of surrounding tissue and skin is a principle of early fistula management.
Patient was instructed on how to prevent pressure ulcer. A proper skin care is crucial and involves inspecting skin daily and an individualized bathing schedule, using warm (not hot) water and mild soap. Avoid massage over bony prominences and use lubricants if skin is dry.
Instructed patient consider nutritional supplementation/support for nutritionally
consistent with overall goals of care.
Instructed patient reposition bed-bound persons at least every two hours and chair-bound persons every hour consistent
with overall goals of care.
Instructed in management and control such as diet as prescribed by MD, adequate hydration 1000-2000cc 24 hours if not contraindicated, importance of high protein (meat, legumes, eggs, daily), iron and vitamin supplements if indicated.
Instructed in factors that contribute to poor skin integrity such as immobilization, poor circulation, moisture, heat, anemia, shearing forces, poor nutritional status.