Wound care assessment
Procedures
Patient is unable to perform woundcare due to complexity of wound, location, size of wound, poor manual dexterity, forgetful (dementia), and knowledge deficit. No skilled/willing caregiver to perform woundcare.
Instructed caregiver in vacuum assisted closure (VAC) that is a type of therapy to help wounds heal. The process heal open wound through the application of negative pressure. Another benefits of the negative pressure wound therapy are draining excess fluid from the wound, keeping your wound moist and warm, helping draw together wound edges and increasing blood flow to your wound. Caregiver verbalized understanding.
SN put on non-sterile gloves. Remove old dressing. Remove gloves and place them in the trash bag, Wash hands and put on a clean pair of gloves. SN cleaned wound with NS solution using gauze pads, checked wound for signs of infection. Then opened new foam sponge dressing, cut it to size, and place it in the wound. Open the drape package. Cut the drape to the size needed. Place the drape over the wound site. Smooth the drape as you stick it around the wound to prevent any wrinkle that may leak. Connect the tubing to the sponge dressing and the tubing to the pump unit. Open the clamp on the tubing. Turn on the VAC pump. Listen and watch for leaks.
SN completed assessment done on all body systems and noted patient with elevated blood pressure during visit. SN completed treatment during visit and noted no drainage on old tx, wound callused and new area found to left medial top of foot remains intact with no drainage noted. SN noted patient complaint of pain to bilateral lower extremities with +2 edema noted. SN educated primary caregiver on the importance of elevation of bilateral lower extremities as well as pain management for patient.
Instructed caregiver to keep patient's ulcer from becoming infected, it is important to: keep blood glucose levels under tight control; keep the ulcer clean and bandaged; cleanse the wound daily, using a wound dressing or bandage; and avoid walking barefoot.
Instructed caregiver the key to successful wound healing is regular podiatric medical care to ensure the following “gold standard” of care: Lowering blood sugar, appropriate debridement of wounds, treating any infection, reducing friction and pressure, restoring adequate blood flow.
SN instructed patient about tracheotomy care suctioning always involves: assessment , oxygenation management, use of correct suction pressure,
liquefying secretions, using the proper-size , suction catheter and insertion distance appropriate patient positioning,
evaluation, using the proper - size suction catheter and insertion distance appropriate patient positioning evaluation.
Physical assessment done to patient after chemotherapy . Medication checked and reconciled. Hydration and nutritional status checked. Diet reviewed. Denies chest pain. Tube care done per physician ( MD ) order. Dressing changed. Still complained in pain in fingers, patient taught that one side effect of chemotherapy is pain in fingers which is called peripheral neuropathy, it results from some type of damage to the peripheral nerves. Certain chemotherapy drugs can cause peripheral neuropathy such as Vinca alkaloids ( vincristine ), cisplatin, Paclitaxel, and the podophyllotoxins ( etoposide and tenoposide) . Other drugs used to treat cancer such as thalidomide and interferon also can cause peripheral neuropathy.
Instruct the patient in care of the incisional wound, reviewing signs of wound infection and thrombus formation in the implant replacement of the aortic valve.
The patient was instructed in cervical cancer explaining of type of cancer and the therapeutic or surgical procedures to be performed.
Patient Undergoing Surgery, the patient was reviewed avoid coitus and douching for 2 to 6 weeks after surgery, avoid heavy lifting and vigorous activities.
Patient Undergoing Cryosurgery/Laser Therapy , the patient was taught that perineal drainage is clear and watery initially progressing to a foul-smelling discharge that contains dead cells, reviewed perineal care and hygiene, recommended need for regular Papanicolaou and pelvic examinations.
Patient Undergoing Pelvic Exenteration, the patient was instructed to obtain appropriate supplies for ostomy care, the patient was taught on perineal care explaining the drainage may continue for several month, the patient was reviewed in wound irrigation procedures and application of sanitary pads, avoid prolonged sitting.