Wound care assessment
Patient was instructed on pressure ulcer also called decubitus or bed sore. A pressure ulcer is the results of damage caused by pressure over time causing an ischemia of underlying structures. Bony prominences are the most common sites and causes.
Instructed patient about some signs and symptoms of pressure ulcers, such as, skin tissue that feels firm or boggy, local redness, warmth, tenderness or swelling.
Skilled Nurse instructed caregiver get at least 4 pillows, include one of those long body pillows since you can and place them between the knees, ankles, under the arms and behind the back when the patient is laid on her side.
SN advised patient to take temperature once a day before bedtime, check for bleeding, pus, hardness, swelling, odor and any color change. If any of these are present, please let your nurse or doctor know as soon as possible. Patient verbalized understanding of instructions given.
The patient was instructed in cellulitis the importance of elevation and immobilization of the affected limb for at least 2 to 3 days or until redness and the swelling have decreased. The patient was taught in woundcare and dressing changes. The patient was advised how to apply cool compresses for discomfort, alternating with a warm compress or warm soak to increase circulation to the affected area.
The patient was instructed in compartment syndrome if surgical treatment was performed such as fasciotomy emphasize there is an increased potential for infection. The patient was reviewed in the proper technique for care of the surgical incision and aseptic procedures for dressing changes. The patient was advised to inspect the wound daily to check for increased drainage. The patient was recommended the need for rest and elevation of the extremity postoperatively. The patient was encouraged to use of assistive devices.
The patient was instructed in fractures in stress the importance of turning and moving frequently to evade skin breakdown. The patient was advised to handle hurt tissues softly by supporting the joint above and below the location. The patient was explained in how to woundcare. The patient was recommended to elevate the extremity and apply ice bags. The patient was instructed in the use of ambulatory aids, crutch walking, cane, and walker. The patient was explained in the importance of range-of-motion exercises to maintain function of natural joints. The patient was taught in exercises to maintain strength and facilitate resolve of inflammation.
The patient was instructed in head trauma in the importance of the wound/incision care in any laceration or medical cut. The patient was advised that possible remaining effects like dizziness, headaches, memory loss can be continue for up to 3 to 4 months after trauma. The patient was reviewed that may experience variations in character, inappropriate social behavior, hallucinations. The patient was taught in finding assistive devices for ambulation. The patient was reviewed in concussion to evade Valsalva maneuvers like pulling during defecation, coughing, nose blowing, sneezing.
The patient was instructed in renal transplant in the importance of all-time immunosuppressant management. The patient was taught in the woundcare and dressing change. The patient was advised in the need of evade contact to multitudes and persons with known supposed infections. The patient was recommended in the need of recording daily weight at the same time, with the same clothing. The patient was reviewed in taking and recording temperature, pulse, and blood pressure.
Instructed patient all bed-bound and chair-bound persons, or those whose ability to reposition is impaired, to be at risk for pressure ulcers.