Wound care assessment
Instructed patient fresh fruits and vegetables eaten daily will also supply your body with other nutrients essential to wound healing such as vitamin A, copper and zinc. It may help to supplement your diet with extra vitamin C. Keep your wound dressed. Wounds heal faster if they are kept warm. 2- Instructed patient getting more sleep can help wounds heal faster eat your vegetables, stay active, don't smoke, keep the wound clean and dressed.
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.
Instructed in woundcare as ordered by MD such as proper storage of dressing supplies, proper handwashing technique and removal of dressing, proper storage of dressing supplies, cleansing of wound as specifically ordered by MD, proper application of ointments, powders, solutions, etc, if ordered by MD, proper application of specific dressing change if ordered by MD, return demonstration of complete dressing change technique; more than one teaching may be needed.
Instructed in proper handwashing before and after woundcare or touching wound site to prevent spread of infection.
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.
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 in signs and symptoms of complications and/or deterioration of wound status such as temperature above 100 grade, increase redness, drainage, edema, increase pain, increase size of wound.
SN instructed patient on s/s of infected wound susch as: Thick green or yellow drainage, Foul odor, Redness or warmth around wound, Tenderness of surrounding area, and Swelling.
Skilled Nurse to educate on S/S of wound deterioration or infection such as: increase pain on wound site, swelling, temperature, and discharge.