Wound Care

Wound Care Teaching 545

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.

Wound Care Teaching 546

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.

Wound Care Teaching 547

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.

Wound Care Teaching 548

Patient was instructed on what to avoid in presence of ulcers. Friction and shear need to be reduced. Friction is the mechanical force exerted when skin is dragged against a coarse surface while shear is the mechanical force caused by the interplay of gravity and friction.

Wound Care Teaching 549

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.

Wound Care Teaching 550

Patient was instructed on the optimization of wound environment. Adequate nutrition and hydration, remove nonviable tissue, maintain moisture balance, protect the wound and peri-wound skin, eliminate or minimize pain, cleanse, prevent and manage infection, control odor.

Wound Care Teaching 551

Patient was instructed on adequate nutrition and hydration to minimize wound development. Encourage protein, calorie-dense foods and fluids (unless contraindicated), monitor intake, weight and skin turgor, assess and address impairments in dentition and swallowing.

Wound Care Teaching 552

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

Wound Care Teaching 553

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.

Wound Care Teaching 554

Patient was instructed on traumatic wounds. Contusions are caused by more extensive tissue trauma after severe blunt or blast trauma. The overlying skin may seem to be intact but later become non-viable. Extensive contusion may lead to infection.