HLTEN506B Apply Principles Of Wound Management In The Clinical Environment

FACTOR

INFORMATION

Patient’s: Name; Age; Address; marital status  

Philomena McCarthy , 78 years, 17/247 Basildon Road BROADMEADOWS NWS, Single

Wound Date Onset

N/A

Wound Type/Etiology

Arterial Lower leg wound:

The wound is arterial ulcer type which has been as a  result of peripheral vascular disease

Pressure Ulcer Stage

Stage X Unstageable:

 Evidently, the  slough or eschar ( necrotic tissue) is covering the bed of the wound as so not possible to determine the depth of  bed of the wound

Legend

N/A

Wound Location

Lower Left foot

Wound Bed

Granulation: Red, moist

Slough: Yellow to brown dead tissue

Eschar: black, dry

Foreign body:  mesh present

Underlying structures: tendon

Exudate Amount

ü Large/copious

Exudate Type

ü Purulent ( Thick cloudy fluid)

ü Suregenous Also, it is noticeable that there is a bloody fluid exudating from Philomena’s wound)

ü Serous ( There is a thin yellowish fluid exudate from the wound of Philomena)

Odour

ü Odour present

Wound Edge

ü Rolled edge

ü Epithelisation

Peri-Wound Skin

ü Erythma (Dark red)

ü Excoriated ( Signs of loss of tissue)

ü Fragile: The skins look loosely attached and at the risk of failing off

ü Calloused (Hyperkeratosis)

ü Indurated ( it is noticeable that the skin around the wound in Philomena’s case has abnormal firmness of tissues with margins being palpable)

Wound Pain

ü Excruciating pain. Rated at 9 on the Visual Analogue Scale of 0-10.

PARAMETER

DIRECTIONS

Facility

Patient Label, Name , Age,

 Philomena McCarthy, 78 Years old/ Single, 17/247 Basildon Road BROADMEADOWS NWS

Assessment

Objective Data: Philomena infected on left foot;  Open wound,; Grimacing

Subjective Data:  The patient complains of pain on turning and ambulating

Medical Diagnoses

ü Arterial ulcers on left foot

Nursing Diagnosis

ü Impaired tissue integrity r/t wound, presence of infection.

Nursing Goals

1. To alter sensation or pain at site of tissue impairment

2. To maintain the wound and protect it from entry of germs

3. To manage/ Monitor wound (Increase wound granulation)

4. . Achieve functional pain goal of zero per patient’s verbalizations

5. To heal tissue and prevent injury

Nursing Actions

1. Monitor the edema, color, temperature, skin appearance around the wound and moisture.

2. Closely examine the site of the impaired tissue daily for infections. Determine if the patient experiences changes in pain or sensation

3. Keeps an eye on the status of skin surrounding the wound.  Also, examine the care practices that the patient uses including cleansing agents

4. Choose a topical treatment that has the ability to maintain the wound in moist condition

5. Make sure you check the nutritional status of the patient. If need be, order nutritional consults.

Rationale

1. It is recommended that regular check up is done. The essence of the check is to ascertain that  any possible problem as regards the early areas in infection is identified

2. The pain that come as a result of the dressing change can be effectively monitored and hence managed by application of interventions that mainly focus on reducing the trauma and possible other sources of wound pain.

3. It is critical to customize each care of plan to a particular patient in question based on the patient’s skin condition preferences and needs at large. As such, it is important care practices that include harsh agents of cleansing, extreme force or friction, hot water and too recurrent cleaning

4. It is imperative to choose dressings that essentially provide an environment that is moist. Also, it is advisable to keep the skin that surrounds the wound dry and also eliminate dead space  in addition to controlling exudate

5. The healing of the wound is largely contributed by the nutritional status of the patient. Arguably, a good diet composed of vitamins and nutritional foods largely promotes the faster wound healing process  

Primary care provider/service

                    Rationale

1. Cessation of smoking

Smoking weakness the body’s immune system. As such, quitting smoking helps improve body immune system that in turn increases body’s resistance to infections

2. Examination of feet on daily bases

One should examine plantar surface of the foot to detect any fungal infections in time and seek immediate medical intervention

3. Foot hygiene (Washing and drying feet at least once a day)

Foot hygiene is important as it eliminate the microorganisms like fungi that may cause infections including arterial ulcers

4. Apply lubricants containing urea or salicylates

This helps in the softening of the dry skin and preventing the cracking that my facilitate entrance of microorganisms thus foot infections

5. Lifestyle Modification

A good lifestyle that includes eating a balanced diet is essential as it improves the body’s immune system thus prevents the ulcers