Case Study On Wound Assessment And Management

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Wound assessment and management
Initial assessment of patient
- The antibiotics patient is having for her chest infection.
Anti-inflammatory drugs reduce the inflammatory response which necessary to prepare wound bed for granulations and affect the function of normal cells.
- A right stroke which leads to the blood supply of lower limb not circulates.
- Obesity. Excessive fat accumulation is one of the factors that make pressure injury become more serious and it decreases tissue perfusion.
- Oxygen saturation. As patient has a chest infection which leads her difficult to swallow already, nurses should concern that might influence her breathing as well. Oxygen is important for cell metabolism, therefore it is critical for all wound healing
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When applying hydrocolloid, warm up the dressing pack between palms of hands.
- This dressing pack may cause over- granulation, if this occur, should consider oxygen permeable dressing. Moreover, the dressing cannot be removed until the gel bubble and forms come close to the edge of dressing because the gel allows atraumatic removal of the dressing.

- Nurses should consider the risk factors of the heel wound. The extrinsic factors are pressure, friction and shear. By choosing foam, dynamic air or low air loss bed reduce the body pressure that will add to heel when patient need to lie down for a long time. When the patient is siting, foam or air cushion can be considered to apply.

- Repositioning patient is essential, so remember to remind patient or help them to turn their side every two hours. Elevate and offload the heel by using foam cushion completely or knee can be in slight five degrees or 10 degrees flexion. Knee hyperextension can cause popliteal vein obstruction and avoid putting pressure on the tendon which can prevent the pressure injury wound
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 Monitor patient’s meal progression and ensure she has enough nutrition supplements. - Additional equipment or support
 Pain scale for the heel wound
 Detect the odour of wound
 Monitor temperature of surrounding skin. Temperature controls the rate of chemical and enzymatic processes occurring within the wound and the metabolism of cells and tissue engaged in the repair process.
 Capillary refill time. Adequate arterial perfusion is essential to the process of wound healing and the presence of persistent eschar indicates poor arterial flow to an area.

- Potential complications
 Pressure injury can develop very fast which as short as 30 minutes. If more external pressure adds to wound site, vessels can collapse. It also cut off the blood and oxygen supply to cells which results in tissue hypoxia and cellular death. Ensuring patient is not putting any pressure on her right heel at any time.
 Apply the heel lift suspension boost


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