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 process and it …show more content…
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
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 process and it …show more content…
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