Internal Code: IAH165
Mrs Rose a 60 year old woman has developed a venous ulcer due to a shopping trolley injury on her R) leg. The specialist who orders the treatment confirmed the diagnosis following an ABPI and a medical history check.
Her treatment was going to be scheduled to include a Doppler ultrasound, and an FBE. The dressing is to include compression bandaging over gauze padding that covers a moistened dressing. Her leg is to be elevated above her waistline when resting.
Additionally her medical condition was taken into the holistic care plan as the objective was to enable her wound to heal as quickly as possible for her to resume her “normal” activities of daily living. Her medical profiling included vital signs, wound assessment, surrounding skin assessment, wound swab, a blood test, a BMI, lifestyle and mobility assessment including her nutritional status.
Wound assessment – appeared to be vascular with minimal bleeding. The wound was measured at 1.0cm x 0.9 cm. It was located at the medial ankle site of the R) foot. There was slight haemoserous and purulent exudate that appeared superficially on the wound.
Surrounding skin – appeared bluish and congested with more oedematous sections at distal and proximal ends of the wound.
Wound Swab – revealed normal wound colonisation
Blood Tests – revealed anaemia , a slight elevated neutrophil count and a fasting blood sugar level of 5.0mmol/l
BMI and Lifestyle- she is in the morbidly obese range and occassionally smokes.
Mobility – She walks minimally but is able to walk normally usually. She gets about with her friends at the local bingo centre. She has refrained from attending bingo in the last few weeks due to fear of further injury to her wound.
Nutritional status – Her diet needs review due to her anaemia.
Short Answer questions (1.1, 1.2, 1.3, 2.5, 2.1, 2.2, 2.3, 2.4, 3.5, and 5.1)
A. Define the underlined words in the case scenario to give the medical term meaning. This will enable you to begin to assess, report and record data on wounds. (1.1)
B. List and describe the PPE (personal protective equipment) worn by the nurse when completing Mrs Rose’s wound care to minimise cross-infection during assessment and implementation of wound management strategies. Today her wound will be irrigated with saline and dressed accordingly. (1.2, 2.5)
C. Observe orders and instructions for Mrs Rose’s wound treatment and:
I. Document the specific orders.
II. Explain the correct way to apply a compression bandage for Mrs Rose’s wound to
allow for venous return (1.3, 2.3)
D. Refer to the “Documentation” of Mrs Rose’s wound following the medical assessment.
I. List and explain the factors that could affect Mrs Rose’s wound from healing and include the lifestyle changes she may need to make for better wound health outcomes.
II. Give your physiological reasoning as to how lifestyle changes can impact on wound health. (2.1)
Explain the possible complications of Mrs Rose’s wound if she did not elevate her leg throughout the day. (2.4, 2.3)
F. Include the psychosocial impact of her wound on the main activity she likes to do in her daily living. (2.3)
G. Explain the pathological and biochemical processes associated with the development of Mrs Rose’s venous ulcer. (2.2)
Explain the impact moist dressings and compression bandaging has on improving healing. Include why compression stockings are used for preventative measures (3.5,5.1)
Refer to the information in the case scenario. Complete a nursing care plan for Mrs Rose’s case scenario. Start with making an assessment of a risk factor related to a nursing diagnosis. Complete the goals, implementation and risk evaluation.
A. Question Identify five (5) risks for Mrs Rose’s case scenario and complete the nurse care plan.
Aim of care:
Consider Infection Control, Check orders & Follow orders Follow the “Principles of Wound Management”
1. Wounds needs to be moist to assist with tissue regeneration.
2.Wound needs to have blood supply to assist with phases of healing.
3. Holistic care of the patient – top to toe assessment
4. Work out your patient risk factors
Manage the wound – appropriate dressings, observations, accurate assessment, reporting/documentation.
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