Initial Patient Assessment
Overview
The patient is 67-year-old Mrs. Finch.
She lives with her husband in their marital home.
Recently, she suffered a CVA and had been in the hospital’s rehabilitation ward recovering from her latest episode.
Before her CVA, Mrs. Finch had a healthy and active lifestyle.
However, her condition has brought with it numerous other complications including a chest infection.
She is also having difficulty staying mobile due to residual weakness on her left side.
She has had a dark wound on her heel for about a week now. This wound keeps deteriorating into the present wound.
A series of CVA specific issues such as limited mobility, the risk for infection and reduced nutrition hinders Mrs. Finch’s capacity to heal.
Wound Bed: Partly granulating. There exist visible signs of red tissue deposits as if in the process of repair. This section is moist pinkish in color and could easily bleed upon irritation.
Partly necrotic. Found on the upper part of the heel. This section appears hard dry and black. It shows a presence to dead tissue that could prevent healing. There are evidences of blood supply before the debris of this part.
Measurement: (Insert Photograph Evidence)
Wound Edges: Mostly healthy wound edges. Partly pink as a sign of the growth of new tissue. Mostly raised to indicate pressure and trauma. Signs of contraction on the upper edge as a sign of semi-healing. An absence of sensation following non-reaction to touch.
Exudate: No odor noted. Partly purulent (yellow-green), sanguineous (reddish) and haemoserous (think clear pink).
Infection: erythema around the wound, abnormal healing pattern, and malodor. The patient has localized pain.
The surrounding wound skin appears healthy.
Pain: Captured evidence of pain. The patient easily scores a four on the Wong-Baker pain chart. We can offer effective pain relief.
Physical and Psychosocial Factors
Hygiene
The personal hygiene of both the nursing staff and patient would have a vital effect on Mrs. Finch’s wound healing process. According to Guo and DiPietro (2010), nurses should wash their hands every time they dress Mrs. Finch’s wound. Also, the appropriate practice would imply that the hospital staff dresses the wound in a sterile environment with clean care products to prevent further infection. This idea seems not to be the case with Finch given the fact that her wound keeps getting worse by day.
Nutrition
Patients that eat healthily have a behavior that can aid in speeding up the wound healing process. Hess (2011) notes that foods high in iron, protein, zinc, copper, and vitamins help facilitate this activity. Also, fats and carbohydrates have an equally vital role for the provision of additional fatty acids and energy. Furthermore, it would be vital for patients of Mrs. Finch’s situation to drink a lot of water for skin hydration. However, her chest infection makes it hard to swallow her meals. This condition reduces her ability to ingest some of the vital nutrients and fluids required for her quick recovery (Hess, 2011).
Age
Age is an important health factor in determining the time wounds take to heal. According to Guo and DiPietro (2010), senior citizens are highly likely to experience longer wound recovery times compared to their younger counterparts. At 67, it is likely that Mrs. Finch’s skin suffers the consequences of reduced elasticity. Thus, the older one gets, the highly likely they require specialized wound treatment. The presence of any chronic condition at this age also makes it hard for their bodies to adapt to various wound healing processes (Guo & DiPietro, 2010).
Chronic Conditions
As suggested above, numerous chronic conditions have a significant effect on one’s body’s ability to make quick recoveries. According to Guo and DiPietro (2010), cardiovascular complications such as coronary artery and peripheral vascular diseases are the most detrimental in affecting the recovery process. Mrs. Finch suffers from CVA. Her condition means that bodily functions cause various barriers that slow the flow of oxygen, blood, and nutrition to her wound’s site.
Stress
Social stressors can result in negative emotions characteristic of anxiety and depression. Hess (2011) asserts that such emotions can have a huge effect on the behavioral patterns and physiologic processes influencing positive health outcomes. Mrs. Finch is going through a transition that is a complete contrast to her previous life. The negative experiences of this transition have a direct influence on immunity and the endocrine system. As a stressed patient, Mrs. Finch is also likely to have poor sleeping habits, less exercise, and unhealthy habits. All these factors have a huge negative effect on the wound health process.
Specific Assessment (T.I.M.E) and management
Tissue: Noticeable non-viable tissue. Partly dead or necrotic tissue characteristic of a black scab that covers a huge section of the wound. Partly yellow slough comprising of pus, fibrinous material, and protein. Debridement would be useful to remove the slough and necrotic tissue. This procedure would happen though flushing, dressing and surgical treatment (Leaper, et al., 2012).
Infection: Mrs. Finch’s wound displays medium exudate, redness, inflammation, fragility, and tenderness. Overall, the tissue is irregular and could bleed easily. Suspected infection. There is a need to reduce the risk of inflammation and infection. This condition is manageable by removing bacteria through the debridement of infected tissue and slough, moisture management and the use of antimicrobial agents (Leaper, et al., 2012).
Moisture Imbalance: Medium exudate. Visible pus in wound fluid. Indicates infection. Partly dry. Mrs. Finch’s wound requires a suitable dressing procedure to add fluid to the wound for a facilitated healing process. Various products available for the moisturizing management of such wounds include skin-friendly hydrogels and gels (Leaper, et al., 2012).
Edge: Mrs. Finch’s wound has moderately even yet worn-out edges. Such wounds may experience a failure to close and heal. It requires urgent promotion of wound closure by tackling wound inflammation, moisture level, tissue viability, and infection issues. However, a further failure to closure would require advanced treatment procedures. Wound measurement would be vital as part of the treatment tracking process (Leaper, et al., 2012).
Type of Wound
Dressing Selection and Rationale
There are two parts that would require different kinds of dressing. Notably, there is blood supply before the debris part of the necrotic segment. The necrotic wound would require rehydration then removal before further treatment. It follows that any treatment that would reverse dehydration can reduce pain and facilitate debridement. A proper hydrogel will act as the best rehydration agent. We will use the hydrogel as a physical barrier to prevent further loss of moisture through the dead skin. It will allow for the ultimate separation of the necrotic covering from the rest of the wound leaving behind the slough.
Next, prepare the field through the thorough cleansing of the areas neighboring the wound. Thomas (2013) suggests that this process starts from the center and works outwards to eliminate chances of contamination. It would also be essential to wash and drape all the regions adjacent to the wound. Next, the nurse would remove all visible debris then image further to search for additional contaminants such as metals, bone fragments, glass, and dirt. Finally, they would irrigate the wound using an appropriate cleansing solution such as salient. The best way of wound irrigation is using a syringe to wet the wound with the solution and allowing it to drain naturally (Thomas, 2013).
According to Spear (2012), nurses should focus on relieving pressure from such wounds as well as protect them from further infection and trauma. Mrs. Finch’s wound requires a specialized assessment to determine its appropriate management. However, we consider treatment and cleansing agents such as a hydrogel, adhesive foam, silicon dressing, and hydro fiber. The primary dressing selection is one that works for moisture retention. Hydrogels such as Intrasite and antimicrobial dressings such as Iodosorb would be useful in cleaning the wound’s bed and edges of debris and dead tissue. These are special healing mechanisms that help the body to moisturize and separate healthy from dead wound tissues (Spear, 2012).
Continuing Management
Patient-centeredness Management
A Patient-centered approach to wound management takes care of the patient’s physical and psychosocial needs. According to Woo (2013), the process requires a general recognition of wounds and pain as an issue that can affect one’s physical and psychosocial states. Thus, a patient-centered physical wound management procedure would require that the nursing assistant applies cleansing and dressing methods that are pain conscious. Notably, it is important to offer pain remedies as part of the healing procedure (Woo, 2013).
Also, it would be essential to note that individuals with pressure wounds would describe the healing process as debilitating, worrisome, and depressing. According to Gouin and Kiecolt-Glaser (2011), such psychosocial states would contribute to high stress and anxiety levels. They would be on the receiving end of additional mental health issues compared to their healthy counterparts at community and family level. They would be unable to apply problem focused thinking required to cope with stress (Gouin & Kiecolt-Glaser, 2011). It would be important for wound managers to offer necessary counseling sessions for Mrs. Finch to help her cope with this condition. Also, the management should encourage Mr. Finch to offer the necessary psychosocial support required for the effective transition.
Education for Ongoing Care
Patient engagement and self-management are essential to pressure wound management. According to Woo (2013), this process offers supportive interventions to increase the patient’s confidence and skills required for proper wound attendance. Mrs. Finch’s educational plan would include directions on self-assessment of issues and progress, problem-solving support, and objective setting. Other interventions would include self-monitoring procedures, cognitive therapy and seeking social support (Woo, 2013).
Additional Equipment and Support
Syringes
Saline
Gauzes
Pressure wounds such as Mrs. Finch’s have an excessive bacterial presence. It means that the absence of appropriate equipment would limit their healing process. Based on Sood et al. (2014), this wound could benefit from periodic debridement at both home and clinical settings. Therefore, it would be vital to offer syringes, saline, and moist gauzes for continued dressing and cleansing as per clinical directions. However, home-based care would have to wait for specialized home visits or supervised assistance from Finch’s care giver.
Potential Complication
The inappropriate management of Mrs. Finch’s pressure wound during home care could result in delaying healing, deterioration, and breakdown. According to Evans (2014) constant reassessments through clinical visits would be essential as a way of minimizing the occurrence of this completion. I would also recommend that Mrs. Finch refers to a health practitioner concerning wound management in case of doubt (Evans, 2014).
References
Evans, J. (2014). A solution to cost-effective wound management in the community . Journal of Community Nursing, 28(2), 46-51. Retrieved from http://www.advancis.co.uk/uploads/files/documents/pdf/Wound-Management-in-the-Community.pdf
Gouin, J., & Kiecolt-Glaser, J. (2011). The Impact of Psychological Stress on Wound Healing: Methods and Mechanisms. Journal of Immunology and Allergy Clinics of North America, 31(1), 81-93. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052954/
Guo, S., & DiPietro, L. (2010). Factors Affecting Wound Healing. Journal of Dental Health, 89(3), 219-229. doi:10.1177/0022034509359125
Hess, T. (2011). Checklist for Factors Affecting Wound Healing. Advances in Skin & Wound Care, 24(4), 192. doi:10.1097/01.ASW.0000396300.04173.ec
Leaper, D., Schultz, G., Carville, K., Fletcher, J., Swanson, T., & Drake, R. (2012). Extending the TIME concept: what have we learned in the past 10 years? International Wound Journal, 9(1), 1-19. Retrieved from https://www.cdhb.health.nz/Hospitals-Services/Health-Professionals/Education-and-Development/Study-Days-and-Workshops/Documents/Extending%20TIME.pdf
Mahalingam, S., Gao, L., Nageshwaran, S., Vickers, C., Bottomley, T., & Grewal, P. (2014). Improving pressure ulcer risk assessment and management using the Waterlow scale at a London teaching hospital. Journal of Wound Care, 2312, 613-622. doi:10.12968/jowc.2014.23.12.613
Sood, A., Granick, M., & Tomaselli, N. (2014). Wound Dressings and Comparative Effectiveness Data. Advances in Wound Care, 3(8), 511-529. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4121107/
Spear, M. (2012). Venous ulcers--an evidence-based update. Journal of Plastic Surgical Nursing, 32(4), 185-188. doi:10.1097/PSN.0b013e31827781b8
Thomas, R. (2013). Managing venous stasis disease and ulcers. Journal of Clinics in Geriatic Medicine, 29(2), 415-424. doi:10.1016/j.cger.2013.01.006
Woo, K. (2013). Advances in Skin & Wound Care: Trends in Wound Management. The Journal for Prevention and Healing, 26(12), 538-541. Retrieved from http://www.nursingcenter.com/pdfjournal?AID=1630550&an=00129334-201312000-00002&Journal_ID=54015&Issue_ID=1630545
