Question

Case 2

You are working at the homelessness clinic when a 57-year-old male patient comes in; he asks you to look at a spot near his ankle. He rolls up his pants and you note a large wound with irregular borders. The wound is very wet, with the drainage seeping onto his pants. The wound has some yellowish-green slough and a small area of black in the middle. The skin on his leg is very swollen and dark brown in color.

How would assess and describe this wound?

Select one appropriate nursing diagnosis and its expected outcomes for this wound. Do you anticipate any barriers in meeting these outcomes?

What nursing care will you provide for this patient?

Answer 1

OPEN WOUND: is an external or internal break or injury in body tissue involving the skin.

HOW TO ASSESS THE WOUNDS? The wound should be assessed to identify the correct location of the wound b) the stages and size of the wound should be assessed and documented c) check for any redness, warmth and edema in the punctured site d) the amount,color, consistency and odor of the wound should be assessed and documented e) the exact cause of the wound should be identified inview to give a tetanus shot. f) the characterictics of the drainage should be assessed. g) The pain scale should be assessed daily .

HOW TO DESCRIBE THE WOUNDS TO THE PATIENT? The condition of the wound and every procedure before doing should be explained to the patient to reduce fear and to coperate with the procedure. The nurse should advice the patient to inform if the pain increases or further discharges felt on the site. The patient is adviced to keep the wound dry and elevated to reduce infection and swelling.

NURSING CARE PLAN: IMPAIRED SKIN INTEGRITY RELATED TO INFLAMMATORY RESPONSE TO SECONDARY INFECTION.

NURSING CARE: As a nurse, the following interventions should be included in the nursing care plan to reduce secondary infection and to promote wound healing. a) The wound should be washed and disinfected with the antiseptic solution to remove dirt and debris. The direct pressure should be applied on the wound and the ankle should be kept elevated to reduce bleeding and swelling. when wrapping the wound, use a sterile dressing and bandages to keep the wound clean from secondary infection. To relieve from pain and to improve faster healing pain killers and antibiotics should be administered repectively. Also, the nurse should instruct the patient to avoid aspirin products to reduce bleeding. Ice packs should be kept on the swelling area to reduce swelling. If it is a puncture wound, tetanus shot must be taken. The patient wound should be daily assessed to check for any color changes, pattern of bleeding, ulceration. The wound should be kept neat and clean by changing the dressing daily. The position of the patient should be changed every second hourly to reduce further skin breakdown. Medications should be given to the patient to reduce pain. Finally, before and after cleaning, hand hygiene should be practiced to prevent from infection.