Question

The Patient with a Decubitus Scenario for Documentation The nurse is caring for a Timothy Willis, 68-year-old male who has been admitted from a local nursing facility. His vital signs are the following BP-121/7802 99%, R-14, HR-74 and T-98.6. The nurse has completed the initial assessment. During the initial assessment, the nurse has noted a sacral wound. There is fu necrotic tissue presence. The wound bed is moist, red tissue, with visible muscle, and quarter size of yellowish tissue, right side of the wound bed. The measurements are 3cm in length, 2 cm in width, 1 cm depth an cm undermining surroundi the wound and the surrounding skin is intact. ll thickness loss with no d with 2 ng the entire circumference of the wound. There is bone exposure in the middle of Using this scenario write out your wound documentation. The dressing changed you perfornm intervention for this patient's wound. Then document what you removed out of the wound, what the wound looked like, note use your skill sheet to discuss what you used to cleanse and dress the wound. bed the color of any drainage, odor and how the patient tolerated removal. Finally, you are going to You wil need to hand your documentation to your mentor after the lab skill has been completed. Make sure to put your mentor's name on the document. Use your nurse's note to document care of the wound. Identified Priority Nursing Diagnosis Impaired skin integrity r/t damage to skin and underlying tissue aeb: Please underline or highlight the "as evidenced by" in the above scenario and initial assessment.

Answer 1

Patient name: Timothy willis
Age : 68years/male
Initial Assessment:
Vital signs checked
Sacral wound noted
Wound documentation:
-There is full thickness loss with no necrotic tissue presence
-The wound bed is moist,red tissue with visible muscle and quarter size of yellowish tissues,right side of the wound bed
-Measurements are 3cm length,2cm width,1cm depth and with 2cm undermining surrounding the entire circumference of the wound.
Wound care:
Patient is in stage IV pressure ulcer stage
Infected tissue removed with normal saline
Thin,pale,red to pink serosanguineous discharge present with unusual odor
Patient had mild to moderate pain during dressing as we removed the infected tissue
Antimicrobial agent used atlast and dressing was closed with absorptive dressings...