Question

write a progress note

Wound packing and wound care plan review 82 year old John is admitted to your care from a nursing home for management of chest infection. John is bed bound due to septicaemia affecting his general functioning. You find on admission that John came in with a sacral pressure injury and has an existing care plan. Johns vital signs are stable. Wound management plan states 3rd daily dressing of wound. You find that the dressing is soaked with exudate. Your Scenario: Remove existing dressing, provide wound care, reassess the wound and review the wound care plan in consultation with RN or supervisor.

Answer 1

WOUND DATE OF THE ONSET: document the date that the wound occurred by going through the patients files.

Goal OF CARE:

• To heal
• to maintain- wound healing is slow, no deterioration.
• to monitor/ manage- wound healing achievable or non achievable due to untreatable condition.

WOUND TYPE: Pressure- wound over a bony prominence, usually deep tissue damage

PRESSURE ULCER STAGE: Stage 3- full thickness skin loss, involves the subcutaneous tissue down to fascia.

DRESSING: record the day month and time for each dressing entry.

WOUND MEASUREMENT ( WEEKLY): record the wound measurement in centimeters ie length, width, depth, sinus tract, undermining.

ODOUR: Record the presence of odour after cleansing.