Please enable JavaScript.

Coggle requires JavaScript to display documents.

Relevant Cues/ Findings (assessment) erythema/blanching on occipital…

- - - - Ensure the patient is getting adequate nutrition and hydration. Ensure the patient is eating protien to promote wound healing and prevent further wound break down. Ensure the patient is getting adequate hydration to maintain skin integrity and elasticity. Request the patient recieves vitamins A, C & E, and zinc which supports wound healing.
        
        Perform wound care. Depending on the patient's orders, keep up on skin care and dressing changes. Apply prescribed ointments, sprays, and foams that promote healing and keep the wound clean. Properly irrigate the wound to remove dead debris. If the wound is open to air, ensure it is getting adequate air flow while staying clean.
        
        Nurse should adequately assess the pressure ulcers frequently. The nurse should ensure the pressure ulcer is not progressing through the stages. The nurse should assess for any tunneling or undermining. The nurse should assess wound dressings for any drainage. The nurse should look for signs of infection such as foul odor and purulent drainage.
    - - Patient's wound bed remains free of infection and does not progress to a farther stage of ulceration. Nurse will assess the patient's wounds Q2hrs. The nurse will notify the provider if there is need for dressings to protect the wound bed.
        
        Wounds remain free of excess pressure that could further injury the ulcerations. Nurse will preform turns every two hours. Nurse will keep heels elevated with pillows. Nurse will use blocks to turn patient from side to side to stay off of occipital bone. Nurse will assess patient's ability to ambulate to chair to allow time to remove pressure from bony prominences that have pressure applied to them while in bed.
      - Discharge: medical and nursing outcomes/resources needed
        
        Patient will follow up to ensure all wounds are healing properly. Nurse will coordinate with wound care experts for further determination of risk of skin breakdown post discharge. If wounds become more severe, schedule follow up with wound specialists to continue assessment of wound healing.
        
        Educate patient on proper nutrition and hydration post-discharge. Educate patient on the need for proper nutrition and protien intake. Educate on adequate hydration. Consult with dietitian if diet plan or further education is required. Patient will obtain adequate nutritional needs long term and promote skin integrity.
        
        Patient will remain active at home and avoid a sedentary lifestyle that promotes pressure wounds. Educate patient on the need for ambulation/activity at home. A sedentary life prevents healing of ulcerations. Educate patient on movement and activity as tolerate to keep pressure off current wounds and allow for healing.
        
        Patient will properly care four any wounds independently post-discharge. Educate patient on wound care at home. Educate the patient on how to properly clean wounds and change dressings ordered by the provider. Instruct the patient to notify the provider if any signs of infection occurs such as purulent discharge, foul odor, fever, or pain.