Patient Assessment and Wound Care Overview

Patient Assessment

• Definition: A systematic approach to collecting and analyzing patient health information.
• Components:
  1. Initial Assessment:
     • Obtain comprehensive health history.
     • Conduct a review of systems (ROS).
  2. Physical Examination:
     • Inspect, palpate, percuss, and auscultate.
     • Assess vital signs (temperature, pulse, respiration, blood pressure).
  3. Psychosocial Assessment:
     • Evaluate mental status, emotional state, and social supports.
  4. Functional Assessment:
     • Assess activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
• Tools:
  • Standardized assessment forms (e.g., nursing assessment templates).
  • Diagnostic tests (labs, imaging).
• Documentation:
  • Accurate and timely recording of findings.
  • Use of electronic health records (EHR).

Wound Care

• Definition: Management of injuries to the skin and underlying tissues to promote healing and prevent infection.
• Types of Wounds:
  1. Acute:
     • Surgical wounds, lacerations, abrasions.
  2. Chronic:
     • Pressure ulcers, diabetic foot ulcers, venous leg ulcers.
• Wound Assessment:
  • Examine the location, size, depth, and type of wound.
  • Identify signs of infection (redness, swelling, heat, discharge).
  • Assess the surrounding skin for maceration or irritation.
• Wound Care Principles:
  1. Cleansing:
     • Use saline or wound cleansers to remove debris and bacteria.
  2. Dressing:
     • Select appropriate dressings (e.g., hydrocolloid, alginate) based on wound type.
     • Change dressings per facility protocol and as needed.
  3. Moisture Management:
     • Maintain a moist wound environment to promote healing.
  4. Infection Control:
     • Apply topical antimicrobials if indicated.
     • Monitor for signs of infection and report as necessary.
• Patient Education:
  • Instruct on proper wound care techniques.
  • Educate about signs of infection to watch for.

Patient Assessment

• A systematic method for gathering and analyzing patient health information.
• Initial Assessment involves:
  • Comprehensive health history collection.
  • Review of systems (ROS) to identify potential issues.
• Physical Examination includes:
  • Techniques: inspection, palpation, percussion, and auscultation.
  • Vital signs measurement: temperature, pulse, respiration rate, and blood pressure.
• Psychosocial Assessment focuses on:
  • Evaluating mental status and emotional well-being.
  • Assessing social supports available to the patient.
• Functional Assessment examines:
  • Activities of daily living (ADLs) such as bathing, dressing, and eating.
  • Instrumental activities of daily living (IADLs) like managing finances and medication.
• Tools for Assessment include:
  • Standardized forms like nursing assessment templates.
  • Diagnostic tests such as laboratory results and imaging studies.
• Documentation is crucial for:
  • Accurate and timely recording of assessment findings.
  • Use of electronic health records (EHR) to ensure information accessibility.

Wound Care

• Management of skin and underlying tissue injuries aimed at promoting healing and preventing infections.
• Types of Wounds can be categorized as:
  • Acute Wounds: Includes surgical wounds, lacerations, and abrasions.
  • Chronic Wounds: Examples include pressure ulcers, diabetic foot ulcers, and venous leg ulcers.
• Wound Assessment entails:
  • Evaluating the wound's location, size, depth, and type.
  • Identifying infection signs such as redness, swelling, heat, and discharge.
  • Checking surrounding skin for maceration or irritation.
• Wound Care Principles consist of:
  • Cleansing: Utilizing saline or specialized wound cleansers for debris and bacteria removal.
  • Dressing: Choosing appropriate dressings (e.g., hydrocolloid or alginate) tailored to wound type.
  • Moisture Management: Preserving a moist environment conducive to healing.
  • Infection Control: Applying topical antimicrobials as needed and monitoring for infection signs.
• Patient Education emphasizes:
  • Instruction in proper wound care techniques to ensure effective healing.
  • Guidance on recognizing and responding to signs of infection.