Question

Pt A- Josephine Morrow

Location: Skilled Nursing Home Care Facility 0800

Report from charge nurse:

Situation: Mrs. Morrow is an obese, 80-year-old white female who developed a venous stasis ulcer on her right medial malleolus while still living at home. She moved into our skilled nursing home care facility 3 days ago. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown.

Background: Mrs. Morrow has a past medical history of chronic obstructive pulmonary disease (COPD), chronic venous insufficiency, and deep vein thrombosis (DVT). Peripheral arterial disease is ruled out by duplex ultrasound. Her daughter had her admitted to this skilled nursing home care facility due to concern for her safety with impaired mobility, an unhealthy diet, and inability to adequately care for herself at home.

Assessment: Mrs. Morrow is alert and oriented, but sometimes forgetful of recent events. Vital signs have been within normal limits and are performed weekly. Results from yesterday's labs are in the chart. She is on a regular diet with nutritional supplement and has been eating the majority of her meals since admission. She requires assistance with positioning in bed and assistance times 1 to get out of bed to the chair or ambulate. Her gait is unsteady, and she is easily fatigued. Her Braden Scale score is 16, and her skin is intact except for the venous stasis ulcer on the right medial malleolus. She has brown hyperpigmentation on both lower legs with +2 edema. The venous stasis ulcer is covered with a hydrocolloid dressing, which is due to be changed. In preparation for her dressing change, she was medicated for pain half an hour ago.

You need to complete a wound assessment, what would that look like? How would you document her current wound?

Answer 1

12 components of wound assessment

1 )Identifythe location of wound

2) Determine wound classification and \ stage

3) Determine etiology of wound

4) Measure the size of wound

5) measure amount of wound tunneling and undermining

6) assess the wound bed

7) assess wound exudate

8) assess wound edges

9) assess surrounding skin

10) assess for signs and symptoms of wound injections.

11)assess individuals pain

12) document findings

Dorsalis pedis , posterior malleolar pulses on feet

Braden scale score 16

Brown hyperpigmentation on both lower legs with +2 edema

Venous status ulcer

Skin is intact