500 Word Care Plan

CNA252 2016/2017 CNA252 Professional Practice 1 Health Laboratory 2 - The wound care Intended Learning Outcomes: Actively participating in these activities will increase your ability to:

• use aseptic technique and understand the principles of sterile aseptic technique [SANTT] • plan and implement evidence based care for secondary prevention of postoperative complications • plan and implement a care plan for a peri-operative patient (wound care focus) • monitor and evaluate health outcomes for a post- operative patient Resources you may find useful: 1. DeL aune , S et al, 2016. Chapter 40 and chapte r 7 2. Focus scenario –– Genevieve Thomas 3. Tollefson, J 2016, Clinical Psychomotor Skills , 6 th ed, Cengage Learning, Melbourne. pp. 372 – 383 Wider reading includes 384- 393(optional) 4. Body defences Lectures CNA252 2016/2017 An important part of wound assessment and documentation is: T: Tissue I: Inflammation/inflammation M: Moisture E: Edges Use wound care chart provided Under the headings above, describe and document Genevieve’s wound: .......................................... Tissue: ........................................................................\ .............................................................................. ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... Inflammation/inflammation: ........................................................................\ .......................................... ........................................................................\ .......................................................................................... Mrs Thomas is 65 years old. She is retired and lives in a rural area with her husband. She was referred by her GP to an orthopaedic surgeon for review of osteoarthritis in her left hip joint. Genevieve has now had a total hip replacement and is mobilising on a full arm support frame with the assistance of a physiotherapist. In addition, the occupational therapist has arrived to work towards her discharge home addressing her capacity to manage independently and safely in her home environment. You notice a cigarette lighter in her draw er, and inquire if she has a history of smoking and talk with her about the impact of smoking on wound healing. Whilst attending to her ADL’s, you notice strikethrough on her dressing that is now evident on her gown and sheets. She is complaining of increasing pain and swelling in the area. Upon taking down the dressing you notice the wound to be very red with a large amount of offensive exudate and the wound has dehisced at the proximal end. Activity 1 – Wound management CNA252 2016/2017 ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... Moisture: ........................................................................\ .......................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... Edges: ........................................................................\ ............................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... Genevieve’s wound has dehisced at the proximal end of the suture line. Wound healing can be classed as primary intention, secondary intention and tertiary intention. What encompasses primary intention and give an example: .............................................................. ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... What encompasses secondary intention and give an example: ........................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... What encompasses tertiary intention and give an example : ............................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... CNA252 2016/2017 ........................................................................\ .......................................................................................... Discuss the factors that impact wound healing under the following headings: ................................ ........................................................................\ .......................................................................................... Age: ........................................................................\ ................................................................................. ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... Smoking: ........................................................................\ .......................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... Medication: ........................................................................\ ...................................................................... ........................................................................\ .......................................................................................... ........................................................................\ ......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... Nutrition: ........................................................................\ ......................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... Activity 2 : Factors affecting wound healing You notice that Genevieve has not been consuming her meals and snacks when they arrive. Genevieve states that she is very tired and does not feel like eating and she appears dehydrated . Her skin is dry with little turgor, her blood pressure remains low 90/50, SaO 2 93% on room air. You rei nforce the importance of deep breathing, coughing and mobilisation. You e xplain to her that nutrition is a key factor in wound healing and you organise a referral for dietician review. CNA252 2016/2017 ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... Chronic disease: ........................................................................\ .............................................................. ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... ........................................................................\ .......................................................................................... . ........................................................................\ ......................................................................................... CNA252 2016/2017 Iden tification of problem Expected outcome Aetiology Activity 3 Using the clinical reasoning cycle establish a care plan that incorporates 3 short term or long term goals for your patient, Genevieve, concentrating on wound healing. Draw on chapter 7 DeLaune to guide you in writing the plan. CNA252 2016/2017 Nursing interventions Identification of problem Expected outcome Aetiology CNA252 2016/2017 Nursing interventions Identification of problem Expected outcome Aetiology CNA252 2016/2017 Nursing interventions Identification of problem Expected outcome Aetiology CNA252 2016/2017 Nursing interventions Identification of problem Expected outcome Aetiology CNA252 2016/2017 Nursing interventions CNA252 2016/2017 CNA252 2016/2017