Outline and evaluate your plan of care, using the Nursing care Plan

Outline and evaluate your plan of care, using the Nursing care Plan.

You have been asked to complete a wound assessment on Sarah Victor who had a hysterectomy 12 days ago. Sarah has beenreadmitted with a wound dehiscenceand has completed a course ofantibioticsfor her wound infection. There are no signs and symptoms of systemic infection at this stage although there is still a moderate amount of exudate. Sarah states that her wound is sore and a bit smelly.

Patient Details:

Name: Sarah Victor
Address: 66 Ellsworth Avenue Umina NSW
Sex: Female D.O.B: 5.2.55
Age: 60 years
Marital status: Married
Country of birth: Australia
Admitted: Accident Emergency
Social history: Smoker ETOH – social only
Medical history

1995

·cholecystectomy

·chronic bronchitis

Current medications: BecotidePRN
Wt: 65 kilograms
Vital signs: Temp 36.5, P 96, BP 130/80
Allergies: Nil

1Complete a wound assessment (using the Wound Assessment and Management Chart provided) and describe the wound (include the chart you used for the assessment when you hand in your assignment).

2Write a report on the case study above, answering the following questions:

  1. a)Describe the strategies that could be used to minimise cross infection prevent the spread of disease and reduce further complications.

  1. b)Discuss the physiological processes of wound healing.

  1. c)Which wound management products would you use for this type of wound and give a rationale for your answer?

  1. d)Outline and evaluate your plan of care, using the Nursing care Plan Template below

  1. e)Discuss how using principles of primary health care can lessen the impact of the management of the wound on the client and their family.

Marking guide – Case Study 1

Student Name

Content

Comment

Marks

Wound assessment

(completed chart)

Student identification

15

1.Strategies to reduce infection and complications

15

2.Wound healing

15

3. Products and rationale

10

4. Implementation

Evaluation of care

(Nursing care plan)

25
5. Principles of primary health care

10

Presentation (including correct referencing)

Submitted on due date

10

TOTAL

100

Pass: ____________Fail: ___________ Resubmit: ____________

Assessor’s name: ________________ Assessor’s signature: _________________

Case Study/ Scenario – Number 2

You are a community nurseand have a new patient Mrs Young, who has presented with a leg ulcer.

Mrs Young tells you she is generally well but she hasan ulcer on her right legjust above the ankle that won’t heal. The wound has deteriorated rapidly over the last month, after knocking it on some household furniture.

She hasa past historyof a leg ulcer 2 years ago. She had hervaricose veinsstripped 5 years ago.

She states herpainis tolerable but relieved by rest. The wound is sore andvery sloughy.The skin around thewound is of a reddish brown appearanceand has an irregular shape. There is nil odour.

Mrs Young states she has normal sensation and you note hair is present and pulses in foot and ankle are palpable. There is alarge amount of exudate.

Mrs Young has a fairlysedentary life styleoftensitting for hoursin front of the television. There isoedemapresent in both legs. Herdiet is poorlacking in fresh fruit and vegetables and she doesn’t really cook often so eats a lotof tinned soups and bread.

Using Mrs Young as your client you are to assess, plan, implement and evaluate her care for her leg ulcer in a written paper, by completing the following:

1Complete a nursing care plan (using the template provided) and a wound assessment (using the chart provided).Your care plan must include 6 actual, and 2 potential problems

2Written paper – answer the following questions.Appropriate referencing and appropriate health terminology related to wounds and wound care must be used must be used.

  1. What contemporary assessment tools you would use to develop your plan and assist in diagnosing your ulcers aetiology.

  1. Who you would consult in developing your wound care strategy and nursing care plan

  1. How you would clean the wound and which would care technique is most appropriate

  1. What cost effective wound care products you would use and your rationale behind your decision, and Databases and websites you have used to inform your decision

  1. Your interventions and rationales for these interventions relating your answer to the physiological and biochemical processes associated with normal wound healing

  1. How you would monitor the client’s response and progress towards your planned wound management goals

  1. How you would assess the effectiveness of wound products and when you would intervene if not effective

  1. Common problems and complications you might expect with a complex wound and pathological processes that might contribute to the cause.

  1. What preventative wound care strategies you would educate Mrs Young on to prevent an ulcer reoccurring.

Outline and evaluate your plan of care, using the Nursing care Plan