Wound Management
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Wound Management
Wounds are treated differently depending on the underlying etiology. The details of the event that caused the wound suggest that she is in pain and she cannot walk as the pressure increases the pain. As the wound’s location is already revealed, fewer questions will be asked during diagnosis. The patient is experiencing acute foot pain from an infected wound.
Infection Control
Goal: stop the wound from spreading by neutralizing the infection and managing pain.
Intervention:
- Remove any devitalized tissue and any debris present — including dressing residue. The foot is an area that is usually harder to keep clean the feet.
- Gauge the moisture level of the wound by removing the excessive crusting is present or dry pus when present. As regards wound care dressing, they work the same way; they maintain the right of moisture in the wound and prevent it from becoming infected. If the wound is too dry, it must be moistened before ceiling and dried if too wet.
- Enact measures to minimize pain including but not limited to pain medication. Restricting patient mobility by confining them to the bed. When navigation is necessary, they will use crutches rather than wheelchairs to facilitate blood flow to the leg.
- Ensuring less pressure is applied to the foot to facilitate proper perfusion of blood. Offloading may require Tina to avoid wearing shoes until the wound is healed.
- Culturing the site for fungal, anaerobic, and aerobic pathogens is crucial. As the wound is infected, determining the foreign body present in it is essential.
Evaluation:
- Ask the patient to rate their pain severity relative to admission time.
- Recognizing that the wound will not be the same after a week and monitoring its progression if time is available is required. Check whether the tissue has been repaired. If exudate persists or redness is present, the wound is infected.
Underlying Condition
Goal: Identifying whether there are underlying condition causing the infection.
Intervention:
- Identifying how the wound was created will provide insight into the most common infections related to it.
- Identifying the exact anatomy, whether the muscle, bone, or tendon that the pain is emanating from, may be strategic. The location will present insights to the most likely underlying condition; if one is present.
- In acute wounds, one must assess damage to the bony structures and soft tissue (Hommel & Santy-Tomlinson, 2018). One must identify co-occurring illnesses that may slow the injury’s healing process. Most wounds tend to be complications from the primary issue. Diabetes is known to inhibit healing by suppressing the body’s default inflammatory response. The high blood glucose levels may trigger a microvascular disease slowing healing. Understanding the wound’s nature increases the healing chances.
- Check Tina’s nutritional status and state of the immune system is standard practice.
Evaluation: Assess blood flow to the wound region. Venous stasis may suggest that there is damaged venous supply. When it is clarified that Tina’s wound is acute, slow healing may suggest a complication.
When time constraints exist, the injury must be disinfected and bandaged. Assessing whether the injury is life-threatening should be the next step. Minor wounds benefit from exposure to air but when in the foot that easily gets dirty it should be bandaged (Kielo-Viljamaa et al., 2021). As it is an acute wound rather than a chronic one, a single nurse can handle it. Requiring an interdisciplinary team, when time limitations exist, could prove problematic. With a single person, decision-making is faster.
As the location of the wound is already established, the next tasks are finding its cause and stage. First stage wounds are superficial and only involve the epidermal layer. Second stage ones extend past the epidermis into the dermis; they materialize in partial-thickness, and noting such distinctions is vital. The tasks will align with the tissue, infections, moisture, and edge of the wound (TIME) comprehensive approach to impaired wound healing (Welsh, 2018). One must note the presence of necrotic or devitalized tissues in the surrounding wound. Note if the infections have spread to the surrounding sites. The last task is assessing the blood supply to the wound. See whether the edges of the wound are advancing or re-epithelialization is occurring. A damaged arterial may be constricting blood flow to the wound.
References
Hommel, A., & Santy-Tomlinson, J. (2018). Pressure injury prevention and wound management. Fragility Fracture Nursing, 85-94. https://library.oapen.org/bitstream/handle/20.500.12657/23127/1007029.pdf?sequence=1#page=99
Kielo-Viljamaa, E., Suhonen, R., Jalonen, L., & Stolt, M. (2021). Areas of nursing competence in acute wound care: A focus group study. Collegian, 29, 44-53. https://doi.org/10.1016/j.colegn.2021.04.003
Welsh, L. (2018). Wound care evidence, knowledge and education amongst nurses: A semi-systematic literature review. International Wound Journal, 15(1), 53-61. https://doi.org/10.1111/iwj.12822