WOUND CARE ASSIGNMENT CASE STUDY TONY

2.Describe in detail(including the pathophysiology) the aspects of Tony's health that would impact on his wound healing. A. Tony is a 78 year old man and his age previlance alone will impact on his wound healing,because as you get older the metabolism in your body slows down. Tony has been resting in bed for the last week which has added more pressure and further complications for his right heel ulcer not getting the appropriate intervention .Because he has immobilized himself,due to his chest infection,his body has lay dormant,reducing the circulation process,there fore not letting the blood get to his heel to help the healing process. Being in bed and immobile,has increased his obesity,making the body harder to restore blood and nutrients needed to assist with the healing process. Tony's diabetes will also contribute to the slowing down of the healing process of Tony's heel because he has had a breakdown of healthy cells and tissues. All these issues need to addressed through a nursing diagnosis and nursing care plan. Once this is complete, steps can be followed to implement strategies to start the healing process 3. Using T.I.M.E outline the principles for the management of Tony's right heel ulcer. A.T. Autolytic debribment would be the most appropriate dressing for Tonys ulcer. This helps with the breakdown of necrotic tissue and promotes the process of new cells to help with healing. I. The amount of infection depends on the type of dressing used and whether it is an acute or chronic ulcer Other factors such as medications may impede on the response of the type of dressing chosen. To control or eliminate further infection,the infected area must be contained.

M. The right amount of moisture can play an important role in the healing of an ulcer. Determining the amount of exudate and the right dressing,the healing process can begin . E. Epithelial advancement is where the wound is starting to heal by way of seeing the edges of the wound moving closer together. With the right treatment ,advancement of this should commence within 4 weeks from the start of management therapy. If this does not occur,their may be some underlying factors which need to be resolved. Other treatments available are the VAC system or skin grafts. 4. Describe the choices you would make when dressing Tony's right heel ulcer and explain the reason for your choices. a. cleansing solution for wound bed The only cleansing solution I would use is saline solution. Any other creams or agent may harbour infection. b. Primary dressing for wound bed I would use hydrogel for the primary dressing as it is enclosed,helping with healing process and eliminate further risk of infection c. Secondary dressing Compression bandage for reduction of oedema ans inflammation plus gives more cushioning for area. 5.Formulate three(3)nursing diagnosis for Tony. For each diagnosis,list three(3) nursing interventions. a. Chest infection- intake of more fluids get Tony to cough up and spit out any infectious sputum\ -more movement/exercise b. Diabetes Mellitus-controlled diet - patient education c.Foot Ulcer Take wound swabs -clean with saline -Inspect site - Maintain good therapies 6.What interventions are needed to prevent the sacral pressure sore from developing. A. Re position Tony frequently at least every 2/24. Moisturise sacrum area. Give Tony a gel ring while he is bed. Get Tony out of bed and moving around as much as possible. Place primapore over area to keep area protected. 7.What discharge instructions would you give Tony.

A. Maintenance of personal hygiene is important. Written information on management of his diabetes. Any telephone numbers he may need. Follow up appointments. Diabetes groups he may like to join. If he feels the ulcer is not improving ,do not hestitate to come back.