wound care for terminally ill patient.pptVIP

Wound CareBest Practice Guidelines Goal To educate healthcare professionals on effective wound care protocols, in order to ensure optimal care for our terminally ill patients. Objectives Identify preventative measures Describe risk factors contributing to skin impairment Describe the parameters of wound assessment including staging of wounds Describe wound types and tissues Describe care planning considerations and the selection of appropriate interventions Prevention Inspect skin Moisture control Proper positioning and transfer techniques Nutrition Avoid pressure on heels and bony prominences Use of positioning devices Monitor and document Risk Assessment Alterations in mobility Level of incontinence Nutritional status Alteration in sensation or response to discomfort Co-morbid conditions Medications that delay healing Decreased blood flow to lower extremities when ulceration is present Contributing Factors1 Assessment and Documentation Location Stage and Size Periwound Undermining Tunneling Exudate Color of wound bed Necrotic Tissue Granulation Tissue Effectiveness of Treatment Assessment and Documentation Wound and Risk Assessment every visit Documentation on Wound Assessment Form every 7 days when 1 or more pressure ulcer exists Physician assessment and documentation on Physician Wounds Care Assessment tool Pressure Ulcer Staging2 Care Planning. Overall strategy and scope of the treatment plan depends on patient’s condition, prognosis, and reversibility of the wound. Appropriate Goals Prevent complications or the deterioration of an existing wound Prevent additional skin breakdown Minimize harmful effects of the wound on the patient’s overall condition Promote wound healing Interventions Dressing considerations should include: Patient’s condition and prognosis Caregiver ability Ease and continuity of use Ability to maintain moisture balance Frequency of change Pain Management 1) Medicate the resident prior to dressing changes 2) Som