Wound Care Process Ch1 Flashcards
There are 4 steps are in the Diagnostic Process
What are they?
Assessment
Diagnosis
Goals
Intervention
The assessment process begins when the clinic does what for the patient?
Begins when he patient is admitted or by referral.
Define Assessment (there are 2 aspects)
Gathering data from the patient history and physical examination.
What is Utilization Management?
Mandatory managerial policy that ensures only medically necessary, reasonable, and appropriate services are provided. This can include whether services should be performed by a PT, Nurse, or Dr.
What is the best way to collect assessment data quickly? 1 in particular. 4 total.
Standardized forms, medical records, caregiver. Computerized systems.
What are the 5 steps of the assessment of a wound patient process?
- Review of reason for admission/referral
- Patient history(which leads to system review)(sometimes history comes from more than one source)
- Systems review and physical assessment
- Wound assessment
- Patient candidacy for PT. (Keep or refer)
Review of Admission/Referral
What is the first thing the PT does?
Where does the nursing department come in to play in the referral process?
When wound care is necessary, who generally comes in to play?
Determine the reason for referral (PTs usually come to play when the wound isn’t healing).
Nursing usually receives the wound care referral first, then refers to the PT.
Often a team concept is optimal in wound care–PT, Nurse, OT, Orthotic, Nutritionist, or Speech Therapy
There are 5 possible reasons a PT would have when a pt. would be referred to a PT for wound care.
What are they?
Maximize and enhance wound repair. Help in cleaning and debridement. Enhance the inflammatory response to reinitiate wound repair. (Get to good tissue) Recurrent infection. Pain.
For both PT and nursing, wound closure may not be the highest priority. Why?
When skin starts to fail during the dying process, skin in a wound will not close. Sometimes it is not ethical to close the wound. Perhaps the priority is to keep patient comfortable.
The 5 components of a patient’s history.
When does one collect a patient’s history?
What is the most important piece of information to discover during history? It’s usually the first part established.
From whom does a history come?
What particular history are you interested when it comes to the wound?
Collect in the interview process –***discover chief complaint.
May come from various sources.
Chance to establish a relationship with the patient.
Begin collecting history by establishing chief complaint
Be aware of the patient’s present health and illness status as well as past illness history.
There are the 4 different types of history outside of medical history Define: Social history Psychological history Cultural history Nutritional history
Social history–live along, facility, unexplained falls, living environment, occupation, education level. Position within the family…support system.
Psychological history–dementia, cognitive ability.
Cultural history–female cannot be treated by a male. Other cultural sensitive accommodations.
Nutritional history–Need proteins. May not have access to healthy nutritious food.
Why do a systems review?
Why is the answer to the first question so important?
Pay attention to comorbidities…ie. congestive heart failure, diabetes***
“The individual’s capacity to heal can be limited by the effects of specific diseases on tissue integrity and perfusion, patient mobility, compliance, nutrition, and risk for wound infection.”
These systems must be assessed.
What is important about the Respiratory System, Cardiovascular System, Gastrointestinal System when it comes to healing a wound?
Critical for delivery of oxygen to promote healing.
Poor circulation = Poor wound healing.
Any disease or malfunction of the GI system can cause poor absorption of nutrients and fluids.
These systems must be assessed.
What is important about the Genitourinary System, Peripheral Vascular System (circulation in appendages), Neurologic/Musculoskeletal (neurons) when it comes to wound healing?
Kidney failure is often an indication of multiple systems involvement. (UTIs are very confusing to pt. changes personality)
Patients are at risk of developing chronic wounds and resultant impaired wound healing. (Lymphadema, lymph-ectomy,, high blodd pressure, blodd clot history, sensation.)
Impaired neurologic or musculoskeletal systems can put patients at high risk of skin impairment secondary to insufficient or imbalanced body movements. (Sensation, spinal cord injury, traumatic head injury, impaired mobility, impaired neurological function.)
Why do you want to assess the Hematologic System(health of blood itself) and Endocrine System when it comes to wound care?
Certain disease processes as well as medication side effects can impair wound healing. (Blood system, anemia, fluid and lectrolyte balance–muscle/cardiac firing, hepatitus, AIDS. BBPs)
Includes numerous glands and hormones which regulate body processes. (Hormone, DIABETES, Thyroid, blood sugar levels consistently over 200 inhibit healing)
