Hlten512b: Principles Of Health And Cultural Environment
CONTENTS:
INTRODUCTION………………………………………………………………..
HLTEN512B - IMPLEMENT AND MONITOR NURSING CARE FOR CLIENTS WITH ACUTE HEALTH PROBLEM……………………………..
HLTEN513B - IMPLEMENT AND MONITOR NURSING CARE FOR CLIENTS WITH CHRONIC HEALTH PROBLEMS………………………...
HLTEN506B - APPLY PRINCIPLES OF WOUND MANAGEMENT IN THE CLINICAL ENVIRONMENT……………………………………………..
CONCLUSION…………………………………………………………………....
REFERENCES…………………………………………………………………....
INTRODUCTION
Mr. XYZ, a fifty-eight year old, grocery store manager, had recently been waking up in the middle of the night with abdominal pain. This was happening several nights a week. My client was also experiencing occasional discomfort in the middle of the afternoon therefore, my client decided to schedule an appointment …show more content…
with his physician.
The doctor listened as Mr. XYZ described his symptoms and then asked him some questions. He noted that his appetite had suffered as a result of the pain he was experiencing and as a result of the fear that what he was eating may be responsible for the pain. Otherwise, Mr.XYZ seemed fine.
The doctor referred my client to a physician that specialized in internal medicine and had him to make an appointment for a procedure called an endoscopy. The endoscopy was performed at a hospital later that week. During the procedure, a long, thin tube was inserted into my client 's mouth and directed into his digestive tract. The end of the tube was equipped with a light source and a small camera which allowed the doctor to observe the interior of client’s stomach. The endoscope was also equipped with a small claw-like structure that the doctor could use in order to obtain a small tissue sample from the lining of client’s stomach, if required.
The endoscopy exposed that my client had a peptic ulcer. Analysis of a tissue sample taken from the site showed that client also had an infection that was caused by Helicobacter pyloribacteria. The doctor who performed the endoscopy gave Mr.XYZ prescriptions for two different antibiotics and a medication that would decrease the secretion of stomach acid. The doctor also instructed my client to schedule an appointment for another endoscopy procedure in 6 months.
HLTEN512B - IMPLEMENT AND MONITOR NURSING CARE FOR CLIENTS WITH ACUTE HEALTH PROBLEM
Introduction to Peptic Ulcer:
A peptic ulcer is a sore that occurs in the lining of a part of the gastrointestinal tract that is exposed to pepsin and acid secretions. Most peptic ulcers occur in the lining of the stomach or duodenum. 90% of all duodenal ulcers and 80% of all gastric ulcers are caused by H. pylori infection. Most of the remaining peptic ulcers are caused by long-term usage of certain anti-inflammatory medications like aspirin.
There is still some question as to how H. pylori is spread. However, H. pylori has been identified in the saliva of infected individuals and may be spread via this fluid. H. pylori bacteria have the ability to survive the acid environment in the stomach because they produce enzymes that neutralize stomach acids. They also have the ability to move through the mucous membrane lining the stomach or duodenum and take up residence in the underlying connective tissue. The damage to the mucous membrane that results from a H. pylori infection allows pepsin and hydrochloric acid to further damage the wall of the stomach or duodenum. The sore that results is the peptic ulcer.
Peptic ulcer disease refers to painful sores or ulcers in the lining of the stomach or first part of the small intestine, called the duodenum.
What Causes Peptic Ulcers?
No single cause has been found for ulcers. However, it is now clear that an ulcer is the end result of an imbalance between digestive fluids in the stomach and duodenum. Peptic Ulcers can be caused by:
Infection with a type of bacteria called Helicobacter pylori (H. pylori)
Use of painkillers called nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, naproxen (Aleve, Anaprox, Naprosyn, and others), ibuprofen (Motrin, Advil, Midol, and others), and many others available by prescription. Even safety-coated aspirin and aspirin in powered form can frequently cause ulcers.
Excess acid production from gastrinomas, tumors of the acid producing cells of the stomach that increases acid output (seen in Zollinger-Ellison syndrome). What Are the Symptoms of a Peptic Ulcer?
A peptic ulcer may or may not have symptoms. When symptoms occur, they may include:
A gnawing or burning pain in the middle or upper stomach between meals or at …show more content…
night
Bloating
Heartburn
Nausea or vomiting
In severe cases, symptoms can include:
Dark or black stool (due to bleeding)
Vomiting blood (that can look like "coffee-grounds")
Weight loss
Severe pain in the mid to upper abdomen
How Serious Is a Peptic Ulcer?
Though ulcers often heal on their own, you shouldn 't ignore their warning signs. If not properly treated, peptic ulcers can lead to serious health problems, including:
Bleeding
Perforation (a hole through the wall of the stomach)
Gastric outlet obstruction from swelling or scarring that blocks the passageway leading from the stomach to the small intestine.
Taking NSAIDs can cause any of the above symptoms without warning. The risk is especially concerning for the elderly and for those with a prior history of having peptic ulcer disease.[1]
Diagnosis of peptic ulcers
Your GP will ask about your symptoms and examine you. He or she may also ask you about your medical history. If your GP thinks you may have a peptic ulcer, he or she may recommend some of the following tests to diagnose you and decide what treatment will suit you best.
H. pylori test
As H. pylori is the most common cause of a peptic ulcer, GP may test patient for the bacterium and, if necessary, prescribe medicines to treat the infection.
H. pylori can be detected in a urea breath test. Patient will be asked to swallow a liquid containing a substance called urea that is broken down by H. pylori to produce water and carbon dioxide then breath of the client will then be tested using a machine for the amount of carbon dioxide in it. If the carbon dioxide is over a certain level, H. pylori is
present.
Alternatively a sample of blood or faeces of the patient will be sent to a laboratory to test for H. pylori.
Endoscopy
If anyone is suspected by peptic ulcer, GP may arrange a gastrointestinal endoscopy (also called a gastroscopy). Not everyone who has abdominal pain needs one, so GP may use one of the other tests first. However, endoscopy is the only way to be certain whether or not patient have a peptic ulcer.
An endoscopy is a procedure that allows a doctor to look at the inside of your body. The test is done using a narrow, flexible, tube-like telescopic camera called an endoscope that is passed through your mouth and into your stomach. The procedure usually lasts a few minutes.
Doctor will be able to see the lining of client 's stomach and can take a sample of stomach lining at the same time. This sample is either sent to a laboratory and examined under a microscope, or directly tested for H. pylori.
Treatment of peptic ulcers
Self-help
There are lifestyle changes that can help the patient to heal their ulcer and prevent them coming back. These include: cutting back or not having food and drink that give you more severe symptoms stopping smoking not taking painkillers that are likely to cause ulcers in the future – your GP or pharmacist can give you advice on other medicines you can take instead.
Medicines
There are two main groups of medicines available to treat symptoms of peptic ulcers. These are: proton pump inhibitors, such as omeprazole and lansoprazole
H2-blockers, such as ranitidine and famotidine.
Both types of medicine reduce acid production in the stomach, allowing your ulcer to heal.
These medicines will relieve symptoms of peptic ulcer and within a few weeks ulcer will heal. However, once patient stop taking the medicine, ulcer may come back unless the H. pylori has been treated and removed.
Treating H. pylori infection
If tests confirm that he/she has H. pylori, he/she will be prescribed medicines to treat it. This is usually a seven-day course of a proton pump inhibitor combined with two antibiotics. Treating the H. pylori infection should allow patient 's ulcer to heal and prevent it from coming back. GP will do the tests again after treatment to make sure it has been successful in getting rid of H. pylori.[2]
Peptic Ulcer- Planning for care
Before the admission of patient, admission data to the client was gathered and recorded. Then the client was admitted to the general ward after surgery and recovery ward. The surgeon had minimally invasive laparoscopic surgery for him. He had drain and IDC . The PCA morphine was created for him, but did not start. I was mentored with an RN and got delivery nurse recovery. Had a cannula in the left hand and runs Hartmanns 1000 ml . My RN and me had to take care of him. We immediately went to his room after delivery as we want to introduce and be familiar with the patient and his room orienting around. The plan and idea of their condition was required, therefore me and my RN write progress notes and discuss about it. My RN helped me to understand a lot of information about patient condition. For their patience optimal health outcomes have to make sure his condition is not degrading. We assess, report , and record signs and symptoms and reactions to treatment and monitor fluids input and output closely. We had to take care of your diet ,provide prescribed diet and avoid irritating foods, coffee, etc. and personal hygiene and care of pressure areas. The IDC was taken in the evening and cannula and drain the next day. We have had to administer their medications for acute and chronic problems of health. He was transferred to oral antibiotics once the cannula was removed. He had a wound dressing applied. We changed his dressing regularly in the morning until the dressing is kept dry and intact. After a few days, he was able to perform daily activities with minimal assistance and slowly independently. He was seen by the doctor and physiotherapist before being discharged.
Discharge planning was done for me and my RN on the fifth day . He was fit and ready to go home . We meet all your documents and reports and prepare the discharge report . His family was notified of his discharge.
HLTEN513B - IMPLEMENT AND MONITOR NURSING CARE FOR CLIENTS WITH CHRONIC HEALTH PROBLEMS
Introduction to Diabetes:
Diabetes mellitus (or diabetes) is a chronic, lifelong condition that affects your body 's ability to use the energy found in food. There are three major types of diabetes: type 1 diabetes, type 2 diabetes, and gestational diabetes.
All types of diabetes mellitus have something in common. Normally, your body breaks down the sugars and carbohydrates you eat into a special sugar called glucose. Glucose fuels the cells in your body. But the cells need insulin, a hormone, in your bloodstream in order to take in the glucose and use it for energy. With diabetes mellitus, either your body doesn 't make enough insulin, it can 't use the insulin it does produce, or a combination of both.
Since the cells can 't take in the glucose, it builds up in your blood. High levels of blood glucose can damage the tiny blood vessels in your kidneys, heart, eyes, or nervous system. That 's why diabetes -- especially if left untreated -- can eventually cause heart disease, stroke, kidney disease, blindness, and nerve damage to nerves in the feet.[3]
Types
Diabetes mellitus occurs in four forms classified by etiology: type 1, type 2, gestational diabetes mellitus, and other specific types. Here’s a breakdown of the types:
Type 1 diabetes is characterized by the lack of insulin production. It is formerly known as insulin-dependent or childhood-onset diabetes. Type 1 is further subdivided into immune-mediated diabetes and idiopathic diabetes. Children and adolescents with type 1 immune-mediated diabetes rapidly develop ketoacidosis, but most adults with this type experience only modest fasting hyperglycemia unless they develop and infection as another stressor. Patients with type 1 idiopathic diabetes are prone to ketoacidosis.
Type 2 diabetes is caused by the body’s ineffective use of insulin. It is previously called non-insulin dependent or adult-onset diabetes. Most patients with type 2 diabetes are obese.
Other specific types category includes people who have diabetes as a result of a genetic defect, endocrinopathies or exposure to certain drugs or chemicals.
Gestational diabetes mellitus (GDM) occurs during pregnancy. Glucose tolerance levels usually return to normal after delivery.[4]
Symptoms
People can often have diabetes and be completely unaware. The main reason for this is that the symptoms, when seen on their own, seem harmless. However, the earlier diabetes is diagnosed the greater the chances are that serious complications, which can result from having diabetes, can be avoided.
Here is a list of the most common diabetes symptoms:
Frequent urination
Have you been going to the bathroom to urinate more often recently? Do you notice that you spend most of the day going to the toilet? When there is too much glucose (sugar) in your blood you will urinate more often. If your insulin is ineffective, or not there at all, your kidneys cannot filter the glucose back into the blood. The kidneys will take water from your blood in order to dilute the glucose - which in turn fills up your bladder.
Disproportionate thirst
If you are urinating more than usual, you will need to replace that lost liquid. You will be drinking more than usual. Have you been drinking more than usual lately?
Intense hunger
As the insulin in your blood is not working properly, or is not there at all, and your cells are not getting their energy, your body may react by trying to find more energy - food. You will become hungry.
Weight gain
This might be the result of the above symptom (intense hunger).
Unusual weight loss
This is more common among people with Diabetes Type 1. As your body is not making insulin it will seek out another energy source (the cells aren 't getting glucose). Muscle tissue and fat will be broken down for energy. As Type 1 is of a more sudden onset and Type 2 is much more gradual, weight loss is more noticeable with Type 1.
Increased fatigue
If your insulin is not working properly, or is not there at all, glucose will not be entering your cells and providing them with energy. This will make you feel tired and listless.
Irritability
Irritability can be due to your lack of energy.
Blurred vision
This can be caused by tissue being pulled from your eye lenses. This affects your eyes ' ability to focus. With proper treatment this can be treated. There are severe cases where blindness or prolonged vision problems can occur.
Cuts and bruises don 't heal properly or quickly
Do you find cuts and bruises take a much longer time than usual to heal? When there is more sugar (glucose) in your body, its ability to heal can be undermined.
More skin and/or yeast infections
When there is more sugar in your body, its ability to recover from infections is affected. Women with diabetes find it especially difficult to recover from bladder and vaginal infections.
Itchy skin
A feeling of itchiness on your skin is sometimes a symptom of diabetes.
Gums are red and/or swollen - Gums pull away from teeth
If your gums are tender, red and/or swollen this could be a sign of diabetes. Your teeth could become loose as the gums pull away from them.
Frequent gum disease/infection
As well as the previous gum symptoms, you may experience more frequent gum disease and/or gum infections.
Sexual dysfunction among men
If you are over 50 and experience frequent or constant sexual dysfunction (erectile dysfunction), it could be a symptom of diabetes.
Numbness or tingling, especially in your feet and hands
If there is too much sugar in your body your nerves could become damaged, as could the tiny blood vessels that feed those nerves. You may experience tingling and/or numbness in your hands and feet.
Diagnosis of diabetes
Diabetes can often be detected by carrying out a urine test, which finds out whether excess glucose is present. This is normally backed up by a blood test, which measures blood glucose levels and can confirm if the cause of your symptoms is diabetes.
If you are worried that you may have some of the above symptoms, you are recommended to talk to your Doctor or a qualified health professional.[5]
Diabetes: Impact, Planning care for the client, Interventions and outcomes
My client was well aware of his chronic health condition and risks. Me and my RN had to make sure he was not taking much stress about his acute health problem which could worsen his chronic health condition. We were told by the client that he was trying his best to control his diabetes. We talked with the client, with his consent, about diabetes and gave him some useful suggestions too. We talked about the types of diabetes and its treatment.
All types of diabetes are treatable. Diabetes type 1 lasts a lifetime, there is no known cure. Type 2 usually lasts a lifetime; however, some people have managed to get rid of their symptoms without medication, through a combination of exercise, diet and body weight control.
Researchers from the Mayo Clinic Arizona in Scottsdale showed that gastric bypass surgery can reverse type 2 diabetes in a high proportion of patients. They added that within three to five years the disease recurs in approximately 21% of them. Yessica Ramos, MD, said "The recurrence rate was mainly influenced by a longstanding history of Type 2 diabetes before the surgery. This suggests that early surgical intervention in the obese, diabetic population will improve the durability of remission of Type 2 diabetes."
Patients with type 1 are treated with regular insulin injections, as well as a special diet and exercise.
Patients with Type 2 diabetes are usually treated with tablets, exercise and a special diet, but sometimes insulin injections are also required.
If diabetes is not adequately controlled the patient has a significantly higher risk of developing complications.
Nursing Intervention:
1) Monitor vital signs.
Rational: hypovolemia can be manifested by hypotension and tachycardia.
2) Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes.
Rational: This is an indicator of the level of dehydration, or an adequate circulating volume.
3) Monitor input and output, record the specific gravity of urine.
Rational: To provide estimates of the need for fluid replacement, renal function, and effectiveness of the therapy given.
4.) Measure weight every day.
Rational: To provide the best assessment of fluid status of ongoing and further to provide a replacement fluid.
5.) Provide fluid therapy as indicated.
Rational: The type and amount of liquid depends on the degree of lack of fluids and the response of individual patients.[6]
HLTEN506B - APPLY PRINCIPLES OF WOUND MANAGEMENT IN THE CLINICAL ENVIRONMENT
Introduction
The skin is the largest organ of the body, making up 16% of body weight. It has several vital functions, which include; immune function, temperature regulation, sensation and vitamin production. Skin is a dynamic organ in a constant state of change; cells of the outer layers continuously shed and are replaced by inner cells moving to the surface. These guidelines have been developed by a range of clinicians who treat children with skin disorders, breakdowns and wounds; they reflect current research and evidence based expert opinion.
Acute Wound:is the result of tissue damaged by trauma. This may be deliberate, as in surgical wounds of procedures, or be due to accidents caused by blunt force, projectiles, heat, electricity, chemicals or friction. An acute wound is by definition expected to progress through the phases of normal healing, resulting in the closure of the wound.
A Chronic Woundfails to progress or respond to treatment over the normal expected healing time frame (4 weeks) and becomes "stuck" in the inflammatory phase. Wound chronicity is attributed to the presence of intrinsic and extrinsic factors including medications, poor nutrition, co-morbidities or inappropriate dressing selection
Epidermis: Is the outer layer of the skin. comprised of epithelial cells avascular 0.04mm thick regenerated every 2-4weeks, subject to an individual 's age and friction forces applied to the skin receives nutrients from the dermis below comprised of 4 to 5 layers depending on the body location
Dermis: Is the middle layer of the skin and is approximately 0.5mm thick subject to anatomical site made up of two layers is very vascular contains nerves, connective tissue, collagen, elastin and specialized cells such as fibroblasts and mast cells responsible for inflammatory reactions which occur in response to trauma and infection receptors for heat, cold, pain, pressure, itch and tickle
Hypodermis: Is the inner most layer of the skin and is referred to as the subcutaneous layer supports the dermis and epidermis varies in thickness and depth comprised of adipose tissue, connective tissue and blood vessels the function is to store lipids, protect underlying organs, provide insulation and regulate temperature
Skin Appendages: Includes Sweat glands, hair, nails and sebaceous glands which are all considered epidermal appendages.
Infection
Wound infection may be defined as the presence of bacteria or other organisms, which lead to a host reaction. A host reaction can present with one or a combination of the following local and systemic clinical indicators:
Local indicators
Redness (erythema or cellulitis) around the wound
Increased amounts of exudate
Change in exudates colour
Malodour
Localised pain
Localised heat
Delayed or abnormal healing
Wound breakdown
2 Systemic indicators
Increased systemic temperature
General malaise
Increased leucocyte count
Lymphangitis
3 If any of the above clinical indicators are present medical review should be instigated and an Microscopy & Culture Wound Swab (MCS) should be considered
Types of Wounds throughout RCH
Acute Surgical Wounds
A clean cut with a sharp instrument which cuts or punctures the skin deliberately during a surgical procedure. Acute surgical wounds normally proceed through an orderly and timely reparative process resulting in sustained restoration of anatomic and functional integrity. If an acute wound fails to heal within six weeks, it can become a chronic wound.
Trauma Wounds
A stressful event caused by either a mechanical or a chemical injury resulting in tissue damage. Depending on its level, trauma can have serious short-term and long-term consequences.
Burns
Injuries to tissues caused by heat, friction, electricity, radiation, or chemicals. Burns may be caused by even a brief encounter with heat greater than 120°F (49°C). The source of this heat may be the sun , hot liquids, steam, fire, electricity, friction (causing rug burns and rope burns), and chemicals (causing a caustic burn upon contact).
Chronic Wounds
Fail to heal in an orderly and timely manner. The chronic wound environment is different to the acute wound environment. The clinical signs of chronic wounds may include:
Non viable wound tissue (slough and/or necrosis)
Lack of healthy granulation tissue (wound tissue may bepale, greyish and avascular)
No reduction in wound size over time
Recurrent wound breakdown
Pressure Injuries
A localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, shear and/or friction, or a combination of these factors.
Infected Wounds
Invasion of wound tissue by and multiplication of pathogenic microorganisms, which may produce subsequent tissue injury and progress to overt disease through a variety of cellular or toxic mechanisms
Management
Phases of Wound Healing to consider
Phase 1 - INFLAMMATORY PHASE (0-3 Days) the body 's normal response to injury. This phase activates vasodilatation leading to increased blood flow causing HEAT, REDNESS, PAIN, SWELLING, LOSS OF FUNCTION (e.g. arm swells and cannot bend). Wound ooze may be present and this is also a normal body response.
Phase 2 - PROLIFERATIVE PHASE (3-24 Days) the time when the wound is healing. The body makes new blood vessels, which cover the surface of the wound. This phase includes reconstruction and epithelialisation. The wound will become smaller as it heals.
Phase 3 - MATURATION PHASE (24-365 Days) the final phase of healing, when scar tissue is formed. The wound at this stage is still at risk and should be protected where possible.
Mechanisms of wound healing to consider
Primary Intention; most clean surgical wounds and recent traumatic injuries are managed by primary closure. The edges of the wounds are approximated with steri strips, glue, sutures and/or staples. Minimal loss of tissue and scarring results.
Delayed Primary Intention; is defined as the surgical closure of a wound 3 -5 days after the thorough cleansing or debridement of the wound bed. Used for 1. Traumatic wounds 2. Contaminated surgical wounds.
Secondary intention; occurs slowly by granulation, contraction and re-epithelialisation and results in scar formation. Commonly used for
1. Pressure Injuries
2. Leg ulcers
3. Dehisced wounds
Skin Graft; removal of partial or full thickness segment of epidermis and dermis from its blood supply and transplanting it to another site to speed up healing and reduce the risk of infection.
Flap; is a surgical relocation of skin and underlying structures to repair a wound
Acute Management
Documentation
It is an expectation that all aspects of care, including assessment, treatment and management plans, implementation and evaluation are documented clearly and comprehensively.
All wounds should be assessed regularly and outcomes of the assessment documented. A Wound Assessment and Treatment Chart can be used to monitor and record the progress of the wound through its stages of healing. Simple wound documentation can be captured in progress notes and treatment plans.
Wound cleansing
Requires the application of fluid to clean the wound and optimise the healing environment.
The goal of wound cleansing is to:
Remove visible debris and devitalised tissue
Remove dressing residue
Remove excessive or dry crusting exudates
Principles:
Use Aseptic Technique procedure
Wound cleansing should not be undertaken to remove 'normal ' exudate
Cleansing should be performed in a way that minimises trauma to the wound
Wounds are best cleansed with sterile isotonic saline or water
The less we disturb a wound during dressing changes the lower the interference to healing
Fluids should be warmed to 37°C to support cellular activity
Skin and wound cleansers should have a neutral pH and be non-toxic
Avoid alkaline soap on intact skin as the skin pH is altered, resistance to bacteria decreases
Avoid delipidising agents as alcohol or acetone as tissue is degraded
Antisepticsare not routinely recommended for cleansing and should only be used sparingly for infected wounds
Method:
Irrigation is the preferred method for cleansing open wounds. This may be carried out utilising a syringe in order to produce gentle pressure - in order to loosen debris. Gauze swabs and cotton wool should be used with caution as can cause mechanical damage to new tissue and the shedding of fibres from gauze swabs/cotton wool delays healing.
Choice of dressing
A wound will require different management and treatment at various stages of healing. No dressing is suitable for all wounds; therefore frequent assessment of the wound is required. Considerations when choosing dressing products -
Maintain a moist environment at the wound/dressing interface
Be able to control (remove) excess exudates. A moist wound environment is good, a wet environment is not beneficial
Not stick to the wound, shed fibres or cause trauma to the wound or surrounding tissue on removal
Protect the wound from the outside environment - bacterial barrier
Good adhesion to skin
Sterile
Aid debridement if there is necrotic or sloughy tissue in the wound (caution with ischaemic lesions)
Keep the wound close to normal body temperature
Conformable to body parts and doesn 't interfere with body function
Be cost-effective
Diabetes - choose dressings which allow frequent inspection
Non-flammable and non-toxic.[7]
Impact Planning and Wound Care:
The management of the wound is more or less similar for all types of injury. The main goal of management is to promote healing. The impact of the wound in a patient depends on the location of the wound, the wound size, how quickly the wound is healing , pain from the wound and etc. physiological and biochemical processes associated with wound management . Normal healing is promoted by all nursing care and proper wound management. Obviously for the patient to get a little worried about the pain and talk about the wound and its condition family members or others. A wound healing should not be emphasized enough that the condition could worsen and exudate can be seen, friction / rubbing against the wound should be completely avoided. If not properly treated and not treated, the wound might get more infected and the wound may not heal and can cause serious complications.
Planning may be necessary before taking care of the wound. Wound care always depends on the size, color, exudate, surrounding the wound. Right Select wound is also important. Wound swabs should be performed regularly check for infection and other wound exudate .
The patient must be notified about what is happening and what will happen. The patient must be guaranteed and encourage on wound healing, so they should be members of the family. Patient should receive knowledge about the performance of their ADL without giving stress and preventing wound healing. If the pain gets worse or patient needs the comfort of the wound, relief of pain and other pain management should be provided to the patient. Usually, antibiotics are given for a short period of time to prevent infection and once the positive response that ceased and so is the pain medication such as pain tolerance of the patient sample. Pressure zones is too vital to be taken care of while wound care. Pressure relieving device and the cream should be applied to ensure that the circulation well in the body parts. Wound should always be cleansed and purified by the solution of sterile water and dressing should be applied. The sutures, clips or drains are the other things that should be taken into account in wound care. Suture and clips require some attention because it keeps intact the wound and promote rapid healing. Some sutures disintegrate in the body, while some are being cut once the wound is reviewed by the physician and the wound is healing properly, making it the clips manually. Drains, on the other hand make sure that no bleeding or fluid from the surgical area and could take once there is minimal leakage and no risk of internal bleeding or fluid buildup . All accessories stained body fluids must be discarded in yellow biohazard container as politics and everything that is going on with the wound should be traced and documented and approved with each delivery.
Handling complex wounds / challenging and outcomes of nursing actions:
The wound management can be a complex area treatment, chronic wounds, acute wounds and surgical wounds each have their own characteristics ; but wounds , like those affected by them, must be treated individually. Each wound is different and requires different levels of attention and care. Some require monitoring and change of dressing according to the size, number and exudate be regular. Wounds may or may not have drains. Depending on the level of infection is chosen. There dressing are several dressing for complex wound VAC dressing ALLEVYN dressing DURAFIBRE dressing or bandage just as the severity of the injury and the risk of infection and need to promote healing. Dressing in a complex wound could be slow and difficult, but dressing right help in healing and wound closure.
Therapy Negative Pressure Wound ( TPN ) is one of the oldest forms of medical therapy used to cure the human body. During the last decade there has been a significant increase in the use of this therapy and today TPN provides physicians with an important option for advanced management of a variety of chronic and acute wounds. [8]
With all nursing care and care for the wound healing is promoted and signs of healing can be seen with swelling, redness down, pain control, etc. Usually, the patient will talk through their care and if is helping with the pain and the condition of the wound. The effectiveness of nursing care will be determined by those chosen to care for and the technique used for wound care products. Contemporary treatment of wounds in collaboration with members of the health team usually results in effective wound management that is cost effective and easy. Documentation is a necessity and the wound is to be reviewed by the physician on the regular basis.
CONCLUSION
My Client named Mr. XYZ, a fifty-eight year old was recently administered in the hospital due to peptic ulcer which is acute disease in my case study. He had history of diabetes mellitus, which was chronic disease. The endoscopy was performed to the patient at a hospital. The endoscopy exposed that my client had a peptic ulcer. A peptic ulcer is a sore that occurs in the lining of a part of the gastrointestinal tract that is exposed to pepsin and acid secretions. A peptic ulcer may or may not have symptoms. A gnawing or burning pain in the middle or upper stomach between meals or at night is some of the symptoms of peptic ulcer. My client was also well aware of his chronic health condition and risks. We talked with the client, with his consent, about diabetes and gave him some useful suggestions too. We talked about the types of diabetes and its treatment. The client was admitted into the general ward after the surgery and recovery ward. He had a cannula in his left hand and Hartmanns 1000 ml was running. I and my RN had to take care of him in every possible way. We wrote the progress notes and discussed about him. The IDC was taken out the next morning and the cannula and the drain the day after. . After a few day, he was able to perform ADLs with minimal assist and gradually independently. He was seen by the doctor and the physiotherapist before he was discharged.
REFERENCES
1) Digestive Disorders Health Center, Accessed on 2014, from http://www.webmd.com/digestive-disorders/digestive-diseases-peptic-ulcer-disease.
2) Peptic ulcer, Reviewed on 30 July 2011, from http://www.bupa.com.au/health-and-wellness/health-information/az-health-information/peptic-ulcers.
3) Diabetes Health Center, Accessed on 2014, from http://www. webmd.com/diabetes/types-of-diabetes-mellitus.
4) Diabetes Mellitus Nursing Care Plans, Reviewed on 2014, from http://nurseslabs.com/6-diabetes-mellitus-nursing-care-plans/, 6 Diabetes Mellitus Nursing Care Plans - Nurseslabs.
5) What is Diabetes? What causes Diabetes?, from www.medicalnewstoday.com/info/diabetes/
6) Nursing Care Plan Diabetes Mellitus – Reviewed on Apr 12, 2012, from nanda-nursinginterventions.blogspot.com/.../3-nursing-care-plan-diabete... 7) Clinical Guidelines (Nursing): Wound care, Accessed on April 2012, from http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Wound_care/
8) Advanced Wound Management, Accessed on 24 November 2014, from http://www.smith-nephew.com/australia/about-us/what-we-do/advanced-wound-management/
INTRODUCTION………………………………………………………………..
HLTEN512B - IMPLEMENT AND MONITOR NURSING CARE FOR CLIENTS WITH ACUTE HEALTH PROBLEM……………………………..
HLTEN513B - IMPLEMENT AND MONITOR NURSING CARE FOR CLIENTS WITH CHRONIC HEALTH PROBLEMS………………………...
HLTEN506B - APPLY PRINCIPLES OF WOUND MANAGEMENT IN THE CLINICAL ENVIRONMENT……………………………………………..
CONCLUSION…………………………………………………………………....
REFERENCES…………………………………………………………………....
INTRODUCTION
Mr. XYZ, a fifty-eight year old, grocery store manager, had recently been waking up in the middle of the night with abdominal pain. This was happening several nights a week. My client was also experiencing occasional discomfort in the middle of the afternoon therefore, my client decided to schedule an appointment …show more content…
with his physician.
The doctor listened as Mr. XYZ described his symptoms and then asked him some questions. He noted that his appetite had suffered as a result of the pain he was experiencing and as a result of the fear that what he was eating may be responsible for the pain. Otherwise, Mr.XYZ seemed fine.
The doctor referred my client to a physician that specialized in internal medicine and had him to make an appointment for a procedure called an endoscopy. The endoscopy was performed at a hospital later that week. During the procedure, a long, thin tube was inserted into my client 's mouth and directed into his digestive tract. The end of the tube was equipped with a light source and a small camera which allowed the doctor to observe the interior of client’s stomach. The endoscope was also equipped with a small claw-like structure that the doctor could use in order to obtain a small tissue sample from the lining of client’s stomach, if required.
The endoscopy exposed that my client had a peptic ulcer. Analysis of a tissue sample taken from the site showed that client also had an infection that was caused by Helicobacter pyloribacteria. The doctor who performed the endoscopy gave Mr.XYZ prescriptions for two different antibiotics and a medication that would decrease the secretion of stomach acid. The doctor also instructed my client to schedule an appointment for another endoscopy procedure in 6 months.
HLTEN512B - IMPLEMENT AND MONITOR NURSING CARE FOR CLIENTS WITH ACUTE HEALTH PROBLEM
Introduction to Peptic Ulcer:
A peptic ulcer is a sore that occurs in the lining of a part of the gastrointestinal tract that is exposed to pepsin and acid secretions. Most peptic ulcers occur in the lining of the stomach or duodenum. 90% of all duodenal ulcers and 80% of all gastric ulcers are caused by H. pylori infection. Most of the remaining peptic ulcers are caused by long-term usage of certain anti-inflammatory medications like aspirin.
There is still some question as to how H. pylori is spread. However, H. pylori has been identified in the saliva of infected individuals and may be spread via this fluid. H. pylori bacteria have the ability to survive the acid environment in the stomach because they produce enzymes that neutralize stomach acids. They also have the ability to move through the mucous membrane lining the stomach or duodenum and take up residence in the underlying connective tissue. The damage to the mucous membrane that results from a H. pylori infection allows pepsin and hydrochloric acid to further damage the wall of the stomach or duodenum. The sore that results is the peptic ulcer.
Peptic ulcer disease refers to painful sores or ulcers in the lining of the stomach or first part of the small intestine, called the duodenum.
What Causes Peptic Ulcers?
No single cause has been found for ulcers. However, it is now clear that an ulcer is the end result of an imbalance between digestive fluids in the stomach and duodenum. Peptic Ulcers can be caused by:
Infection with a type of bacteria called Helicobacter pylori (H. pylori)
Use of painkillers called nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, naproxen (Aleve, Anaprox, Naprosyn, and others), ibuprofen (Motrin, Advil, Midol, and others), and many others available by prescription. Even safety-coated aspirin and aspirin in powered form can frequently cause ulcers.
Excess acid production from gastrinomas, tumors of the acid producing cells of the stomach that increases acid output (seen in Zollinger-Ellison syndrome). What Are the Symptoms of a Peptic Ulcer?
A peptic ulcer may or may not have symptoms. When symptoms occur, they may include:
A gnawing or burning pain in the middle or upper stomach between meals or at …show more content…
night
Bloating
Heartburn
Nausea or vomiting
In severe cases, symptoms can include:
Dark or black stool (due to bleeding)
Vomiting blood (that can look like "coffee-grounds")
Weight loss
Severe pain in the mid to upper abdomen
How Serious Is a Peptic Ulcer?
Though ulcers often heal on their own, you shouldn 't ignore their warning signs. If not properly treated, peptic ulcers can lead to serious health problems, including:
Bleeding
Perforation (a hole through the wall of the stomach)
Gastric outlet obstruction from swelling or scarring that blocks the passageway leading from the stomach to the small intestine.
Taking NSAIDs can cause any of the above symptoms without warning. The risk is especially concerning for the elderly and for those with a prior history of having peptic ulcer disease.[1]
Diagnosis of peptic ulcers
Your GP will ask about your symptoms and examine you. He or she may also ask you about your medical history. If your GP thinks you may have a peptic ulcer, he or she may recommend some of the following tests to diagnose you and decide what treatment will suit you best.
H. pylori test
As H. pylori is the most common cause of a peptic ulcer, GP may test patient for the bacterium and, if necessary, prescribe medicines to treat the infection.
H. pylori can be detected in a urea breath test. Patient will be asked to swallow a liquid containing a substance called urea that is broken down by H. pylori to produce water and carbon dioxide then breath of the client will then be tested using a machine for the amount of carbon dioxide in it. If the carbon dioxide is over a certain level, H. pylori is
present.
Alternatively a sample of blood or faeces of the patient will be sent to a laboratory to test for H. pylori.
Endoscopy
If anyone is suspected by peptic ulcer, GP may arrange a gastrointestinal endoscopy (also called a gastroscopy). Not everyone who has abdominal pain needs one, so GP may use one of the other tests first. However, endoscopy is the only way to be certain whether or not patient have a peptic ulcer.
An endoscopy is a procedure that allows a doctor to look at the inside of your body. The test is done using a narrow, flexible, tube-like telescopic camera called an endoscope that is passed through your mouth and into your stomach. The procedure usually lasts a few minutes.
Doctor will be able to see the lining of client 's stomach and can take a sample of stomach lining at the same time. This sample is either sent to a laboratory and examined under a microscope, or directly tested for H. pylori.
Treatment of peptic ulcers
Self-help
There are lifestyle changes that can help the patient to heal their ulcer and prevent them coming back. These include: cutting back or not having food and drink that give you more severe symptoms stopping smoking not taking painkillers that are likely to cause ulcers in the future – your GP or pharmacist can give you advice on other medicines you can take instead.
Medicines
There are two main groups of medicines available to treat symptoms of peptic ulcers. These are: proton pump inhibitors, such as omeprazole and lansoprazole
H2-blockers, such as ranitidine and famotidine.
Both types of medicine reduce acid production in the stomach, allowing your ulcer to heal.
These medicines will relieve symptoms of peptic ulcer and within a few weeks ulcer will heal. However, once patient stop taking the medicine, ulcer may come back unless the H. pylori has been treated and removed.
Treating H. pylori infection
If tests confirm that he/she has H. pylori, he/she will be prescribed medicines to treat it. This is usually a seven-day course of a proton pump inhibitor combined with two antibiotics. Treating the H. pylori infection should allow patient 's ulcer to heal and prevent it from coming back. GP will do the tests again after treatment to make sure it has been successful in getting rid of H. pylori.[2]
Peptic Ulcer- Planning for care
Before the admission of patient, admission data to the client was gathered and recorded. Then the client was admitted to the general ward after surgery and recovery ward. The surgeon had minimally invasive laparoscopic surgery for him. He had drain and IDC . The PCA morphine was created for him, but did not start. I was mentored with an RN and got delivery nurse recovery. Had a cannula in the left hand and runs Hartmanns 1000 ml . My RN and me had to take care of him. We immediately went to his room after delivery as we want to introduce and be familiar with the patient and his room orienting around. The plan and idea of their condition was required, therefore me and my RN write progress notes and discuss about it. My RN helped me to understand a lot of information about patient condition. For their patience optimal health outcomes have to make sure his condition is not degrading. We assess, report , and record signs and symptoms and reactions to treatment and monitor fluids input and output closely. We had to take care of your diet ,provide prescribed diet and avoid irritating foods, coffee, etc. and personal hygiene and care of pressure areas. The IDC was taken in the evening and cannula and drain the next day. We have had to administer their medications for acute and chronic problems of health. He was transferred to oral antibiotics once the cannula was removed. He had a wound dressing applied. We changed his dressing regularly in the morning until the dressing is kept dry and intact. After a few days, he was able to perform daily activities with minimal assistance and slowly independently. He was seen by the doctor and physiotherapist before being discharged.
Discharge planning was done for me and my RN on the fifth day . He was fit and ready to go home . We meet all your documents and reports and prepare the discharge report . His family was notified of his discharge.
HLTEN513B - IMPLEMENT AND MONITOR NURSING CARE FOR CLIENTS WITH CHRONIC HEALTH PROBLEMS
Introduction to Diabetes:
Diabetes mellitus (or diabetes) is a chronic, lifelong condition that affects your body 's ability to use the energy found in food. There are three major types of diabetes: type 1 diabetes, type 2 diabetes, and gestational diabetes.
All types of diabetes mellitus have something in common. Normally, your body breaks down the sugars and carbohydrates you eat into a special sugar called glucose. Glucose fuels the cells in your body. But the cells need insulin, a hormone, in your bloodstream in order to take in the glucose and use it for energy. With diabetes mellitus, either your body doesn 't make enough insulin, it can 't use the insulin it does produce, or a combination of both.
Since the cells can 't take in the glucose, it builds up in your blood. High levels of blood glucose can damage the tiny blood vessels in your kidneys, heart, eyes, or nervous system. That 's why diabetes -- especially if left untreated -- can eventually cause heart disease, stroke, kidney disease, blindness, and nerve damage to nerves in the feet.[3]
Types
Diabetes mellitus occurs in four forms classified by etiology: type 1, type 2, gestational diabetes mellitus, and other specific types. Here’s a breakdown of the types:
Type 1 diabetes is characterized by the lack of insulin production. It is formerly known as insulin-dependent or childhood-onset diabetes. Type 1 is further subdivided into immune-mediated diabetes and idiopathic diabetes. Children and adolescents with type 1 immune-mediated diabetes rapidly develop ketoacidosis, but most adults with this type experience only modest fasting hyperglycemia unless they develop and infection as another stressor. Patients with type 1 idiopathic diabetes are prone to ketoacidosis.
Type 2 diabetes is caused by the body’s ineffective use of insulin. It is previously called non-insulin dependent or adult-onset diabetes. Most patients with type 2 diabetes are obese.
Other specific types category includes people who have diabetes as a result of a genetic defect, endocrinopathies or exposure to certain drugs or chemicals.
Gestational diabetes mellitus (GDM) occurs during pregnancy. Glucose tolerance levels usually return to normal after delivery.[4]
Symptoms
People can often have diabetes and be completely unaware. The main reason for this is that the symptoms, when seen on their own, seem harmless. However, the earlier diabetes is diagnosed the greater the chances are that serious complications, which can result from having diabetes, can be avoided.
Here is a list of the most common diabetes symptoms:
Frequent urination
Have you been going to the bathroom to urinate more often recently? Do you notice that you spend most of the day going to the toilet? When there is too much glucose (sugar) in your blood you will urinate more often. If your insulin is ineffective, or not there at all, your kidneys cannot filter the glucose back into the blood. The kidneys will take water from your blood in order to dilute the glucose - which in turn fills up your bladder.
Disproportionate thirst
If you are urinating more than usual, you will need to replace that lost liquid. You will be drinking more than usual. Have you been drinking more than usual lately?
Intense hunger
As the insulin in your blood is not working properly, or is not there at all, and your cells are not getting their energy, your body may react by trying to find more energy - food. You will become hungry.
Weight gain
This might be the result of the above symptom (intense hunger).
Unusual weight loss
This is more common among people with Diabetes Type 1. As your body is not making insulin it will seek out another energy source (the cells aren 't getting glucose). Muscle tissue and fat will be broken down for energy. As Type 1 is of a more sudden onset and Type 2 is much more gradual, weight loss is more noticeable with Type 1.
Increased fatigue
If your insulin is not working properly, or is not there at all, glucose will not be entering your cells and providing them with energy. This will make you feel tired and listless.
Irritability
Irritability can be due to your lack of energy.
Blurred vision
This can be caused by tissue being pulled from your eye lenses. This affects your eyes ' ability to focus. With proper treatment this can be treated. There are severe cases where blindness or prolonged vision problems can occur.
Cuts and bruises don 't heal properly or quickly
Do you find cuts and bruises take a much longer time than usual to heal? When there is more sugar (glucose) in your body, its ability to heal can be undermined.
More skin and/or yeast infections
When there is more sugar in your body, its ability to recover from infections is affected. Women with diabetes find it especially difficult to recover from bladder and vaginal infections.
Itchy skin
A feeling of itchiness on your skin is sometimes a symptom of diabetes.
Gums are red and/or swollen - Gums pull away from teeth
If your gums are tender, red and/or swollen this could be a sign of diabetes. Your teeth could become loose as the gums pull away from them.
Frequent gum disease/infection
As well as the previous gum symptoms, you may experience more frequent gum disease and/or gum infections.
Sexual dysfunction among men
If you are over 50 and experience frequent or constant sexual dysfunction (erectile dysfunction), it could be a symptom of diabetes.
Numbness or tingling, especially in your feet and hands
If there is too much sugar in your body your nerves could become damaged, as could the tiny blood vessels that feed those nerves. You may experience tingling and/or numbness in your hands and feet.
Diagnosis of diabetes
Diabetes can often be detected by carrying out a urine test, which finds out whether excess glucose is present. This is normally backed up by a blood test, which measures blood glucose levels and can confirm if the cause of your symptoms is diabetes.
If you are worried that you may have some of the above symptoms, you are recommended to talk to your Doctor or a qualified health professional.[5]
Diabetes: Impact, Planning care for the client, Interventions and outcomes
My client was well aware of his chronic health condition and risks. Me and my RN had to make sure he was not taking much stress about his acute health problem which could worsen his chronic health condition. We were told by the client that he was trying his best to control his diabetes. We talked with the client, with his consent, about diabetes and gave him some useful suggestions too. We talked about the types of diabetes and its treatment.
All types of diabetes are treatable. Diabetes type 1 lasts a lifetime, there is no known cure. Type 2 usually lasts a lifetime; however, some people have managed to get rid of their symptoms without medication, through a combination of exercise, diet and body weight control.
Researchers from the Mayo Clinic Arizona in Scottsdale showed that gastric bypass surgery can reverse type 2 diabetes in a high proportion of patients. They added that within three to five years the disease recurs in approximately 21% of them. Yessica Ramos, MD, said "The recurrence rate was mainly influenced by a longstanding history of Type 2 diabetes before the surgery. This suggests that early surgical intervention in the obese, diabetic population will improve the durability of remission of Type 2 diabetes."
Patients with type 1 are treated with regular insulin injections, as well as a special diet and exercise.
Patients with Type 2 diabetes are usually treated with tablets, exercise and a special diet, but sometimes insulin injections are also required.
If diabetes is not adequately controlled the patient has a significantly higher risk of developing complications.
Nursing Intervention:
1) Monitor vital signs.
Rational: hypovolemia can be manifested by hypotension and tachycardia.
2) Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes.
Rational: This is an indicator of the level of dehydration, or an adequate circulating volume.
3) Monitor input and output, record the specific gravity of urine.
Rational: To provide estimates of the need for fluid replacement, renal function, and effectiveness of the therapy given.
4.) Measure weight every day.
Rational: To provide the best assessment of fluid status of ongoing and further to provide a replacement fluid.
5.) Provide fluid therapy as indicated.
Rational: The type and amount of liquid depends on the degree of lack of fluids and the response of individual patients.[6]
HLTEN506B - APPLY PRINCIPLES OF WOUND MANAGEMENT IN THE CLINICAL ENVIRONMENT
Introduction
The skin is the largest organ of the body, making up 16% of body weight. It has several vital functions, which include; immune function, temperature regulation, sensation and vitamin production. Skin is a dynamic organ in a constant state of change; cells of the outer layers continuously shed and are replaced by inner cells moving to the surface. These guidelines have been developed by a range of clinicians who treat children with skin disorders, breakdowns and wounds; they reflect current research and evidence based expert opinion.
Acute Wound:is the result of tissue damaged by trauma. This may be deliberate, as in surgical wounds of procedures, or be due to accidents caused by blunt force, projectiles, heat, electricity, chemicals or friction. An acute wound is by definition expected to progress through the phases of normal healing, resulting in the closure of the wound.
A Chronic Woundfails to progress or respond to treatment over the normal expected healing time frame (4 weeks) and becomes "stuck" in the inflammatory phase. Wound chronicity is attributed to the presence of intrinsic and extrinsic factors including medications, poor nutrition, co-morbidities or inappropriate dressing selection
Epidermis: Is the outer layer of the skin. comprised of epithelial cells avascular 0.04mm thick regenerated every 2-4weeks, subject to an individual 's age and friction forces applied to the skin receives nutrients from the dermis below comprised of 4 to 5 layers depending on the body location
Dermis: Is the middle layer of the skin and is approximately 0.5mm thick subject to anatomical site made up of two layers is very vascular contains nerves, connective tissue, collagen, elastin and specialized cells such as fibroblasts and mast cells responsible for inflammatory reactions which occur in response to trauma and infection receptors for heat, cold, pain, pressure, itch and tickle
Hypodermis: Is the inner most layer of the skin and is referred to as the subcutaneous layer supports the dermis and epidermis varies in thickness and depth comprised of adipose tissue, connective tissue and blood vessels the function is to store lipids, protect underlying organs, provide insulation and regulate temperature
Skin Appendages: Includes Sweat glands, hair, nails and sebaceous glands which are all considered epidermal appendages.
Infection
Wound infection may be defined as the presence of bacteria or other organisms, which lead to a host reaction. A host reaction can present with one or a combination of the following local and systemic clinical indicators:
Local indicators
Redness (erythema or cellulitis) around the wound
Increased amounts of exudate
Change in exudates colour
Malodour
Localised pain
Localised heat
Delayed or abnormal healing
Wound breakdown
2 Systemic indicators
Increased systemic temperature
General malaise
Increased leucocyte count
Lymphangitis
3 If any of the above clinical indicators are present medical review should be instigated and an Microscopy & Culture Wound Swab (MCS) should be considered
Types of Wounds throughout RCH
Acute Surgical Wounds
A clean cut with a sharp instrument which cuts or punctures the skin deliberately during a surgical procedure. Acute surgical wounds normally proceed through an orderly and timely reparative process resulting in sustained restoration of anatomic and functional integrity. If an acute wound fails to heal within six weeks, it can become a chronic wound.
Trauma Wounds
A stressful event caused by either a mechanical or a chemical injury resulting in tissue damage. Depending on its level, trauma can have serious short-term and long-term consequences.
Burns
Injuries to tissues caused by heat, friction, electricity, radiation, or chemicals. Burns may be caused by even a brief encounter with heat greater than 120°F (49°C). The source of this heat may be the sun , hot liquids, steam, fire, electricity, friction (causing rug burns and rope burns), and chemicals (causing a caustic burn upon contact).
Chronic Wounds
Fail to heal in an orderly and timely manner. The chronic wound environment is different to the acute wound environment. The clinical signs of chronic wounds may include:
Non viable wound tissue (slough and/or necrosis)
Lack of healthy granulation tissue (wound tissue may bepale, greyish and avascular)
No reduction in wound size over time
Recurrent wound breakdown
Pressure Injuries
A localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, shear and/or friction, or a combination of these factors.
Infected Wounds
Invasion of wound tissue by and multiplication of pathogenic microorganisms, which may produce subsequent tissue injury and progress to overt disease through a variety of cellular or toxic mechanisms
Management
Phases of Wound Healing to consider
Phase 1 - INFLAMMATORY PHASE (0-3 Days) the body 's normal response to injury. This phase activates vasodilatation leading to increased blood flow causing HEAT, REDNESS, PAIN, SWELLING, LOSS OF FUNCTION (e.g. arm swells and cannot bend). Wound ooze may be present and this is also a normal body response.
Phase 2 - PROLIFERATIVE PHASE (3-24 Days) the time when the wound is healing. The body makes new blood vessels, which cover the surface of the wound. This phase includes reconstruction and epithelialisation. The wound will become smaller as it heals.
Phase 3 - MATURATION PHASE (24-365 Days) the final phase of healing, when scar tissue is formed. The wound at this stage is still at risk and should be protected where possible.
Mechanisms of wound healing to consider
Primary Intention; most clean surgical wounds and recent traumatic injuries are managed by primary closure. The edges of the wounds are approximated with steri strips, glue, sutures and/or staples. Minimal loss of tissue and scarring results.
Delayed Primary Intention; is defined as the surgical closure of a wound 3 -5 days after the thorough cleansing or debridement of the wound bed. Used for 1. Traumatic wounds 2. Contaminated surgical wounds.
Secondary intention; occurs slowly by granulation, contraction and re-epithelialisation and results in scar formation. Commonly used for
1. Pressure Injuries
2. Leg ulcers
3. Dehisced wounds
Skin Graft; removal of partial or full thickness segment of epidermis and dermis from its blood supply and transplanting it to another site to speed up healing and reduce the risk of infection.
Flap; is a surgical relocation of skin and underlying structures to repair a wound
Acute Management
Documentation
It is an expectation that all aspects of care, including assessment, treatment and management plans, implementation and evaluation are documented clearly and comprehensively.
All wounds should be assessed regularly and outcomes of the assessment documented. A Wound Assessment and Treatment Chart can be used to monitor and record the progress of the wound through its stages of healing. Simple wound documentation can be captured in progress notes and treatment plans.
Wound cleansing
Requires the application of fluid to clean the wound and optimise the healing environment.
The goal of wound cleansing is to:
Remove visible debris and devitalised tissue
Remove dressing residue
Remove excessive or dry crusting exudates
Principles:
Use Aseptic Technique procedure
Wound cleansing should not be undertaken to remove 'normal ' exudate
Cleansing should be performed in a way that minimises trauma to the wound
Wounds are best cleansed with sterile isotonic saline or water
The less we disturb a wound during dressing changes the lower the interference to healing
Fluids should be warmed to 37°C to support cellular activity
Skin and wound cleansers should have a neutral pH and be non-toxic
Avoid alkaline soap on intact skin as the skin pH is altered, resistance to bacteria decreases
Avoid delipidising agents as alcohol or acetone as tissue is degraded
Antisepticsare not routinely recommended for cleansing and should only be used sparingly for infected wounds
Method:
Irrigation is the preferred method for cleansing open wounds. This may be carried out utilising a syringe in order to produce gentle pressure - in order to loosen debris. Gauze swabs and cotton wool should be used with caution as can cause mechanical damage to new tissue and the shedding of fibres from gauze swabs/cotton wool delays healing.
Choice of dressing
A wound will require different management and treatment at various stages of healing. No dressing is suitable for all wounds; therefore frequent assessment of the wound is required. Considerations when choosing dressing products -
Maintain a moist environment at the wound/dressing interface
Be able to control (remove) excess exudates. A moist wound environment is good, a wet environment is not beneficial
Not stick to the wound, shed fibres or cause trauma to the wound or surrounding tissue on removal
Protect the wound from the outside environment - bacterial barrier
Good adhesion to skin
Sterile
Aid debridement if there is necrotic or sloughy tissue in the wound (caution with ischaemic lesions)
Keep the wound close to normal body temperature
Conformable to body parts and doesn 't interfere with body function
Be cost-effective
Diabetes - choose dressings which allow frequent inspection
Non-flammable and non-toxic.[7]
Impact Planning and Wound Care:
The management of the wound is more or less similar for all types of injury. The main goal of management is to promote healing. The impact of the wound in a patient depends on the location of the wound, the wound size, how quickly the wound is healing , pain from the wound and etc. physiological and biochemical processes associated with wound management . Normal healing is promoted by all nursing care and proper wound management. Obviously for the patient to get a little worried about the pain and talk about the wound and its condition family members or others. A wound healing should not be emphasized enough that the condition could worsen and exudate can be seen, friction / rubbing against the wound should be completely avoided. If not properly treated and not treated, the wound might get more infected and the wound may not heal and can cause serious complications.
Planning may be necessary before taking care of the wound. Wound care always depends on the size, color, exudate, surrounding the wound. Right Select wound is also important. Wound swabs should be performed regularly check for infection and other wound exudate .
The patient must be notified about what is happening and what will happen. The patient must be guaranteed and encourage on wound healing, so they should be members of the family. Patient should receive knowledge about the performance of their ADL without giving stress and preventing wound healing. If the pain gets worse or patient needs the comfort of the wound, relief of pain and other pain management should be provided to the patient. Usually, antibiotics are given for a short period of time to prevent infection and once the positive response that ceased and so is the pain medication such as pain tolerance of the patient sample. Pressure zones is too vital to be taken care of while wound care. Pressure relieving device and the cream should be applied to ensure that the circulation well in the body parts. Wound should always be cleansed and purified by the solution of sterile water and dressing should be applied. The sutures, clips or drains are the other things that should be taken into account in wound care. Suture and clips require some attention because it keeps intact the wound and promote rapid healing. Some sutures disintegrate in the body, while some are being cut once the wound is reviewed by the physician and the wound is healing properly, making it the clips manually. Drains, on the other hand make sure that no bleeding or fluid from the surgical area and could take once there is minimal leakage and no risk of internal bleeding or fluid buildup . All accessories stained body fluids must be discarded in yellow biohazard container as politics and everything that is going on with the wound should be traced and documented and approved with each delivery.
Handling complex wounds / challenging and outcomes of nursing actions:
The wound management can be a complex area treatment, chronic wounds, acute wounds and surgical wounds each have their own characteristics ; but wounds , like those affected by them, must be treated individually. Each wound is different and requires different levels of attention and care. Some require monitoring and change of dressing according to the size, number and exudate be regular. Wounds may or may not have drains. Depending on the level of infection is chosen. There dressing are several dressing for complex wound VAC dressing ALLEVYN dressing DURAFIBRE dressing or bandage just as the severity of the injury and the risk of infection and need to promote healing. Dressing in a complex wound could be slow and difficult, but dressing right help in healing and wound closure.
Therapy Negative Pressure Wound ( TPN ) is one of the oldest forms of medical therapy used to cure the human body. During the last decade there has been a significant increase in the use of this therapy and today TPN provides physicians with an important option for advanced management of a variety of chronic and acute wounds. [8]
With all nursing care and care for the wound healing is promoted and signs of healing can be seen with swelling, redness down, pain control, etc. Usually, the patient will talk through their care and if is helping with the pain and the condition of the wound. The effectiveness of nursing care will be determined by those chosen to care for and the technique used for wound care products. Contemporary treatment of wounds in collaboration with members of the health team usually results in effective wound management that is cost effective and easy. Documentation is a necessity and the wound is to be reviewed by the physician on the regular basis.
CONCLUSION
My Client named Mr. XYZ, a fifty-eight year old was recently administered in the hospital due to peptic ulcer which is acute disease in my case study. He had history of diabetes mellitus, which was chronic disease. The endoscopy was performed to the patient at a hospital. The endoscopy exposed that my client had a peptic ulcer. A peptic ulcer is a sore that occurs in the lining of a part of the gastrointestinal tract that is exposed to pepsin and acid secretions. A peptic ulcer may or may not have symptoms. A gnawing or burning pain in the middle or upper stomach between meals or at night is some of the symptoms of peptic ulcer. My client was also well aware of his chronic health condition and risks. We talked with the client, with his consent, about diabetes and gave him some useful suggestions too. We talked about the types of diabetes and its treatment. The client was admitted into the general ward after the surgery and recovery ward. He had a cannula in his left hand and Hartmanns 1000 ml was running. I and my RN had to take care of him in every possible way. We wrote the progress notes and discussed about him. The IDC was taken out the next morning and the cannula and the drain the day after. . After a few day, he was able to perform ADLs with minimal assist and gradually independently. He was seen by the doctor and the physiotherapist before he was discharged.
REFERENCES
1) Digestive Disorders Health Center, Accessed on 2014, from http://www.webmd.com/digestive-disorders/digestive-diseases-peptic-ulcer-disease.
2) Peptic ulcer, Reviewed on 30 July 2011, from http://www.bupa.com.au/health-and-wellness/health-information/az-health-information/peptic-ulcers.
3) Diabetes Health Center, Accessed on 2014, from http://www. webmd.com/diabetes/types-of-diabetes-mellitus.
4) Diabetes Mellitus Nursing Care Plans, Reviewed on 2014, from http://nurseslabs.com/6-diabetes-mellitus-nursing-care-plans/, 6 Diabetes Mellitus Nursing Care Plans - Nurseslabs.
5) What is Diabetes? What causes Diabetes?, from www.medicalnewstoday.com/info/diabetes/
6) Nursing Care Plan Diabetes Mellitus – Reviewed on Apr 12, 2012, from nanda-nursinginterventions.blogspot.com/.../3-nursing-care-plan-diabete... 7) Clinical Guidelines (Nursing): Wound care, Accessed on April 2012, from http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Wound_care/
8) Advanced Wound Management, Accessed on 24 November 2014, from http://www.smith-nephew.com/australia/about-us/what-we-do/advanced-wound-management/