a nurse is caring for a patient who is admitted with multiple wounds This is a topic that many people are looking for. bluevelvetrestaurant.com is a channel providing useful information about learning, life, digital marketing and online courses …. it will help you have an overview and solid multi-faceted knowledge . Today, bluevelvetrestaurant.com would like to introduce to you Wound Care for Nurses – Introduction; Skin Assessment on Admission. Following along are instructions in the video below:
Im kathy and i am a certified wound care nurse in this video. Series. Series.
I want to help nurses. As well as nursing students to feel comfortable and in providing wound care for our patients. So in this video series.
I will talk about how to do a thorough skin assessment. How to identify wounds how to care for those wounds and how to chart effectively on those wounds. I will also cover how to stage pressure injuries and i will also talk about care of very common type wounds.
Such as skin tears or moisture associated skin damage related to incontinence and then finally. I will be talking about wound vacs. What theyre used for how they work how to troubleshoot issues with wound vacs and how to change a dressing on a wood back.
So those are some of the topics. I want to cover in this playlist. So im gonna start off in this video by talking about how to do a thorough skin assessment.
When your patient is admitted that skin assessment is probably going to be the most important skin assessment. Youll do over the course of the patients hospitalization that is because if the patient comes in with a pressure injury that we dont identify and dont chart on within the first 24 hours of their admission. It becomes what we call a hospital acquired pressure injury.
And what does that mean that means we officially caused that pressure injury. Doesnt matter if were fairly confident that the patient came in with it if we didnt document it within 24 hours then we own it we caused it and we will not get reimbursed for the care of that injury. And we may get a visit from the state department to figure out why we had this outage and we basically get dinged as a hospital.
So finding and documenting pressure injuries as well as all other kinds of its gonna be super.
Important to do within the first 24 hours so if you are the admitting nurse. Youre gonna want to do a very thorough skin assessment and youre gonna want to do this for all your patients. It doesnt matter if your patient is 90 years old or 20 years old.
Youre gonna want to do that thorough head to toe skin assessment. And its always better if you can get a second nurse or other staff member to come in there with you to do this assessment. Because two sets of eyes is always better than one because things can get easily missed.
So what are you looking for when you do the skin assessment. Well youre going to be looking for pressure injuries. This used to be called pressure ulcers.
But the latest terminology is a pressure injury pressure injuries will occur over a bony prominence due to pressure so if you think about all the bony parts of your body. This includes like the back your head your scapula your coccyx bone or your sacrum your heels anywhere. Where theres a bony prominence.
Youre definitely going to want to take a look at that to see if there is a wound present in addition. There are other types of wounds that you may see on your patient. If your patient is incontinent.
Then they may also have moisture associated skin damage so when youre doing your head to toe assessment. You definitely want to look within the buttocks like help spread those cheeks and see whats going on there. Because if the patient is incontinent.
You will likely see redness or erythema and possibly a rash if they have like a fungal infection. So youre going to want to identify and chart on that as well for patients who have diabetes diabeetus foot foot. Ulcers are very common as well as other wounds.
So some of these wounds can be found on the bottom of the feet so when youre doing your assessment.
You definitely want to take off your patient socks and inspect their entire feet as well so do not skimp on this assessment. Its really important again two sets of eyes is better than one. And you just want to go head to toe and check the front and the back and all the folds for the presence of wounds.
When you find a wound. You want to take a picture of that wound and you want to see if you can identify it sometimes wounds are hard to determine whether theyre a pressure injury or the result of diabetes or the result of moisture. If you can pull in your mentor nurse or your charge nurse to help identify what that wound is thats great they may be able to help you if no one else is available or theyre not sure what the wound is then you just need to take your best guess on what it is again pressure injuries will be over bony prominences.
If its not over a bony prominence. If a wound you find is not over a bony prominence likely. It is not a pressure injury.
Its probably related to either some kind of trauma or diabetes or moisture. So just take your best guess at what that wound is and documented in the patients electronic medical record to the best of your ability. And then put in a wound.
Consult if youre not sure about how to identify that wound or how to care for that wound and we will come out and do an assessment on that patient. But as long as you took a picture and charted that wound in some way in the patients chart then we are covered from like a hospital perspective. It will be clear that the patient came in with that wound right it was present on admission.
And it wont be a hospital acquired wound. So its very easy for us after the wound care team comes. And does an assessment to like reclassify that wound if maybe you thought it was a pressure injury.
But its not or vice versa we can easily fix that charting. But what we cant fix is if you didnt document anything on that wound for the first 24 hours. So thats why the first 24 hours that first skin us that is so so important so hopefully.
Thats been helpful and we will pick it up with more good wound care information in my next videos thanks for watching. .
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