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Nursing Process: Wound V.A.C

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by

Monique Mesa

on 4 April 2013

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Transcript of Nursing Process: Wound V.A.C

Objectives:
Properly assess a patient
Create a proper diagnosis
Create an individualized plan & outcomes for patient
Be able to effectively implement interventions: Wound V.A.C
Properly evaluate and measure expected outcomes Scenario:
P.Matthews., who is 65 years old male, came into the Eastern Hospital on August 8, 2007 with an open abdominal wound. According to his health history, he was diagnosed with bladder cancer in 2007 and had a cystectomy. The cystectomy was very successful and the patient was sent home in a timely manner.The surgical incision, according to the patient, had began slowly opening up and without realizing how quickly it became infected. Diagnosis Planning Nursing Process: Wound V.A.C
Male (P.M.), 65 years old
positive attitude
Willing to learn how to preform proper wound care
Large open abdominal wound with slough present
Wound tissue shows erthyema and edema, surrounding skin appears to be in good condition
Wound extends from quadrants LUQ, LLQ, & RLQ
Measurements: 200mm x 150mm, 30mm deep
Pain level: 8/ 1-10 (O: started 2 weeks ago, L: lower abdomen, D: 2 weeks, C: interferes with ADLs, A: movement, R: less pain with no movement , T: constant, S: stabbing)
Facial grimacing when turning
Doctor order: wound V.A.C Identification of client needs:
Increase skin integrity and healing (by method of wound V.A.C. as ordered by doctor)
Lessen pain (get level 8 down to a level 3)
Teach proper clean techniques to reduce the risk of infection
Patient needs to be educated about his wound and is ready to learn about his healing process.
Analysis and interpretation of data:
Pt. is in a lot of pain (level 8 on a 1-10 scale). The wound is very large and open, and requires a wound V.A.C. prescribed by doctor to enhance healing. The skin integrity and tissue integrity are both impaired due to the large opening of the wound accompanied by present slough, purulent drainage, erythema, and edema. This puts the pt. at a risk for infection and impaired skin healing. The patient is willing to learn about the wound and be educated about his condition and increase his health.
Priorities:
Reduce acute pain to a 4 or less on a scale of 1-10 after ordered analgesic has been administered
Patient’s wound will signs of healing after wound V.A.C. has been implemented for 2 weeks
Gain comfort
Maintain skin integrity
Increase physical mobility
Promote health
Incorporate a diet high in protein to promote wound healing
Educate patient about the signs/symptoms of wound infection
Educate patient about the implementation of wound V.A.C.
Educate patient regarding what a dressing change involves
Monique Mesa, Morgan Joyner, Lizbeth Medrano, Jacyln Hilts, & Brenda Navarro Concept Map:
Abdominal wound Impaired skin integrity
Signs & Symptoms: surgical incision damage, tissue trauma, large open abdominal wound, slough, drainage, erthyema, edema Acute Pain
Signs & Symptoms: tissue trauma, edema, pain level is 8/1-10, facial grimacing, restricted turning and positioning Readiness for wound care education
Signs & Symptoms: positive attitude, willing to be educated Risk for impaired skin healing
Signs & Symptoms: damaged tissue from surgical wound, slough is present Wound V.A.C Information:
Wound vacuum-assisted closure or Negative-pressure wound therapy (NPWT)
"A device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together" (Potter & Perry, 2013)
Treating acute and chronic wounds
Primary effects: edema reduction, fluid removal, macro deformation and wound contraction, and micro deformation and mechanical stretch perfusion
Secondary effects: angiogenesis, granulation tissue formation, and reduction in bacterial bioburden Diagnosis including all components:
Impaired skin integrity related to surgical incision damage and tissue trauma as evidence by large open abdominal wound and present slough, drainage, erythema and edema.
Risk for infection related to open abdominal wound.
Acute pain related to tissue trauma and edema as evidence by level 8/1-10 pain, facial grimacing, restricted turning and positioning.
Readiness for wound care education related to positive attitude and willingness to be educated.
Risk for impaired skin healing related to damaged tissue from surgical wound as evidence by slough.
Assessment Measurable client-centered goals:
•Patient’s wound will have a higher percentage of granulation tissue in wound base after wound V.A.C. has been applied for 2 weeks
•Patient will be able to identify 3 ways to prevent wound infection after 3 days
•Patient identifies at least 3 signs/symptoms of wound infection after 3 days
•No further skin breakdown in any body location by day of discharge
•Patient’s wound will be completely healed and closed by day of discharge

Measurable client-centered outcomes:
Patient will achieve pain relief by day of discharge
Patient’s wound will no longer present signs of edema after 5 days
Patient’s wound will decrease in measurement after 3 weeks using wound V.A.C.
Patient will be able to identify the proper diet to promote wound healing after 3 days
Patient will be able to ambulate independently by day of discharge
Patient will be able to identify 3 ways to promote wound healing by day of discharge
Patient will be able to identify the steps used in wound V.A.C. therapy after 3 days
Patient will be able to identify the steps involved in dressing changes

Others types of wounds:
Acute and traumatic wounds
subacute wounds (dehisced incisions)
Pressure ulcers
Chronic open wounds (stasis & diabetic ulcers)
Meshed grafts
Flaps
Additional Information
on Wound V.A.C References

Potter, P. A., & Perry, A. G. (2013). Fundamentals of nursing. St. Louis: Elservier Mosby
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