Chronic Wound Care: Nursing Assessment The NANDA diagnosis list is a primary tool to refine the process of diagnosis to treatment and beyond. Through having a verifiable and reliable process, the NANDA criteria offer a way to improve nursing care and patient safety through the use of evidence-based practice (NANDA International, 2010).
Chronic Wound Care: Nursing Assessment and Intervention
Chronic Wound Care: Nursing Assessment and Intervention
Chronic wounds are a challenge for both the clinician and the patient. For the nurse, issues of chronic wound care include the type of wound, the condition of the patient, and presence of infections, possible antibiotic therapy, and patient education on chronic wound care management. For the patient, issues revolve around how the patient will provide for their own long-term chronic wound care, compliance, cosmetic issues, effects on quality of life, potential self-esteem issues, and other factors related to the overall health of the patient. The following paper discusses the topic of chronic wound care for the nurse and for the patient. A nursing assessment for chronic wound care is provided using two approaches: the NANDA diagnostic approach, and the PICO process. In order to properly illustrate the issue, a vignette case study is offered. First an overview is provided of the relevant issues of chronic wound care for the nurse. The NANDA and PICO nursing assessment are then described for their applicability to chronic wound care. A literature review of nursing intervention and patient education is provided. A conclusion highlights the main points of the paper for topic synthesis.
Chronic Wound Care: Issues
Categories of Chronic Wounds
A chronic wound is one that does not heal in the expected fashion of other wounds; a wound that last longer than three months may be considered a chronic wound (Bryant & Nix, 2007). A chronic wound falls into one of three primary categories. A venous wound accounts for the majority of chronic wounds; the group typically affected by these wounds are the elderly, with the wound typically being found on the legs (Gist, Tio-Matos, Falzgraf, Cameron, & Beebe, 2009). These types of chronic wounds may be due to insufficient blood supply to the veins and arteries of the leg, causing ischemia leading to tissue injury. The second major type of chronic wound is the diabetic ulcer. These types of wounds typically appear on the extremities, often occurring on the feet. High circulating blood sugar leads to nerve damage, causing a loss of sensation in the affected area; possible pressure injuries can result which are not treated properly due to the lack of pain perception by the patient (Kosinski & Lipsky, 2010). The third major category of chronic wounds is pressure ulcers; these do occur in diabetics, yet also happen in persons who are paralyzed or otherwise bedridden. Pressure points include the sacrum, heels, elbows, and shoulder blades. Due to the ongoing nature of the pressure on these areas, a loss of blood flow to capillaries and veins occurs, leading to tissue damage (e Laat, Scholte op Reimer, & van Achterberg, 2005).
Nurses are involved in the care of patients displaying chronic wounds, from geriatric nursing and venous ulcers, to palliative care and pressure ulcers, and onto primary care for diabetic patients with ulcers. Primary considerations for the nurse in chronic wound care include the patient characteristics, the type of wound, and evidence-based practice for remediation. This may or may not include antibiotic therapy (Bryant & Nix, 2007).
The role of the nurse in caring for patients with chronic wounds and in managing chronic wounds necessitates knowledge of wound characteristics, such as depth, bacteria presence, and relevance of wound location to healing. The nurse is involved in assessing the wound and in dressing the wound. The type of dressing and use of other elements such as anti-infectives are within the nurse's sphere of influence. Additionally, time spent on wound dressing changes is a large consumer of the nurse's professional time. Wound cleansing and amelioration of pressure on the wound are also considerations of the nurse (Bryant & Nix, 2007).
Green and Jester (2010) not that in caring for the patient with leg ulcerations, the nurse is not only dealing with the chronic wound; the nurse is also dealing with the physical and psychological effect of the wound upon the patient. Factors of pain, odor, wound exudates, and the social marginalization experienced by the patient are issues the nurse must deal with (Green & Jester, 2010). Kohr and Gibson (2008) note the heavy toll that the pain of the wound has on the patient, and the challenge that presents to the nurse in managing chronic wound care. Pain is as much psychological and it is biological. A patient experiencing pain may not wish to be touched; this is a problematic aspect for the nurse involved in wound care. In this regard, the nurse must not only be a professional and skilled healthcare provider, they must also employ compassionate and patient-centered strategies to allow for an optimal wound care outcome (Kohr & Gibson, 2008).
Nursing Assessment Strategies and Processes
The North American Nursing Diagnosis Association provides diagnostic tools to ...
Evidence-based nursing medicine necessitates utilizing empirical clinical information and sound knowledge resources to find answers to questions for the clinical setting. This is a skill set and is effective for identifying the best practices for clinical questions (Gerrish & Lacey, 2010). PICO stands for Patient, Intervention, Comparison and Outcome; in keeping with that acronym the method of PICO is to utilize the best evidence-based care to develop an intervention and treatment plan for optimal patient health outcomes. Evidence-based knowledge is that which is gathered from clinical and peer-reviewed research on the issue at hand, where the knowledge base in enhanced, has external validity, and can be generalized (Weaver, Warren, Delaney, Association, (IMIA-NI), & Group., 2005). Evidence-based care requires that there is some method by which articles selected can be assessed for their relevance, reliability, and validity to the patient care issue in question (Gerrish & Lacey, 2010).
The utilization of NANDA diagnoses and evidence-based practice through the application of PICO is a tangible and educated process of correctly assessing the patient with chronic wound issues, applying a framework to approach treatment, and finding the best evidence-based knowledge available for treatment intervention and patient education.
Literature Review: Nursing Interventions and Patient Education
The following vignette case study opens this literature review section in order to demonstrate the applicability of NANDA diagnoses and the PICO process from which relevant studies will be examined and discussed in the literature.
Case Study: Mr. H -- PICO and NANDA
Mr. H is a 75-year-old white male. He has advanced Parkinson's Disease with syncope, resulting in a fall which caused an anterior pelvic wound that would not heal. He has co-morbid conditions obstructive pulmonary disease, gastric esophageal reflux, hypertension, and coronary artery disease with a history of a myocardial infarction. Mr. H was admitted to an acute care facility following the fall, and was later transferred to a sub-acute care facility. He was assessed by a wound care nurse for evaluation of the anterior pelvic wound, which was evolving into a chronic wound (Glenn, 2006).
Human Needs Assessment
The nurse is responsible for assessing the patient and determining the best model of care, with a client care plan. Notwithstanding the reason for the patient/nurse encounter, the nurse must make an assessment and using an assessment model is the chosen and most efficacious means of accomplishing this (Buluta, Hisara, & Guler Demir, 2010). Aside from being exceptionally trained in a specific discipline and employing a model of care specific to that specialty, the nurse has a basic responsibility to assess the physiological needs of the patient, a priori.
Following the NANDA diagnosis criteria and in keeping with a human needs assessment, Mr. H would receive the following diagnoses:
Altered Human Needs
NANDA Nursing Diagnosis
Safety; Infection Risk
NANDA: SAFETY; Infection Risk
Goal: To mitigate any possibility of Mr. H's wound becoming infected or gangrenous.
Intervention: Aggressively treat Mr. H's wound with debridement therapy, antibiotics, and specialized anti-infective wound dressing (Gist, Tio-Matos, Falzgraf, Cameron, & Beebe, 2009).
Safety; Tissue Integrity Impaired
NANDA: SAFETY; Tissue Integrity Impaired
Goal: To allow for wound healing and closure.
Intervention: Rinse and dress wound daily; use compression therapy (O'Meara, Cullum, & Nelson, 2009).
Tissue Perfusion; Altered
NANDA: TISSUE PERFUSION; Altered blood flow to anterior pelvic area; risk of reperfusion injury.
Goal: To avoid reperfusion injury to Mr. H's wound.
Intervention: Properly saturate the wound with oxygen to speed healing and reduce risk of ischemia/reperfusion events (Beckert, Konigsrainer, & Coerper, 2007).
NANDA Source list: (Herdman, 2009).
Interventions Evidence Base
Gist et al. (2009) discuss the challenges in treating the chronic wound in a geriatric patient. The authors note that co morbid diseases that compromise blood flow exacerbate issues related to chronic wound care. The tissue breaks downs where wounds are present. In wound healing, there should be four stages involved:…
The NANDA diagnosis list is a primary tool to refine the process of diagnosis to treatment and beyond. Through having a verifiable and reliable process, the NANDA criteria offer a way to improve nursing care and patient safety through the use of evidence-based practice (NANDA International, 2010).
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