Instructed in S/S of complications which require need for medical intervention, including redness, increase or change in drainage, heat at the wound site, fever, bleedind or increased pain.
Patient was instructed on adequate nutrition and hydration to minimize wound development. Encourage protein, calorie-dense foods and fluids (unless contraindicated), monitor intake, weight and skin turgor, assess and address impairments in dentition and swallowing.
Patient was instructed on eliminate or minimize pain of wound. Address the cause (remove the source if external, treat the infection or medicate based on physiological stimulus), pharmacological strategies
Patient was instructed on factors that contribute in chronic wounds as repeated trauma. Repeated physical trauma plays a role in chronic wound formation by continually initiating the inflammatory cascade. The trauma occurs by accident, for example when a leg is repeatedly bumped against a wheelchair rest, or it may be due to intentional acts.
Instructed caregiver that treatment includes proper positioning, always avoid placing any weight
or pressure on the wound site.
SN instructed patient to always assess wound dry sterile dressing when removed for any symptoms / signs of infection, such as increase drainage amount, any odor, drainage color, etc . Check your temperature once or twice a day. Report any fever or increase pain.
SN instructed patient to eat a balanced diet and drink fluids, eat protein like red and white meat, eggs, beans and take vitamins from vegetables/fruits , to promote wound healing.
Patient was instructed on how to prevent pressure ulcer. A proper skin care is crucial and involves inspecting skin daily and an individualized bathing schedule, using warm (not hot) water and mild soap. Avoid massage over bony prominences and use lubricants if skin is dry.
Instructed patient consider nutritional supplementation/support for nutritionally
consistent with overall goals of care.
Instructed patient reposition bed-bound persons at least every two hours and chair-bound persons every hour consistent
with overall goals of care.