Wound Evaluation

Review the Millie Larsen case update within this assignment, read the questions, consult your resources–particularly the texts and National Patient Safety Goals web site concerning Hospital Chapter, Goal 7, NPSG.07.01.01 and NSPG.07.03.01. Brainstorm ideas and formulate your responses. Use the Braden Scale form to score her skin risk; access the Braden Scale form through the link below.

Several weeks have passed since the clinic visit, and Millie is now re-admitted to the hospital with a diagnosis of urinary tract infection and dehydration. Her presentation is atypical, and she is confused. Upon the admission assessment, the nurse notices that Millie has a wound on her sacrum and asks her if it is painful. Millie states that “it does hurt, so I have just been lying down more.” The nurse places a gauze dressing over the wound and continues with the assessment.

She is now being cared for on a medical-surgical unit and because she is confused, she has a bed alarm for her safety. Millie needs much encouragement to get out of bed and walk to the bathroom so has become more incontinent and requires frequent bed changes. She is receiving intravenous fluids and medications for the urinary tract infection. Millie appears weak and underweight as she is only eating about one-quarter of her meals. She refuses to drink the supplements that she is offered and sometimes refuses to take her medications.

A few days later, it is noted that the wound has worsened and now has purulent drainage with a foul odor which will require referral to a wound nurse for additional care. Wound cultures are positive for methicillin-resistant staphylococcus aureus (MRSA).

Before responding to the questions, review the following videos:

1. Obtaining a Wound Culture by Swab (Links to an external site.)
2. Removing and Applying Wet to Damp Dressings (Links to an external site.)
3. Open-Pore Reticulated Polyurethane Foam Therapy (i.e., Vacuum-Assisted Closure [V.A.C.]) (Links to an external site.)

Respond to the Following Questions

 Oval wound on person with deep wound bed. Overall skin color is lightly pigmented.  Yellow fatty tissue noted in part of wound bed. Remainder of wound bed is red.

1. View the picture to help you assess the wound. What are the “clinical findings” and how would you stage Millie’s wound?
2. What would be included in the plan of care for treatment of Millie’s wound? Please include all aspects of a team-based approach that will be utilized in a successful treatment plan.
3. What are three (3) nursing interventions that the nurse would incorporate into the plan of care? Give a rationale for each intervention.
4. If the wound nurse orders a dressing change for this wound, what technique would be appropriate? (Medical asepsis, clean technique? Or surgical asepsis, sterile technique)? Describe the procedure and give a rationale for your choice.
5. What are some of the risks that Millie demonstrates for forming a pressure injury? Using the Braden Scale  Download Braden Scale, how would you score Millie at this time?