A To E Nursing Assessment

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The first step in nursing care is assessment. An accurate assessment can decrease the potential for the dermatitis to become more severe and helps the patient gain control over their illness. Without an accurate assessment, interventions may be inappropriate. For a nurse to complete an efficient assessment they must work together along the patient to identify needs and concerns (The Royal Marsden, 2015). Information on the patient’s background, lifestyle and presence of illness should be collected. The A to E assessment should be carried out. This includes assessing Airway, Breathing, Circulation, Disability and Exposure. By using the A to E assessment an overall assessment can be achieved. It can highlight the emergency factors that need to be treated (Thim et al, 2012). In this case it would be the exposed skin. A skin assessment should be performed this includes assessing changes in skin colour, level of desquamation, drainage, odour and signs of …show more content…

The key measures include keeping the wound clean, protecting the site from contamination and infection (Leventhal and Young, 2017). When trying to decide which dressing is appropriate the following factors should be considered is the dressing absorbent, comfortable, easy to apply and remove and non-adhesive (Saint James Institute of Oncology, 2008). A study be Gollins et al (2008) showed that hydrogel dressings had reduction in moist desquamation and improved healing time. Mepilex Lite reduced pain, burning and itchiness in patients (Diggleman et al, 2010). When using dressings to manage acute radiation dermatitis wound management guidelines should be adhered to (Health Service Executive, 2009). These guidelines include assessing the wound for pain, slough and infection, cleaning the wound using aseptic technique to reduce risk of infection and documenting progress notes in order to see if the management of the wound is

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