Wound Care Reflection

On September 26th, 2016, I shadowed the wound care nurse with another classmate. We saw all the patients that needed anytype of wound care, from surgical incisons and pressure ulcers to minor skin tears and abrasions. The wound care nurse at Artman is responsible to assess certain patients vital signs, lung, and bowel sounds. I was able to gain experience by doing dressing changes, measuring and cleaning the wounds, and counting the number of staples if present.

On September 28th, 2016, I was assigned to a patient on the rehab floor. I looked up this residents information before hand in his chart. There I was about to see his past medical history which concluded: Cancer, MS, Hypertension, and a right upper lobectomy. I assisted with this

reisents wound care a few day prior. We cleansed and dressed his wounds from the recent lobectomy as well as a unstagable pressure ulcer. I assisted this resident with AM care.

I completed a head to toe assessment on this resident as well. He was awake alert and oriented x3. He verbalized bo acute or chronic pain. The Neuro assessment showed that his pupils are equal, round, and reactive to light. He has ative range of motion in all of his extremities. Decreased strength in his lower extremities due to MS. No difficulty swallowing. Cardiovascular assessment: capillary refill <3 seconds, no edema, and no JVD. Mucous membranes pink and moist. Heart rate within normal limits. Skin was warm dry and intact. Respiratory assessment included clear and equal breath sounds. Breathing unlabored and chest expansion symmertrical. No secretions or suptum. GI assessment: abdomen soft and non-distended. Patient states his last bowel movement was on September 28th, 2016. GU assessment: voiding clear yellow urine without any pain or discomfort. Integumentary assessment includes 6 laproscopic insision sites on the right side. Unstageable sacral pressure ulcer noted. Braden score 19. Musculoskeletal assessment: fall risk score more thank 5, this patient is at rsk for falls. Active range of motion, lower extremities strength +3 and upper extremities +5. No recent falls. Psychosocial : coping well/ appropriate. Short and long-term memory intact. Family support includes his wife and children.