University:
Stevenson University
Course:
NURS 460 | Medical/Surgical Nursing II
Academic year:

2020
Views:

277

Pages:

3
Author:

Dania Lynch

Josephine Morrow Documentation Assignments 1. Document the findings of a focused skin assessment of Ms. Morrow, including any findings that identify the presence of chronic venous insufficiency Skins shows normal findings for skin color based on ethnicity. Skin is intact and even other than brown pigmentation on knees with 2+ pitting edema. There is an ulcer on right medial malleolus dressed with hydrocolloiod. Skin is dry, no tenting, and elastic. Pulses are 95 bpm. Dressing and irrigation of wound were completed successfully with new dressing applied. Document the findings of a focused skin assessment of Ms. Morrow, including any findings that identify the presence of chronic venous insufficiency. Upon skin assessment, the patients skin color is normal for ethnicity and intact, except she does have brown hyperpigmentation bilaterally from the knees and down both sides with 2+ edema. She has venous stasis ulcer on the right medial malleolus, it is covered with a hydrocolloid dressing. Skin is dry, elasticity is normal, and there is no evidence of tenting. Pedal and radial pulses were 95, strong and regular. The dressing was removed and the w 2. Document any abnormal laboratory results that are associated with the presence or status of Ms. Morrow's stasis ulcer. Albumin level is 3.4 g/L, this is below normal value and can affect the process of would healing. 3. Record the results of Ms. Morrow's Braden Scale assessment. Braden scale assessment shows score of 16, putting Ms. Morrow at moderate risk for a pressure ulcer (not including already present ulcer on medial malleolus). 4. Document the characteristics of Ms. Morrow's venous stasis ulcer. Mostly pinkish-red colored with 1 in depth. The ulcer is shallow and not presenting any signs of infection. 5. Document the dressing change and irrigation of Ms. Morrow’s wound. Ulcer was irrigated and hydrocolloid dressing was applied. Previous dressing showed no drainage or moistness. Dressing was intact. Patient was medicated prior to wound procedures. Ulcer should continue to be monitored regularly. 6. In the chart, record patient education on ways to promote venous return. Anti-embolism socks and ambulating frequently (goal of two hours).