Comprehensive Wound Care Assessment and Plan

Clinician Specialty: Nurse Practitioner Comprehensive Wound Care Assessment and Plan Patient Information: - Sarah Jenkins - 05/12/1968 - Female - Medicare ID: 123-45-6789 - Braden Score: 14 (Moderate Risk) Wound Assessment: - Wound Location: Right sacral area, 3 cm above the gluteal fold. - Wound Etiology: Pressure ulcer, Stage III. - Wound Characteristics: - Measurements (in cm): Length: 4.2, Width: 3.8, Depth: 1.5 - Tissue Type/Color: 70% granulating tissue, 30% yellow slough. - Exudate: Moderate serosanguineous, no odor. - Pain Level: 5/10 (at dressing changes) - Edges: Irregular, partially undermined. - Periwound Condition: Intact, slightly erythematous but not macerated. - Signs of Infection: Localized redness, no warmth, no purulent drainage. Nutrition Assessment: - Dietary Intake: Adequate protein and calorie intake with oral nutritional supplement (Ensure Plus twice daily). - Lab Results: Albumin: 3.2 g/dL, Prealbumin: 18 mg/dL, Creatinine: 0.8 mg/dL, BUN: 15 mg/dL. - BMI: 22.5 - Hydration Status: Well-hydrated, fluid intake approximately 1.8 litres per day. Plan of Care: - Cleansing Protocol: Normal saline irrigation with 30cc syringe, once daily. - Debridement Type: Autolytic debridement with hydrogel. - Dressing Type and Frequency: Hydrogel applied to wound bed, covered with foam dressing (Mepilex Border Sacrum) changed daily. - Topical/Antimicrobial Treatments: Mupirocin ointment applied to periwound erythema BID. - Systemic Treatments: None indicated at this time. - Pressure Redistribution Interventions: High-specification foam mattress, repositioning every 2 hours, foam wedges for offloading. - Frequency of Wound Monitoring: Daily assessment by home health nurse, weekly assessment by Nurse Practitioner. - Referrals: - Dietitian consult for further nutritional optimisation. - Patient/Caregiver Education: Detailed instructions provided to daughter regarding dressing changes, repositioning techniques, and signs of infection. Written instructions provided. - Therapeutic Goals: Reduce wound size by 10% in two weeks, achieve 100% granulation tissue within four weeks, prevent infection. - Additional Interventions: None at this time. Evaluation: - Wound Healing Status: Progressing well, reduction in slough noted since last visit. - Response to Interventions: Good response to current dressing regimen and pressure redistribution; wound bed appears healthier.