Creating a Plan of Care for Wound Management

One of the biggest challenges that practitioners in the medical field face are wound management. To properly undertake a course of action, information must be gathered from sources and assessed to formulate a plan that will benefit the patient and promote healing.
healing wound care

Communication and Documentation

It was surgeon general C. Everett Koop who once stated that there was no prescription more valuable than knowledge. Understanding the cause of a patient’s wound and relaying this information to the medical staff in charge of care is crucial. These include, but are not limited to;

  • Attribute of the wound, definition, date of occurrence, and details relating to any care or management before admission.
  • Accurate assessment of any pain the patient might be feeling
  • Investigation into the cause
  • Dimension and appearance of the wound in its current stage
  • Current management & care, such as dressing, bandages, etc.

When the information on the wound is recorded, the next phase is collecting vital information on the patient. The following items should be accessed by the team in charge of the patient’s care.

  • Medical and surgical history
  • Any allergies
  • Any current or past medications to diagnoses
  • Blood pressure and glucose levels
  • Alcohol, nicotine, or recreational drug use
  • The dietary practices and nutrition of the patient
  • Psychological and socio-economic barriers that could possibly hinder treatment or aftercare.
  • The presence and involvement of caregivers, therapists, or other medical personnel.

All of these items that are listed must be taken into account when implementing a care plan for the benefit of the patient. After these have been accounted for, there must be a proper diagnosis of the wound.

  • The type of wound it is; surgical, laceration, abrasion, and whether or not it’s chronic or acute.
  • Type of ulcer
  • The location of the wound and the condition of the skin adjacent to the wound
  • Any substantial loss of tissue
  • Clinical appearance of the wound depth and edge
  • The current stage of the healing process
  • The presence of any infection, biofilm, or exudate
  • Any information related to the level of pain currently experienced by the patient

Development and Implementation of a Care Plan

Once all the information has been collected, it’s important that a proper care plan is implemented. Any changes in the patient’s wound during their stay should be documented and their care plan adjusted accordingly. Using the right type of dressing and applying the right treatment is crucial for the patient to be healed properly.

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