wound care - Nursing Case Study

Pathophysiology

• Primary mechanism: Inflammation initiates wound healing by bringing immune cells to the injury site, which helps remove debris and prevent infection. This phase causes redness, warmth, and swelling as blood vessels dilate.

• Secondary mechanism: Proliferation involves the formation of new tissue and blood vessels, where fibroblasts produce collagen to replace the damaged tissue and promote closure of the wound.

• Key complication: Inadequate blood supply can hinder these processes, leading to delayed healing and increased risk of infection, emphasizing the need for proper wound assessment and care.

Patient Profile

Demographics:

34-year-old female, office administrator

History:

• Key past medical history: No significant past medical history

• Current medications: None

• Allergies: None

Current Presentation:

• Chief complaint: Minor laceration on the right forearm

• Key symptoms: Mild pain, slight redness around the wound, no signs of infection

• Vital signs: Temperature 98.6°F, Heart rate 72 bpm, Blood pressure 118/76 mmHg, Respiratory rate 16 breaths/min, Oxygen saturation 98% on room air

Section 1

Initial Assessment Findings:

Upon conducting the initial assessment of the 34-year-old female patient with a minor laceration on her right forearm, the nurse notes the wound measures approximately 3 cm in length and has clean, well-defined edges. There is minimal exudate present, and the surrounding skin appears slightly erythematous, which is consistent with the normal inflammatory response. The patient rates her pain as 2 out of 10 on the pain scale, indicating mild discomfort. There is no noticeable swelling beyond the immediate area of the laceration, and the wound bed itself is free of necrotic tissue, suggesting that the wound is in the early stages of healing.

The nurse also evaluates the patient's peripheral circulation as part of the assessment, given the concern for adequate blood supply to the wound. Capillary refill in the fingers of the involved arm is less than 2 seconds, and radial pulses are palpable and strong. This suggests that there is no significant circulatory compromise, which is crucial for effective wound healing. Sensation and motor function in the affected limb are intact, and the patient denies any numbness or tingling.

Based on these findings, the nurse develops a care plan that includes cleansing the wound with normal saline, applying a non-adherent dressing to protect the area, and educating the patient on signs of infection to monitor at home, such as increased redness, swelling, or drainage. The patient is encouraged to maintain good hydration and nutrition to support tissue repair and is scheduled for a follow-up visit in one week to reassess wound healing progress. These steps aim to support the natural healing process while preventing potential complications.

Section 2

Response to Interventions:

One week later, the patient returns for her follow-up appointment to reassess the wound healing progress. Upon examination, the nurse observes that the wound appears to be healing as expected. The edges are well approximated, and there is a noticeable reduction in erythema around the wound margins, indicating a reduction in the inflammatory response. The minimal exudate observed during the initial assessment has decreased further, and the wound bed remains free of necrotic tissue. The patient reports that her pain has decreased to 1 out of 10, suggesting that the discomfort is resolving as the wound heals.

The nurse reviews the patient's self-reported adherence to the wound care instructions provided during the initial visit. The patient confirms that she has been cleansing the wound with normal saline and changing the non-adherent dressing daily. She has also been vigilant in monitoring for signs of infection, as instructed, and reports no increased redness, swelling, or drainage. Additionally, the patient states she has been maintaining good hydration and nutrition, as advised.

Vital signs taken during this visit are within normal limits, with the patient's temperature at 98.6°F, indicating no fever or systemic infection. The nurse performs a capillary refill test, which remains less than 2 seconds, and the radial pulse is still strong and palpable. These findings suggest that the peripheral circulation remains adequate, supporting continued effective wound healing. Based on the positive response to interventions and the absence of complications, the nurse provides reassurance to the patient and schedules the next follow-up in another week to ensure complete wound closure and healing.

Section 3

Two weeks later, the patient returns for her scheduled follow-up appointment. During this visit, the nurse notes a slight change in the wound's appearance. While the wound continues to show signs of healing, there is now a small area of increased erythema measuring approximately 1 cm around the superior edge of the wound. The patient reports a mild increase in discomfort, rating her pain at 3 out of 10, localized to the area of redness. Despite these changes, there is no increase in exudate, and the wound bed remains clean, free of necrotic tissue, and does not have any foul odor.

The nurse decides to conduct a more thorough assessment to rule out any emerging complications. The patient's vital signs are reassessed, with a temperature recorded at 99.0°F, slightly elevated from the last visit but not indicative of a systemic infection. The radial pulse remains strong, and the capillary refill time is still under 2 seconds, suggesting that peripheral circulation is not compromised. The patient is questioned about any recent changes in her routine, and she admits to having been less attentive to her hydration and possibly missing a couple of dressing changes due to a busy schedule.

In response to these findings, the nurse discusses the importance of maintaining consistent wound care practices and adherence to the recommended hydration and nutrition guidelines. The nurse suggests applying a cool compress to the erythematous area to help alleviate discomfort and advises the patient to monitor the redness closely for any further changes. The patient is reminded to return promptly if the redness spreads or if she experiences any systemic symptoms such as fever or increased pain. A follow-up appointment is scheduled in one week to reassess the wound and ensure that any potential complications are addressed early.

Section 4

A week later, the patient returns for her scheduled follow-up appointment. The nurse begins with an assessment, observing that the erythema around the superior edge of the wound has slightly diminished, now measuring approximately 0.5 cm. The patient reports that she has been diligent in following the updated care plan, including the regular application of cool compresses, which she states has significantly reduced her discomfort. Her pain level has decreased to 2 out of 10.

Vital signs are reassessed, revealing a temperature of 98.6°F, indicating that the slight elevation noted previously has normalized. The patient's blood pressure is 118/76 mmHg, and her pulse is 72 beats per minute, both within normal limits. The capillary refill time remains under 2 seconds. The nurse also notes that the wound bed continues to appear healthy, with granulation tissue present and no signs of increased exudate or odor, suggesting that the wound is progressing well in its healing process.

To further ensure no complications are developing, the nurse conducts a brief review of systems and confirms that the patient has not experienced any systemic symptoms, such as fever, chills, or general malaise. The patient is praised for her improved adherence to the care plan and is advised to continue monitoring the wound closely. Given the positive response to the interventions, the nurse recommends another follow-up in two weeks to ensure continued healing and to make any necessary adjustments to the care plan. This approach allows for ongoing assessment and timely intervention, promoting optimal wound healing and patient outcomes.

Section 5

Two weeks later, the patient arrives for her follow-up appointment, expressing a mixture of optimism and slight concern. She notes that while overall comfort has continued to improve, she recently observed a small, new area of redness developing around the inferior edge of the wound. During the initial assessment, the nurse confirms the presence of this erythema, measuring approximately 0.4 cm, which is confined to a limited area without any signs of swelling or warmth. The patient's pain level remains low, at 2 out of 10, and she denies any new symptoms such as itching or increased tenderness.

Vital signs are stable and within normal limits: temperature at 98.5°F, blood pressure at 120/78 mmHg, and pulse at 70 beats per minute. The nurse conducts a focused assessment of the wound, noting that the granulation tissue is still healthy, and there is no significant increase in exudate or any foul odor. The new area of erythema appears superficial and not indicative of a deeper infection at this time, suggesting it may be related to minor irritation or an issue with the dressing application.

In response to these findings, the nurse reinforces the importance of proper dressing changes and suggests a slight modification to the care plan, such as repositioning the dressing to reduce friction in the affected area. The nurse also advises the patient to apply a protective barrier cream around the wound edges to prevent further irritation. The patient is reassured and scheduled for another follow-up in a week to closely monitor the new development. This plan ensures that any potential complications are addressed promptly, maintaining the positive trajectory of the wound healing process.