Focused assessment

  1. im a nursing student doing first rotation on surg. I have a pt. admitted with wound sepsis (previous surgery was amputation after staph infection) his/her current procedure was incision and drainage of abcess to left thigh and removal of femoral graft. Im familiar with all the wound care procedures ieacking ect. what Id like some input about is regarding my careplan and what my focused assessment should be r/t the wound? I would appreciate any suggestions
  2. Visit Breezy1979 profile page

    About Breezy1979

    Joined: Nov '07; Posts: 1


  3. by   HM2VikingRN
    Assess for:
    odor, purulent drainage, pain, redness,heat, swelling....color (red, yellow, black)

    possible diagnosis:
    impaired skin integrity

    Check out your med surg book for some other possibilities and interventions...
  4. by   Daytonite
    hi, breezy1979, and welcome to allnurses!

    hm2viking gave you good advice about the wound assessment. you should also assess it's specific location, depth, length and width of its margins (in other words, get measurements), note the amount of any drainage, the amount of any drainage on the packing that is being removed, how many times a day the dressing is needing to be changed, and any information on cultures of the wound drainage. nowadays they are also taking pictures of these wounds and placing them in the charts.

    as for your care plan. . .you always follow the nursing process in writing a care plan. the nursing process is a problem solving process. you follow the steps in sequence which are:
    1. assessment (collect data from medical record and by doing a physical assessment of the patient)
    2. nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
    3. planning (write measurable goals/outcomes and nursing interventions)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)
    assessing this patient's wound is step #1 of the process. step #2 involves making a list of the symptoms of this wound and then searching for the right nursing diagnosis label(s) to apply to them.
    (from page 4 of nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig)
    "when the assessment is complete, identify common patterns/symptoms of response to actual or potential health problems and select an appropriate nursing diagnosis label using critical thinking skills.
    • highlight or underline the relevant symptoms.
    • make a short list of the symptoms.
    • cluster similar symptoms.
    • analyze/interpret the symptoms.
    • select a nursing diagnosis label that fits with the appropriate related factors and defining characteristics.
    the process of identifying significant symptoms, clustering or grouping them into logical patterns, and then choosing an appropriate nursing diagnosis involves diagnostic reasoning (critical thinking) skills that must be learned in the process of becoming a nurse."
    i frequently recommend that students use some sort of nursing diagnosis reference to make sure they are diagnosing correctly. each nursing diagnosis has a definition as well as a list of symptoms. and, you want to make sure you are making a correct diagnostic assessment, don't you? it's not a good idea to just pick a diagnostic label (or title) and use it without checking any reference information about it. the definitive work on nursing diagnoses is the nanda taxonomy and can be obtained from nanda in this publication: nanda-i nursing diagnoses: definitions & classification 2007-2008 which costs $24.95 and you purchase directly from nanda. this taxonomy is re-printed with nanda's permission in many current nursing care plan books that also include nursing outcomes and interventions as an added feature. a limited number of nursing diagnoses with the nanda information are able to be accessed for free online if you don't have a nursing care plan or nursing diagnosis book. yyou can get to those weblinks by going to post #109 on this thread: however, the point i am stressing is that each nursing diagnosis has specific symptoms connected with it that your patient should meet in order to attach that diagnosis to their situation.

    there is more about writing care plans and choosing nursing diagnoses on these two threads in the nursing student forums of allnurses:
    i don't know that you'll find specific wound assessment information here, but allnurses does have a sticky thread with all kinds of assessment weblinks and information on it in the student forums as well:
    if you still need more help with this care plan, please do not hesitate to ask. good luck with this assignment. fyi. . .i had a septic infection in a post-op abdominal surgical wound a few months ago for which i was hospitalized and on iv antibiotics for 11 days. the wound took about 4 months to finally close. during that time i was flushing and packing the wound several times a day until it closed.
  5. by   HM2VikingRN
    Thanks for adding to my knowledge base!