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Wound bed, wound edge and periwound skin should be examined before the initial treatment plan is devised. It should also be re-assessed at each visit or each dressing change. For wound bed, the following parameters are assessed: Tissue type; presence and percentage of non-viable tissue covering the wound bed; Level of exudate; Presence of infection
Wound, ostomy, and continence nursing is a nursing specialty involved with the treatment of patients with acute and chronic wounds, patients with an ostomy (those who have had some kind of bowel or bladder diversion), and patients with incontinence conditions (those with issues of bladder control, bowel control, and associated skin care).
NANDA International (formerly the North American Nursing Diagnosis Association) is a professional organization of nurses interested in standardized nursing terminology, that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnosis. In 2002, NANDA became NANDA ...
It is vital that a recognized nursing assessment framework is used in practice to identify the patient's* problems, risks and outcomes for enhancing health. The use of an evidence-based nursing framework such as Gordon's Functional Health Pattern Assessment should guide assessments that support nurses in determination of NANDA-I nursing diagnoses.
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician ...
Chronic wound healing may be compromised by coexisting underlying conditions, such as venous valve backflow, peripheral vascular disease, uncontrolled edema and diabetes mellitus. If wound pain is not assessed and documented it may be ignored and/or not addressed properly. It is important to remember that increased wound pain may be an ...
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Since the year 2000, the wound bed preparation concept has continued to improve. For example, the TIME acronym (Tissue management, Inflammation and infection control, Moisture balance, Epithelial (edge) advancement) has supported the transition of basic science to the bedside in order to exploit appropriate wound healing interventions [6] and has not deviated from the important tenets of ...