Nursing -improper identifacation of non pressure wound - Research Paper Example

Nurses often fail to recognize non-pressure ulcers and document them as pressure ulcers, thus leading to confused and suboptimal treatments and devastating consequences to the patient. In diabetic ulcers, delayed and inappropriate treatment increases the risk of amputation. Thus, it is very important to identify and documents ulcers appropriately. In this essay, improper identification of non-pressure wounds will be discussed through review of appropriate literature. Evaluation and improper identification and documentation of non-pressure wounds The first step in the evaluation of a patient with ulcer is taking appropriate medical history and hence this aspect is very important to ascertain whether the ulcer is pressure or non-pressure type.

History should include age and sex of the patient and presenting complaints. The chronology of events, whether the onset of the wound was traumatic or spontaneous, the treatments taken for the wounds and the outcomes of the treatments must be enquired. The history should also include whether the ulcer is associated with pain and if present, whether the pain is sudden in onset, and whether it is nocturnal or present when the leg has been in the dependent position for a long time. Other details to be included in the history are history of any chronic disease like diabetes and hypertension, occupational history, history of varicose veins, previous history of lower limb wounds/ulcers/gangrene, history of amputations and history of any other surgeries.

Family history of similar ulcers also must be enquired into (Kunimoto, 2001). Influence of biological and social factors also must be assessed. The next step in assessment is to determine the etiology and risk factors of the wound. Age, malnutrition, collagen disease and drugs like steroids inhibit wound healing (Kunimoto, 2001). After medical history, physical examination of the wound must be undertaken. Physical examination gives valuable information especially in the elderly who cannot recall history details.

One of the aims of physical examination is to differentiate between venous leg ulcers and non-venous leg ulcers. Venous leg ulcers occur in the distal medial third of the lower extremity and they are shallow without punched margins. The amount of granulation tissue and its color must also be assessed. Nurses are often confused here. Differences in documentation of the quantity and color of granulation tissue by the nurses have been reported (Frank-Stromborg et al, 2001). Decreased granulation tissue or bluish hue color of this tissue are indicators of bacterial infection.

The drainage from the wound must be examined as to whether it is serous, purulent or serosanguinous. There is evidence that there is no homogeneity among nurses and other health professionals in ascertaining the type of secretion from wound (Stremitzer et al, 2007) and this aspect plays a very important role in wound evaluation and diagnosis. Purulent discharge is an indicator of bacterial infection. The length, depth and width of the ulcer must also be assessed. Surrounding skin examination gives a valuable clue to differentiate between venous and non-venous ulcers.

Peripheral arterial circulation assessment is a must in ulcer evaluation. Palpation of the dorsalis pedis artery is useful for this purpose. However, it is absent in about 10% of people. Color and perfusion are other markers for arterial sufficiency. Nurses must be aware of