WOUND CARE CASE STUDY: OPEN ABDOMEN WOUND – TOM WILLIAMS
General information:
(fictitious information has been added below for the purpose of this assessment)
Family Name: Williams
Given Name: Tom
UR number: 29275
Date of Birth: 01/10/1962
Initial operation date: 01/08/2019
Date of wound: 03/08/2019
Wound Swabs taken: 15/11/2019
History: Due to complications of diverticulitis Tom had to have part of his bowel removed and a temporary stoma was created.
Post-operatively Tom became very sick and due to intra-abdominal sepsis, he was taken back for further surgery. He was then left with an ‘open abdomen’ and was in an induced coma for a month in ICU. He was also on dialysis during this time.
Due to his stoma and abdominal compartment syndrome, closure of the open abdomen was complex. As a result of late closure of his abdominal wall, reconstruction and skin grafting was required for wound closure.
A VAC abdominal dressing system is being used to promote wound healing and closure.
The home health nurse performs wound care to replace the VAC therapy system every Monday, Wednesday and Friday
Tom has been readmitted to hospital for a wound evaluation and possible debridement.
QUESTION 1
Using the Wound Care Record, document a full assessment of Tom’s abdominal wound from the video footage provided.
QUESTION 2
Complete the handover sheet provided
Write a script for handover to next shift.
CLINICAL HANDOVER TEMPLATE
ASSESSMENTS / TREATMENTS / MANAGEMENT RECOMMENDATIONS / TO DO LIST
PATIENT NAME
PATIENT AGE
TREATING DOCTOR / TEAM
DAYS IN HOSPITAL
DIAGNOSIS / CONDITION
NFR ORDERS
INFECTION CONTROL (none, contact, droplet, airborne)
ALLERGIES (if any)
OBSERVATIONS (ADDS/BGL)
IV SITE /LINES
MOBILITY (self, assist, rib)
ADLS (self, assist, full assist – meals, cares etc.)
SKIN INTEGRITY (PAC)
RENAL (urine output, FBC, IDC,urinalysis)
GIT (diet, FBC, bowels)
WOUND MANAGEMENT
PAIN
OTHER
