1 answer

Write a progress note for this Scenario Wound Assessment Mr. Santiago, a 62 year old gentleman...

Question:

Write a progress note for this Scenario

Wound Assessment
Mr. Santiago, a 62 year old gentleman is transferred to your ward from the Emergency department. Mr. Santiago had a Left Total Knee replacement done 2 weeks ago. He presented to ED with fever and severe pain in his Right knee. He stated that he could not stand or walk for last 2 days due to pain and weakness in his knee. He has a history of Diabetes Mellitus, osteoarthritis and is an average smoker. You have been called in to assess the wound and remove alternate staples (as per doctor's advice)


Answers

Progress note:
Wound assessment:
Wound healing is an important satisfactory outcome after joint replacement surgery.
confirmed patient ID and physician order
  informed to the patient about the procedure
handwashing is done
unsterile gloves used to remove the dressing
Dressing removed in a gentle way
There is erythema, swelling, drainage on the incision site.
Patients with diabetes, older age, osteoarthritis there is a high risk for wound healing and infection.
The patient had severe pain and fever.
Surgical area progress notes informed to the doctor.
Analgesics administered as per doctors' orders and ask the doctor whether to remove the staples or not to avoid further complications. Becuase to remove staples wound should be sufficiently healed
Get advice from doctors for wound swap for culture, irrigation, debridement, and antibiotics therapy, etc...

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