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How would you undertake an holistic assessment of a patient who has a grade 2 pressure sore ?

How would you undertake an holistic assessment of a patient who has a grade 2 pressure sore , has reduced mobility and has dementia?
Asked On : Fri, 18 Dec 2009
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Never heard of a holistic nursing assessment. There are just nursing assessments. We treat the whole person and if that makes it holistic than so be it. For a stage II pressure ulcer, you assess it by measuring for size, width, length, depth and check for and measure tunneling/undermining. You assess the color or colors of the wound bed and describe what you see - example A: 100% red; Example B: 80% red and 20% yellow; Example C: 10% black, 60% yellow and 30% red. Describe odor and drainage. If none, you document that there is none. Photos are taken of all pressure ulcers to later assess for improvement. The entire skin is examined and assessed for scars, wounds, bruises, skin tumors, surgical openings (tracheostomy, etc.) sutures, swellings, etc. and this is described. Photos are taken when appropriate. Mobility is assessed by determining the extent of movement and balance the person is capable of. A fall assessment is also made at this time to determine the risk for falls and bed injuries. Such things as rails padding or restraints will be applied accordingly. Physical therapy will determine what special needs the patient has special for transfers, wheelchairs or ambulation. Dementia is part of a neurological assessment. If the patient is admitted with dementia, it may already be well documented. The patient will be assessed for confusion, depression, appropriate responses, ability to follow simple verbal commands, ability to speak and ability to complete ADLs. ADLs are activities of daily living which are grooming, feeding, hygiene, toileting and dressing. There are several components to an assessment. Pain, psychosocial needs, nutritional needs, risk for dehydration, spiritual needs and incontinence are included in this.
Answered: Fri, 18 Dec 2009
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