The initial evaluation involves the person as a whole and ulcer, being the base to not only plan the treatment and to evaluate its effect. Ahead of this, the elaboration of a individualizado program of prevention and precocious intervention are a necessary instrument in the plan of cares drawn for the necessities of each patient. An adequate evaluation also is essential so that it has a communication between the professionals. Evaluation and repeated reevaluation of the patients of auto risk help the nurse to prove the effectiveness of the preventive therapies, or then to consider new interventions that it seem necessary. The careful comment of the skin in the search of any area of hiperemia is made during bath and the reposicionamento in the stream bed.
Interventions De Enfermagem – To evaluate the wound how much: – Classification. – Format and size. – Depth. – Localization. – Exsudato. – Appearance of the wound.
– Color of the injury. – Extension of the wound. – Odor. – Pain. – Time of existence. Avaliar the progression/regression or any change in the wound. Definir appropriate the necessary products/for each phase of the wound. Identificar the educational necessities of the cuidador patient/how much to the cares with the wound in domicile. Encaminhar the patient to other professionals (Psychology, Social Service etc.) in appropriate way. Care with the ulcer for pressure the initial care of the Ulcer of Pressure involves cleanness of the wound, desbridamento application of the dressing and possibly an associate therapy, in some cases the surgery repairman will be necessary. – Cleanness of the wound the cicatrizao of the wound is optimized and the potential for diminished infection when all the necrticos fabrics, exsudatos or metabolic remaining portions are removed of the wound. Cleanness: initially cleans the wounds and to each exchange of dressing. Utilize one not traumatic technique .