The nurse is caring for a patient with multiple sclerosis and chronic nonhealing wounds. The nurse should assess the following: -Patient’s skin color, turgor, temperature, moisture -Assess neuro status of the patient (e.g., cranial nerves) .Assess the patient’s cognition The nurse should also assess for changes in level of consciousness, reflexes, muscle tone and ability to move.
Other considerations are what medications the patient is on (including dose), physical therapy exercise program or other interventions that have been tried. The goals with this type of wound care are: cleanse wounds without infection; remove debris from wounds using enzymatic washes or antibiotic ointments as needed; provide moist wound environment such as hydrocolloids dressing/gel foam dressings; promote healing by keeping exposed areas bandaged except when necessary to perform hygiene measures.
The nurse should assess the following: -Patient’s skin color, turgor, temperature, moisture. The patient is pale but warm to touch and has a wet wound surface with dried blood on his back near the site of injury. His neuro status seems normal for this type of MS patient and he can move all muscle groups in response to commands; however cognitive assessment reveals an inability to follow basic requests (e.g., “what are you doing now?”). He cannot remember anything from today or yesterday, so it is difficult for him to answer questions about current activities like what medications they’re taking at home. -Assess changes in level of consciousness, reflexes, muscle tone and ability to move from day.