J.V.S., 83 years old, male, married, illiterate, retired.
He sought care presenting venous ulcer in IIM.
The patient suffered a burn in the left lower limb approximately 40 years ago, with frequent inflammation, even in an open wound as it is today.
I've been here for many years, though I've been here for five years.
She denied diabetes, alcoholism or hypertension.
Located anxiety before surgery, on March 29, 2010.
Other surgeries were performed to prepare the area for the skin graft.
During admission care was taken to improve the injury: healing every other day, using 0.9% saline (SF), calcium alginate, essential fatty acids (AGE) and non-adherent mesh.
She complains of pain in the cure and when the pain is low.
Physically oriented: conscious, communicative (Glasgow Coma Scale=15).
Walking, not walking, using wheels as support
Hemodynamically stable.
Spontaneous breathing, without the help of O2.
Pulmonary and cardiac anomalies were normal.
Upper limbs (ULMM) without edema, normohydrated, peripheral venous access in upper left limb (ULF), sustained peripheral perfusion.
Acid plan, hydroaerial noises
Partially accept the offered diet.
Lower limbs (LLL) with sustained peripheral perfusion, dressing or dressing in IIM.
Physiological eliminations present.
Complete blood count, urea, creatinine, glycemy, coagulogram, electrocardiogram, and chest x-ray were performed.
Pharmacological therapy included: antibiotics, analgesics, antipyretics, prokinetics, anti-ulcer medications, platelet anti-coagulant guidance, in addition to maintaining the lower limbs elevated to 40o.
Systematization of nursing care
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Nursing Staff
11/03/2010
J.V.S., 83 years old, male, 14th day of hospitalization (DIH) for surgical cleaning in IIM.
Awake, conscious.
Chest pain, chest pain
Spontaneous breathing without supplementary O2.
Pulmonary and cardiac physiologic auspices.
Resected MMSS, hypohydrated, maintained peripheral tissue perfusion, absence of venoclysis.
You accept diet.
The abdomen was flat, painless to palpation.
Reduced spontaneous diuresis.
Vaccinations present.
Renewed dressing on the left foot: extensive, deep wound, small fibrin stitches, large granulation area, serous exudate, moderate quantity.
Calcium alginate + AGE + 0.9% saline + non-adherent mesh was used.
Change in 48 hours and if necessary change secondary dressing.
16/03/2010
19o IDH.
Renewed dressing on the left foot of venous ulcer: extensive, deep wound, small areas of fibrin in the peripheral region, extensive granulation area to the center, presence of serous exudate.
Calcium alginate + non-adherent mesh + EFA + 0.9% saline were used.
Change in 72 hours and, if necessary, change secondary dressing.
Set up for evaluation by a plastic surgeon for a skin graft
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Final considerations
Given the above, it is observed that nursing plays a fundamental role in the care of patients with venous ulcers, as it constitutes a chronic disease, with slow recovery and possibility of recurrence, with important implications for the patient's life.
Health education is extremely important for this patient, as it needs guidance regarding changes in their lifestyle, implying changes in relation to eating habits, sedentarism and smoking.
Some aspects should be focused on the treatment of venous ulcers, especially the continuous use of compression stockings by patients, who should be instructed to follow the medication treatment completely.
The nurse educator enables his/her students to take measures that provide the patient's release for self-care.
It is essential that nursing acts not only in wound care, but also holistically, seeing the patient globally.
Nurses' orientation to patients contributes significantly to the search for quality of life strategies aimed at preventing this disease, its complications and health promotion, thus achieving better patients with venous ulcers.
