Community Nursing Note

Patient Information

• Aroha Williams, NHI: ZAC4829, DOB: 14/05/1952
• 24/05/2024 at 10:30 NZST
• Patient's home (Community Nursing Visit, Auckland)

Subjective

• Scheduled visit for R lower leg venous ulcer dressing change and T2DM review. Pt reports increased exudate over past 2 days.
• Reports 3/10 aching pain at R medial malleolus ulcer site, worse on standing.
• Anxious about compression bandaging feeling too tight at night.
• Pt and daughter understand the need for compression therapy and strict glycaemic control to promote healing.

Objective

• BP 138/82 mmHg, HR 76 bpm, RR 16 /min, Temp 36.7 °C, SpO2 98 % on RA.
• Alert, oriented, NAD. R medial malleolus ulcer measures 3.2 cm x 2.5 cm x 0.2 cm depth; wound bed 80 % granulating, 20 % slough; moderate serous exudate; periwound skin slightly macerated, no surrounding erythema or warmth. 1+ pitting oedema to R ankle. Dual heart sounds, chest clear bilaterally. Mobilises independently with a single-point stick.
• Capillary blood glucose (fasting): 7.8 mmol/L.
• Recent wound swab (20/05/2024): mixed skin flora, no significant pathogens. GP recently increased metformin to 1,000 mg PO BID.

Assessment

• Impaired skin integrity related to chronic venous insufficiency; mild periwound maceration secondary to increased exudate.
• Priority 1: Wound bed preparation and exudate management. Priority 2: Oedema reduction via tolerable compression. Priority 3: Ongoing T2DM monitoring.

Plan

• Transition primary dressing to cadexomer iodine (Iodosorb®) to manage slough and exudate, with foam secondary dressing and reduced-compression two-layer system.
• Nil further diagnostic tests scheduled for today.
• Update GP (Dr. S. Patel) via electronic task regarding dressing change and wound progress.

Interventions

• Administered paracetamol (Panadol®) 1,000 mg PO 30 mins prior to wound care. Cleansed ulcer with warmed normal saline. Applied barrier film (Cavilon®) to periwound skin, cadexomer iodine ointment to wound bed, silicone foam dressing (Mepilex® Border), and two-layer compression bandage (Coban™ 2 Lite).
• Pt tolerated procedure well; pain reduced to 1/10 post-analgesia and states the lite compression feels comfortable.

Evaluation

• Exudate contained, periwound skin protected, and compression therapy successfully re-established with good pt tolerance.
• Ulcer dimensions stable compared to last week; no clinical signs of spreading infection.

Plan for Continuing Care

• Next community nurse visit scheduled for 27/05/2024 for dressing change and wound reassessment; GP review in 2 weeks.

Additional Notes:

• Educated pt and daughter on red-flag infection signs (increased pain, redness, heat, malodour, or fever) and advised to elevate legs when sitting.
• Discussed transition to compression hosiery once ulcer is fully healed; pt agreeable.
• Home environment assessed: clear walkways, good lighting, nil acute falls hazards identified.