Surgical Wound Care: Phases, Classification, and Complications, Exams of General Surgery

Download Surgical Wound Care: Phases, Classification, and Complications and more Exams General Surgery in PDF only on Docsity! Chapter 14 Surgical Wound Care (Notes/NCLEX) Phases of Wound Healing - Four Phases: 1. Hemostasis: (termination of bleeding) begins as soon as the injury occurs. 2. Inflammatory Phase: initial increase in the flow of blood elements (antibodies, electrolytes, plasma proteins) and water out of the blood vessel into the vascular space. This process causes the cardinal signs and symptoms of inflammation: erythema(redness), heat, edema(swelling), pain, and tissue dysfunction. During the inflammation phase, cells in the injured tissue migrate, divide, and form new cells. Slowly blood clots dissolve and the wound fills; the sides of the wounds usually meet in 24-48 hours. 3. Reconstruction: Collagen formation occurs during the reconstruction phase. this phase begins on the third or fourth day after the injury and lasts for 2-3 weeks. Fibroblasts produce collagen, a glue like protein substance that add tensile strength to the wound and tissue. Wound dehiscence most frequently occurs during the reconstruction phase. 4. Maturation: Approximately 3 weeks after surgery, fibroblasts begins to exit the wound. The wound continues to gain strength, although healed wounds rarely return to the strength the tissue had before the surgery. Occasionally, a keloid which is an over growth of collagenous scar tissue at the site of a wound forms during the maturation phase. Process of Wound Healing - 1. primary intention(primary union): minimal scaring results. Primary intention healing begins during the inflammatory phase of healing; in surgery, this is usually during the closure of the wound. A) -incision with blood clot -edges approximated with suture -fine scar 2. secondary intention(granulation): heals when a wound must granulate during healing, occurs when skin edges are not close together (approximated) or when puss has formed. Some wounds develop purulent exudate when injured or disease tissue dies. Slowly, the necrotized tissue decomposes and escapes, and the cavity begins to fill with granulation tissue, or soft, pink, fleshy projections that consist of capillaries surrounded by fibrous collagen. B)-irregular, large wound with blood clot-granulation tissue fills in wound-large scar 3. tertiary intention(third): delayed primary intention. the practitioner leaves a contaminated wound open and closes it later, after the infection is controlled, by stuttering two layers of granulation tissue together in the wound. This type of healing occurs when a primary wound becomes infected, is opened, is allowed to granulate, and is then sutured. C)-contaminated wound-granulation tissue-delayed closure with suture Surgical Wound Classification - Class #1 => CLEAN *clean (not infected or inflamed) Class #2 =>CLEAN/CONTAMINATED *evidence of infection or contaminated/major break in technique Class #3 =>CONTAMINATED *fresh, open, or accidental/visible spillage from gastrointestinal tract/have non-purulent inflammation Class # 4 =>DIRTY/CONTAMINATED old wound/retained devitalized tissue/existing clinical infection/ perforated viscera Types of Wound Drainage - A)Serous: clear, watery plasma B)Purulent: thick, yellow, green, tan, or brown C)Serosanguineous: pale, red, watery: mixture of serous and sanguineous D)Sanguineous: bright red: indicates active bleeding Terms Associated With Wound Complication - Abscess: Cavity that contains pus and is surrounded by inflamed tissue. Adhesion: Band of scar tissue that binds together two anatomic surfaces normally separated. cellulitis: Infection of the skin characterized by heat, pain, erythema, and edema. dehiscence: Separation of a surgical incision or rupture of a wound closure. evisceration: Protrusion of an internal organ through a wound or surgical incision. extravasation: Passage or escape into the tissues (blood,serum,lymph) hematoma: Collection of extravasated blood trapped in the tissues or in an organ that results from incomplete hemostasis after surgery or injury. 13. The student nurse is changing the patient's dressing. What actions indicate the need for further indication? - 2. clean the wound in circles toward the incision 3. free the tape by pulling it away from the incision 4. remove the soiled dressing using sterile technique 5. applying the clean dressing with clean gloves When emptying the drainage in a Hemovac reservoir which nursing action is essential for reestablishing the negative pressure within the drainage device? - 3. Compress the reservoir and close the vent. 15. Which patient is most at risk of wound dehiscence? - 2. obese patient. 16. Which wound drain is classified as providing gravity assisted drainage? - 3. Penrose 17. The health care provider has ordered all sutures on a patient with an abdominal hysterectomy be removed on the 5th postoperative day and Steri-Strips applied. During the suture removal, the nurse notices the incision edges slightly separating. What is the best decision by the nurse? - 4. Stop the suture removal, apply Steri Strip where suture have already been removed, and notify the health care provider. 18. When providing care to a patient with a Hemovac drain, what actions are included in the plan of care? - 1. Record the appearance of the drainage in the nursing progress notes and include the amount in the output and intake calculations. 19. During the assessment of a patient after abdominal surgery, the nurse suspects internal hemorrhaging based on which finding? - 2. The dressing is dry and intact, and the patient's blood pressure has decreased and pulse and respiration have increased. 1.What is the nurse's first step when caring for a patient needing wound care? - D. Check the medical records for physician's orders. 2. The nurse is caring for a patient with a wound on the right arm. The wound is covered by a bandage. What would be the priority nursing assessment when inspecting the skin that is distal to the bandage? - A. circulatory impairment 3. When classifying wounds, which classification results from the presence of gastrointestinal products? - A. Contaminated 4. If a patient with an abdominal incision begins to cough, which intervention is the most appropriate? - B. Apply a pillow to the incision with slight pressure. 5. When removing staples from a surgical incision, which intervention is most appropriate? - D. Remove every other staple first, and replace with Steri-Strips while ensuring that the incision remains closed. 6. The physician has ordered a sterile dry dressing change. What is the most appropriate way to cleanse the wound and surrounding area? - B. Using an aseptic swab, start from the incision outward, one stroke per swab, then allow to air-dry. 7. The physician has ordered for a patient's leg wound to be irrigated using an antiseptic solution. What would the nurse do to reduce the chance of contamination? - C. Have the solution flow from the least contaminated to the most contaminated area. 8. A patient has come to the PACU after hip replacement surgery. Following the nursing assessment, the health care teams needs to set up a plan of care. What would the nurse anticipate to be the highest priority nursing diagnosis? - D. Skin integrity, impaired A patient is 3 days postoperation from abdominal surgery. Which conditions would the nurse assessing the abdominal incision consider normal? (select all that apply) - -Clean, well-approximated edges -Staples or sutures intact -A small amount of serous drainage