Wound care and Perioperative nursing

1. Wound care and Perioperative nursing Unit Eight

3. Classification of wounds 1. Intentional Vs. Unintentional. 2. Open Vs. Closed. 3. Degree of contamination. 4 . Depth of the wound.

4. Intentional Vs. Unintentional wounds Intentional wound: occur during therapy. For example: operation or venipuncture. Unintentional wound: occur accidentally. Example: fracture in arm in road traffic accident.

5. Open Vs. Closed wounds Open wound: the mucous membrane or skin surface is broken. Closed wound: the tissue are traumatized without a break in the skin.

6. Degree of contamination Clean wounds: are uninfected wounds in which minimal inflammation exist, are primarily closed wounds. Clean �contaminated wound: are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. There is no evidence of infection.

7. Degree of contamination Contaminated wounds: include open, fresh, accidental wounds. There is evidence of inflammation. Dirty or infected wounds: includes old, accidental wounds containing dead tissue and evidence of infection such as pus drainage.

8. Depth of the wound Partial thickness: the wound involves dermis and epidermis. Full thickness: involving the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone.

9. Types of wounds 1. Incision: open wound, painful, deep or shallow, due to sharp instrument. 2. Contusion: closed wound, skin appears ecchymotic because of damaged blood vessels, due to blow from blunt instrument.

10. Types of wounds 3. Abrasion: open wound involving skin only, painful, due to surface scrape. 4. Puncture: open wound, penetrating of the skin and often the underlying tissues by a sharp instrument.

11. Types of wounds 5. Laceration: open wound edges are often jagged, tissues torn apart. Often from accidents. 6. Stab wound: open wound, penetration of the skin and the underlying tissues, usually unintentional.

12. Pressure Ulcer * Pressure ulcer are also called bedsore. * A pressure ulcer: is any lesion caused by unrelieved pressure that results in damage to underlying tissue.

13. Pressure Ulcer Risk Factors 1. Immobility and inactivity. 2. Inadequate nutrition (specifically, inadequate intakes of protein, carbohydrates, fluids, and vitamin C) 3. Fecal and urinary incontinence: because moisture make the skin easily to break and injury.

14. Pressure Ulcer Risk Factors 4. Decreased mental status: because there is decreased in the respond to the pain associated with prolonged pressure. 5. Diminished sensation: paralysis or other neurologic disease may cause loss of sensation in a body area.

15. Pressure Ulcer Risk Factors 6. Other factors as: incorrect positioning, poor reposition, and repeated injections in the same area.

16. Stages of Pressure Ulcer Formation Stage I: erythema of intact skin. Stage II: Partial- thickness skin loss involving epidermis and dermis.

17. Stages of Pressure Ulcer Formation Stage III: Full- thickness skin loss involving damage of subcutaneous tissue. Stage IV: Full- thickness skin loss involving damage of muscle, and bone.

18. Wound Healing * Healing is regeneration (renewal) of tissues. * The time needed for healing depends on location, and size of wound, and health status of the client.

19. Complications of wound healing 1. Hemorrhage: some escape of blood from a wound is normal, but persistent bleeding is abnormal. 2. Hematoma: localized collection of blood underneath the skin, and may appear as a reddish blue swelling. 3. Infection

20. Factors affecting wound healing 1. Developmental considerations (child and elderly) 2. Nutrition: epically protein, carbohydrates, lipids, Vitamin A and C, and minerals. 3. lifestyle: regular exercises enhance healing.

21. Factors affecting wound healing 4. Medications: such anti-inflammatory drugs. 5. Contamination and infection: it�s delay the healing process.

22. Phases of Perioperative Nursing 1. Preoperative phase (before surgery) 2. Intraoperative phase (during surgery) 3. Postoperative phase (after surgery)

23. Preoperative phase *Nursing Assessment 1. History: -Allergies: for any medication. -Artificial teeth. 2. Learning and discharge needs: if the patient have any special needs.

24. Preoperative phase 3.Screening tests: 1. complete blood count (CBC): RBC, WBC, HB, Platelets. 2. Blood groping and cross-matching. 3. Serum electrolytes: Na, K, Ca,�. 4. Blood urea nitrogen (BUN), Creatinine. 5. Fasting blood glucose. 6. Liver functions test. 7. Urine analysis.

25. Preoperative phase 3.Screening tests: 8. Chest X-ray. 9. Electrocardiogram (ECG). 10. serum albumin and total protein.

26. Preoperative phase Nursing Interventions 1. Client teaching: What will happen and what he will fell during surgery. Skills training: moving, deep breathing, coughing, splinting incisions with hands or a pillow, using incentive spirometer.

27. Preoperative phase 2. Informed consent: Patient agreement to perform therapeutic procedure. 3. Client preparation: Shaving the operation site. Give preoperation medication. Psychological support.

28. Preoperative phase Nutrition and fluids: The patient should be fasts (NPO) for 6 to 8 hours at least before the surgery. clear fluids such as water or juice may be permitted up to 2 hours before the surgery. Vital sign: assess vital sign and report any abnormal findings.

29. Intraoperative phase Types of Anesthesia: General Anesthesia. Local Anesthesia. Topical Anesthesia. Epidural Anesthesia. Nerve block Anesthesia.

30. Intraoperative phase The nurse role in operation room: 1. Circulating nurse. 2. Scrub nurse.

31. Intraoperative phase Circulating nurse role: 1. help position the client for operation. 2. Obtain any additional supplies as needed. 3. Arrange the lighting.

32. Intraoperative phase Scrub nurse role: Assist the surgeons. Draping the client with sterile drapes. Handling sterile equipments and supplies. *they wear sterile gowns, gloves, and caps.

33. Postoperation Phase Postoperation Phase includes: Recovery unit. Post operation (Surgical) unit

34. Postoperation Phase In recovery unit: Monitor for level of consciousness. Assess vital sign. Assess operation site for bleeding or sever pain. Administration of fluids and medications. Assess for skin color. Maintain patient safety as he is not full conscious.

35. Postoperation Phase In Surgical Unit: Pain management: by using PRN analgesia medication. Positioning: position the patient as ordered. After spinal surgery the patient should be in supine position.

36. Postoperation Phase 3. Deep- Breathing and coughing exercises: its helps in preventing atalectasis (collapse of alveoli) 4. Leg exercise: every 1 or 2 hours to prevent deep vain thrombosis (DVT) 5. Applying elastic stocking: helps in prevent DVT and its improve the circulation.

37. Postoperation Phase 7. Moving and ambulation: Encourage the patient to turn from one side to other on the bed. the patient should ambulate as soon as possible. 8. hydration: maintain IV fluids as ordered.

38. Postoperation Phase 9. Diet: Diet can be started after hering bowel sounds. Diet should be given gradually. First clear fluids, then soft diet, then regular diet.

39. Postoperation Phase 10. wound site: Assess the wound for hemorrhage. Assess the wound for sign of infection (color, pain, heat, odor) Assess the wound drainage (color, amount, odor) Suture: remove sutures as ordered. Do sterile dressing as ordered.

40. Postoperation Phase 11. Administration of medication: usually there is antibiotic drugs after the operation. 12. Home care teaching: How to take care for the surgical wounds. When to change the dressing and how to change the dressing. Referrals time.

41. The End *Good luck *