N370 q2 - Wound care, pressure injury, hemorrhage, DVT, pt position

surgical wound infection S/sx:

- tachycardia, hyperthermia

- elevated WBC (>5k)

- wound swelling, warmth, tenderness, discharge

- increased incisional pain

Surgical wound infection interventions:

- Blood and culture

- initiate antimicrobial and wound care regimen: Clean, debride, - Absorb fluid and exudate, Fill dead space

- antibiotic use PRN, monitor

- If found in surgical incision, the surgeon may insert a drain

Prevention of surgical site infections (SSI)

- Must be done in pre-op phase

- Selection, timing of antibiotics prophylaxis: administer 1 hr before incision; discontinue in 24

- chlorhexidine 6 wipes body bath

- PRN hair clipping removal (NO routine hair removal, DO NOT shave)

- Control blood glucose postop <180 mg/dL

- Maintain body temp 36-38 C w/in 1 hr of surgery

Antibiotic prophylaxis why is it done and what should a post-op understand?

- to prevent infection

- know what med and SE

Primary Intention - Def:

Muscle and skin edges are held intact

Secondary Intention - Def:

muscle layer closed BUT skin layers open

Delayed Primary closure (delayed suture) - Def:

When a wound is intentionally left open and packed moist w/ saline dressing for 3 days

Rule of thumb for moist wounds

MUST be kept MOIST and COVERED

What seals wounds and when?

Epithelial cells seal wound only AFTER granulation is complete

Wound closure phases and what is done

- Hemostasis: day 0 - 5; platelet aggregate

- Inflammation: Day 5 - 10; Neutrophils and keratinocytes come together

- Proliferation: Day 10 - 20, monocytes/macrophages/endothelial cells are present

- Maturation and remodeling: Day 25 - 2 yrs: fibroblasts close wound

Special consideration r/t steroid use and wound closure phases

will have a shorter inflammation phase d/t lack of neutrophils

The highest risk of infection in what days?

4 - 7

What major components help wound healing?

Collagen and fibroblasts

What increases collagen?

Vitamin A intake

What increases fibroblasts

Protein and vitamin C

Dehiscence wound def

When edges of a wound are not closing, this is a result of excessive stress on wounds that are not healed

Dehiscence Interventions:

- Keep open tissue moist until healed

- Change dressing

- Do B+C if abnormal discharge is found

Stage 1 PI - def + special note

- Non-blanch-able erythema of intact skin

- The presence of a non-bursted blister is indicative of stage 1; if bursted then it is stage 2

Stage 2 PI - def

Partial thickness skin loss w/ exposed dermis

Stage 3 PI - def

Full-thickness skin loss to the subcutaneous layer (fatty tissue); may have undermining or tunneling

Stage 4 PI- def

Full-thickness skin and tissue loss w/ ulceration to the tendon, cartilage, or bone; tunneling or/and undermining may be present

def Unstageable-

When the depth of the wound is obscured by eschar (black necrotic tissue) or slough (yellow dead tissue and wbcs)

def Deep tissue injury-

persistent non-blanch-able deep red, marron, or purple discoloration. May be boggy (mushy). May be a blood-filled blister. Is due to pressure and/or shearing.

Cause of tissue death:

lack of oxygen

Cause of lack of oxygen:

shear forces and/or friction

def Friction -

When an object is dragged or rubbed across the skin

def Shearing -

when forces are applied to body tissue or parts that cause the tissue to move in opposite directions (gravity)

Pressure injury prevention:

- Risk assessment (BRADEN)

- Skin assessment

- follow facility protocol

- Provide cushion to protect bony prominences

- Turn/reposition q2hrs

- Minimize skin moisture and Manage incontinence via barrier creams, fecal pouches, foley, etc.

- pressure reduction via bed/mattress, cushion, offloading (pillow underneath heels)

- Promote nutrition of high protein diet

- support surfaces

PI risk assessment

- Braden scale

- risk factors:

immobility,

inactivity,

mechanical forces,

nutrition issues,

medical conditions (hypotension, CF, DM, joint contractures, cancer, impaired mental status),

Incontinence, perspiration, wound draiange, dryness, poor skin turgor,

s/sx Pulmonary edema:

SOB, light headache, coughing w/ bright blood

s/sx Pulmonary embolism:

Fat embolism syndrome, petechiae neck/chest

Venous thrombosis RISK factors

VIRchows’s TRIAD

V -vascular trauma

I - increased coagulaility

R - Reduced blood flow (stasis)

- vascular trauma, increased coagulability, blood stasis (60+ yrs old)

- Obesity,

- Trauma,

- Pregnancy, contraceptives,

- Concomitant diseases (Afib, PVD, sickle cell, malignancies)

Effects of immbolity

DVT

Deep Vein Thrombosis Clinical Findings:

-Leg/calf pain

- Redness

- Swelling

- Warmth

- Difficult to palpate pulse

DVT interventions:

- O2 admin

- Anticoagulants and thrombolytics ASAP

- ambulate ONCE on anticoagulants

DVT contraindications:

DO NOT use compression devices or ambulate if positive

DVT prevention:

- Ambulate ASAP

- Graduated compression stocking

- Sequential compression devices

- Anticoagulation (low-molecular-weight-heparin, enoxaparin, fondaparinux)

a position to prevent aspiration

Rescue position aka lateral sim’s

(Side-lying with HOB flat; maintain open airway w/ head tilt and chin lift)

Position for For Airway, breathing (ventilation), gas exchange

Upright, high Fowler's, dangle at bedside, chair

Position For Cardiovascular system (CVS): Low BP, Pre-syncopal, dizzy

Supine, head flat, w/ legs elevated (modified Trendelenburg)

position For Neuro Pathology (head injury, craniotomy, stroke)

HOB low for blood flow to the brain; and elevate for drainage from the brain

position for Body part (Trauma, injury complication)

Dependent for arterial flow; elevates for venous drainage and edema reduction

Position of comfort (whatever pts want, not contraindicated)

what for

Usually for pain

cause of hemorrhage

This can be due to a missed suture to tie off blood vessels or dehiscence

Hemorrhage Interventions:

- The area of bleeding is marked

- Apply another dressing on top (reinforce dressing)

- DO NOT remove the dressing unless the surgeon says so

- Hold direct pressure

- Call surgeon immediately

- Assess vital signs

Which of the following conditions is a result of blood loss, hypoventilation, position changes, pooling of blood in extremities, or side effects of medication and anesthesia?

- hypotension

- hypertension

- hyperglycemia

- hypoglycemia

Hypotension

Evisceration

Def:

Total separation of wound layers resulting in organ spillage; a medical emergency

Evisceration Interventions:

- Immediately apply a large sterile gauze dressing wet with normal saline (if available sterile saline is best!)

- Immediately call surgeon

- Expect pt to return to surgery for repair