73 Managing wound care
Diagnostic tests
White blood cell (WBC) count with differential:
Nursing diagnosis:
Impaired tissue integrity: wound
Desired Outcome: Patient exhibits the following signs of wound healing: well-approximated wound edges, good initial postinjury inflammatory response (erythema, warmth, induration, pain), no inflammatory response past the fifth day after injury, no drainage (without drain present) 48 hr after closure, healing ridge present by postoperative day 7-9.
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess wound for absence of a healing ridge, presence of drainage or purulent exudate, and delayed or prolonged inflammatory response. | These signs are indications of impaired healing. |
| Assess vital signs for elevated temperature and heart rate (HR). Document findings. | These are signs of infection, a manifestation of impaired wound healing. |
| Assess for hyperglycemia with serial capillary glucose measures and maintain blood glucose at prescribed level using insulin as indicated. | Hyperglycemia increases risk for infection, thereby adversely affecting wound healing. |
| As indicated, assess pulse oximetry. Report O2saturation 92% or less, and consult health care provider about administration of O2. | Oxygen saturation 92% or less often signals need for supplemental oxygen to support tissue function and healing. |
| Assess perfusion status by checking blood pressure (BP) and HR as well as capillary refill time adjacent to the incision. | These measures determine if blood flow to the area is adequate for healing. BP and HR optimally should be within patient’s normal range; capillary refill less than 2 sec signals inadequate tissue perfusion. |
| Assess hydration status by monitoring peripheral pulses, moisture of mucous membranes, skin turgor, volume and specific gravity of urine, and intake and output. | Hypovolemia adversely affects wound healing. |
| Assess serum albumin and total lymphocytes for decreased values. Consult health care provider about significant findings. | Serum albumin less than 3.5 g/dL and total lymphocyte count less than 1800/mm3 may indicate need for supplemental protein. |
| Assess wound pain using a numeric rating scale. Treat pain with pharmacologic and nonpharmacologic interventions. Anticipate pain associated with dressing change and premedicate. | Pain causes vasoconstriction and may impair healing. See “Pain,” p. 37, for details. |
| Follow agency policy and use sterile/clean technique when changing dressings. If a drain is present, keep it sterile, maintain patency (e.g., empty drainage reservoir and recharge suction on closed drainage systems as needed), and handle it gently to prevent it from becoming dislodged. | Sterile technique eliminates introduction of nosocomial organisms to prevent infection. Most outpatient wound care is done with clean technique. |
| Encourage deep breathing q2h while patient is awake. Splint incision as needed. If indicated, provide incentive spirometry. | Deep breathing promotes oxygenation, which enhances wound healing. |
| Stress importance of position changes at least q2h and activity as tolerated. | Movement, exercise, and activity promote ventilation and circulation, and hence oxygenation to the tissues. |
| For nonrestricted patients, ensure a fluid intake of at least 30 mL/kg body weight/day. | Adequate hydration is critical to wound healing. |
| Provide a diet with adequate protein, vitamin C, and calories. If patient complains of feeling full with three meals per day, give more frequent small feedings. Encourage between-meal high-protein supplements (e.g., yogurt, milkshakes). | This diet promotes positive nitrogen balance and nutrients needed for wound healing. Smaller, more frequent meals are often more easily tolerated. |
| If wound care is necessary after hospital discharge, teach clean dressing change procedure to patient and significant other. Immunosuppressed patients require sterile technique. | Clean technique is used at home because most people have antibodies to familiar organisms. Immunosuppressed patients have Increased risk of Infection. |
✓ patient-family teaching and discharge planning
✓ Local wound care, including type of equipment necessary, wound care procedure, and therapeutic and potential side effects of topical agents used. Have patient or significant other demonstrate dressing change procedure before hospital discharge.
✓ Signs and symptoms of improvement or deterioration in wound status, including those that necessitate notification of health care provider or clinic.
✓ Diet that promotes wound healing. Discuss importance of adequate protein and calorie intake. See “Providing Nutritional Support,” p. 521. Involve dietitian, patient, and significant other as necessary.
✓ Activities that maximize ventilatory status: a planned regimen for ambulatory patients and deep breathing and turning (at least q2h) for those on bedrest.
✓ Importance of taking pain medication, antibiotics, multivitamins, and supplements of iron and zinc as prescribed. For all medications to be taken at home, provide the following: drug name, purpose, dosage, schedule, precautions, and potential side effects. Also discuss drug-drug, herb-drug, and food-drug interactions.
< div class='tao-gold-member'>
Only gold members can continue reading. Log In or Register to continue
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
