Surgical Wound Care

Types of Wounds
* According to how they are acquired
* Abrasion, laceration, cut/incision, trauma
* According to the degree of wound contamination
* Dependent for how the is the wound, if there is any antibiotic, other treatments
* According to depth
* Dermis, epidermis, subcutaneous, muscle
Purpose
* Promote wound healing
* To promote optimal condition

Factors affecting wound healing
* Developmental considerations
* Nutrition
* Lifestyle
* Medications
* Infections

Complications of Wound Care Healing
* Hemorrhage
* Hypovolemic Shock
* Hematoma
* Infection
* Dehiscence with possible evisceration

Types of Dressing
* Gauze
* Synthetic Dressings
* Hydrocolloids
* Foams
* Alginates
* Hydrogels

Modes of Applying the Drainage
* Dry to dry
* Use clean gauze
* Pat dry inner to outer
* Wet to dry
* Use the sterile bowl
* Place sterile gauze
* Put NSS to the gauze at the sterile bowl
* Prepare another sterile gauze. Maintain it dry.
* Use 2 forceps. Grab the end of the gauze with forcep A, then another end with forcep B * Pigain ng hindi gumagamit ng kamay. Only rolling the forceps * Place the wet gauze at the wound site

* Then cover the wet gauze with a dry gauze.
* Wet to damp
* Wet to wet

Kinds of Wound Drainage
* Serous exudate
* Clear in color
* Purulent exudate
* Yellowish
* Might need the swab
* You do not need to clean the area when you are going to get a sample / culture * Sanguineous exudate

Wound Drains
* To excrete excess fluids and promote healing
* Jackson Pratts
* Do not kink when draining
* Penrose drain
* To drain excess fluids
* Pin – to hold in place
* Serve a stopper
* T-Tube
* Hemovac
* Gomco Suction Device

Change of Dressing
* First 24 hours, post op dressing do not touch because it is a pressure dressing * For preventive measures
* Type depends upon the type of wound that you patient has. * Principle: CLEAN TO DIRTY
* Inscision site is the cleanest area
* Sterile dry dressing
* Use of antiseptic and then apply dry gauze
* Before you change the dressing, check first condition of the patient * Post op site is worse, call the physician
Methods
* Sterile technique
* Clean Technique

Abdominal Binder
* For post op abdominal surgery
* Scultetus Binder
* Cloth only
* OB Case – top to bottom (involution)
* Post Abdominal Surgery – bottom to top (to tighten the abdominal muscles)

Care of the Unconscious
* Eye Care
* Make a mitten (to avoid the drip of the excess fluids of the patient, to prevent in drying easily of the washcloth, inner to outer) * Moisten the muta first before removing it
* Unconscious client = diminished blinking reflex apply eyepad * In applying eye drips hyperextend the neck to lessen blinking reflex * Non dominant to lower the conjunctive, dominant hand to squeeze the eye drop * After placing the solution, tell the patient to close the eyes gently, rotate the eyeballs * Eye ointment inner to outer canthus

* Ophthalmic solution first then eye ointment
* Oral Care
* Toothette
* Position of patient
* Conscious = semi fowlers
* Unconscious = side lying, flat or supine while the head is on the side (to promote drainage of secretions) * Place the towel on the chest
* Patient has artificial dentures
* Use the padded tongue depressor or toothette (only foam) * Dip on the water then press on the side
* Use as a tooth brush
* Artificial dentures
* Brush it
* Conscious patient
* Semi fowlers
* Place kidney basin at the chin part
* Unconscious
* Do not place the artificial dentures
* Dentures = place in an opaque container with water (to keep it moisturize, keep from dryness) * Make sure not to forget the suction machine is always available at bedside * Can apply petroleum jelly

* Nasal Care
* Use cotton buds
* Can moisten with salinase
* Treatment of Pressure Ulcers
* Stage 1
* Reddened, hard
* Stage 2
* Stage 3
* Stage 4
* Apply antiseptic solutions, antibiotics
* flushing
* Pinakamadumi ang insertion site kapag draigage – so inner to outer

Psoriasis
* Use of potassium permanganate
* Use gloves
* Has drying effect
* Use tap water, then place small bits of potassium permanganate (will turn purple, but it should be light pink)

Post Mortem Care

Signs of Absolute Death
* CBF(Cerebral Blood Flow)
* Normal cerebral blood flow study showing cranial space filled with blood * Flat EEG
* Cerebral blood flow study showing no blood entering the brain

Body Changes after Death
* Algor Mortis
* Rigor Mortis
* Livor mortis

Post Mortem Care
* Talk to it even when it is already dead
* Give some time to grief
* After some time, tell the family that you have to prepare the patient * Accomplish the cadaver form
* Time of death
* Give it a bath
* Oral care
* Nasal care
* If for autopsy
* Cut all the tubes, do not remove
* It not for autopsy
* Remove all

Death related Rituals and Funerals of selected religious groups * Muslim
* Dying person must confess sins and ask forgiveness in presence of family, family washes and prepares body and turns body towards Mecca * Judaism
* Body ritually washes by members of ritual burial society; burial as soon as possible * Lutheran, Methodist, Presbyterian
* Roman Catholic