Wounds

Questions

• 1.

  What surgical procedure did the patient have, and when was it performed?

  • It is important to consider the nature of the surgery performed and the important anatomy in the surgical region. This helps you think about the possible causes of the wound problem. For example, consider a draining abdominal wound. If the patient had a small-bowel resection, you may consider a draining enteric fistula. On the other hand, if the patient had an operation limited to the abdominal skin and the fascia, you would probably consider a draining seroma or wound infection.

  • The number of days a patient is postoperative is also an important piece of information. For example, if you are asked to evaluate a wound with erythema, recall that early streptococcus and anaerobic infections may present at postoperative days 1 and 2. Typical wound infections with S. aureus and other flora are most common between postoperative days 4 and 5.

• 2.

  What are the vital signs?

  • It is important to know if the patient is hypotensive, tachycardic, or febrile.

• 3.

  What is the presenting problem (e.g., is there pain, fever, swelling, drainage, or bleeding)?

• 4.

  What medical problems does the patient have?

  • A patient who has wound healing problems resulting from steroid use, diabetes, malnutrition, advanced malignancy, or chronic disease is more likely to have wound dehiscence and infection. Diabetic patients and patients taking steroids are immunosuppressed and often have few symptoms until they present with a serious wound problem.

• 5.

  What medications is the patient taking (e.g., anticoagulants, antibiotics, or steroids)?

  • It is important to know if a patient is anticoagulated. You should be careful when manipulating a wound in an anticoagulated patient. If the patient has significant bleeding from the wound and is anticoagulated, platelets or fresh frozen plasma (FFP) may be indicated. If a patient is receiving intravenous (IV) antibiotics and develops a wound infection, consider the possible organisms responsible and adjust antibiotic therapy accordingly.

Orders

• 1.

  Have dressing supplies, sterile gloves, eye protection, and proper lighting and suction available at the bedside.

• 2.

  If the patient has significant bleeding from the wound or evidence of hematoma, have the RN draw a hematocrit immediately. If there is concern for bleeding, have a needle driver, a stitch, and local numbing medication ready at bedside.

• 3.

  Have or bring a pen or marker to be able to outline the erythema surrounding the wound to track changes over time, especially important when considering necrotizing fasciitis.

Informing the RN

Tell the RN you will arrive at the bedside in XX minutes.

Wound problems represent a variety of postsurgical complications, ranging from benign to life-threatening processes. Examine the patient expeditiously.

Surgical Chart Biopsy

• Review the vital signs. Check for fever curve (trend over time), tachycardia, and hypotension.

• What is the trend in white blood cell (WBC) on complete blood count (CBC)?

• How has the wound been described in notes?