Care Plan for Surgical Wound Management

Category / Primary Body System

• Integumentary System / Musculoskeletal System

Problem

• Patient is at risk for complications due to surgical wound.

Goal

• Patient’s surgical wound will heal without complications (i.e., new onset infection, dehiscence) for 90 days.

Plan/Approach

1. Pain Management

   • Administer pain medication as ordered

2. Monitoring and Assessment

   • Monitor labs as ordered
   • Monitor surgical site for signs and symptoms of new infection, notify MD/NP if any
   • Monitor circulation, sensation, and movement (CSM) to affected extremities as needed

3. Consultations and Evaluations

   • Seek orthopedic consult as ordered
   • Provide PT/OT evaluation and treatment as ordered

4. Wound Care

   • Provide treatment to surgical wound as ordered
   • Reposition patient in a position of comfort as indicated

5. Patient and Family Education

   • Educate patient and family on signs of infection and proper wound care techniques

Rationale

1. Pain Management

   • Effective pain control promotes comfort and facilitates participation in physical activities, aiding recovery.

2. Monitoring and Assessment

   • Regular monitoring helps detect complications early, enabling prompt intervention.
   • Monitoring labs ensures early identification and management of potential complications, such as infection or anemia.

3. Consultations and Evaluations

   • Orthopedic consultations provide specialized care and recommendations for optimal wound healing.
   • PT/OT evaluations help maintain mobility and prevent complications related to immobility.

4. Wound Care

   • Proper wound care reduces the risk of infection and promotes healing.
   • Repositioning prevents pressure ulcers and enhances patient comfort.

5. Patient and Family Education

   • Educating the patient and family empowers them to participate in care, promoting adherence to treatment and early identification of complications.

Actions

1. Pain Management

   • Administer prescribed pain medications on schedule and as needed, monitoring for effectiveness and side effects.

2. Monitoring and Assessment

   • Draw and monitor labs as ordered, reviewing results for any abnormalities.
   • Assess the surgical site every shift for signs of infection (redness, swelling, warmth, discharge) and report any concerns to the MD/NP immediately.
   • Check CSM of affected extremities regularly, documenting and reporting any changes.

3. Consultations and Evaluations

   • Schedule and facilitate orthopedic consults to ensure proper wound management.
   • Arrange PT/OT sessions and assist the patient with prescribed exercises and activities.

4. Wound Care

   • Perform wound care as ordered, using aseptic techniques to prevent infection.
   • Reposition the patient every 2 hours or as needed to promote comfort and prevent pressure ulcers.

5. Patient and Family Education

   • Provide education on wound care, including cleaning, dressing changes, and signs of infection.
   • **Teach the patient and family about the importance of reporting any signs of infection or wound changes immediately.