Surgical Wound

Surgical Wound Management

Category / Primary Body System

• Integumentary System

Problem

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

Goal

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

Plan/Approach

1. Pain Management

   • Administer pain medications as ordered to ensure the patient is comfortable and to facilitate healing.

2. Lab Monitoring

   • Monitor labs as ordered to track healing progress and detect any signs of infection or other complications early.

3. Specialist Consultation

   • Facilitate orthopedic consults as ordered to ensure proper assessment and treatment of the surgical wound.

4. Rehabilitation Services

   • Provide PT/OT evaluation and treatment as ordered to support mobility and prevent complications related to immobility.

5. Positioning and Comfort

   • Reposition the patient in a position of comfort as indicated to prevent pressure sores and promote wound healing.

6. Wound Care

   • Administer treatment to the surgical wound as ordered to promote healing and prevent infection.
   • Monitor the surgical site for signs of new infection, such as redness, swelling, warmth, or discharge, and notify MD/NP if any are observed.

7. Circulation, Sensation, and Movement (CSM) Monitoring

   • Monitor CSM to affected extremities as needed to ensure adequate blood flow, sensation, and movement, which are essential for healing.

Rationale

1. Pain Management

   • Proper pain management is essential for comfort and to facilitate participation in activities that promote healing.

2. Lab Monitoring

   • Regular lab monitoring helps detect any early signs of infection or other complications, allowing for prompt intervention.

3. Specialist Consultation

   • Orthopedic specialists can provide targeted care and recommendations to ensure optimal healing of the surgical wound.

4. Rehabilitation Services

   • PT/OT services help maintain or improve mobility, which is crucial for overall health and to prevent complications.

5. Positioning and Comfort

   • Regular repositioning helps prevent pressure ulcers and supports wound healing by improving blood flow.

6. Wound Care

   • Proper wound care is critical to prevent infection and ensure the wound heals effectively.

7. CSM Monitoring

   • Monitoring circulation, sensation, and movement helps detect any issues early, ensuring timely interventions.

Actions

1. Pain Management

   • Administer prescribed pain medications regularly and as needed, documenting effectiveness and any side effects.

2. Lab Monitoring

   • Draw and monitor labs as ordered, reporting results to the healthcare team promptly.

3. Specialist Consultation

   • Arrange and facilitate orthopedic consultations as ordered and follow through on specialist recommendations.

4. Rehabilitation Services

   • Coordinate PT/OT evaluations and treatments as ordered, ensuring the patient participates as recommended.

5. Positioning and Comfort

   • Reposition the patient every 2 hours or as needed to maintain comfort and prevent pressure sores.

6. Wound Care

   • Administer wound care treatments as prescribed, ensuring the wound is cleaned and dressed according to protocol.
   • Monitor for signs of infection (e.g., redness, warmth, swelling, discharge) and notify the MD/NP immediately if any signs are present.

7. CSM Monitoring

   • Assess circulation, sensation, and movement in affected extremities regularly, documenting findings and reporting any concerns to the healthcare team.