Medical-surgical Nursing Demystified

(Sean Pound) #1

(^412) Medical-Surgical Nursing Demystified
PROGNOSIS
Prognosis depends on the size, location, and cause of the wound. Items which
need to be assessed in patients with wounds include chronic disease, such as dia-
betes, impaired circulation; nutrition; hydration status; and immunosuppression,
such as corticosteroid or chemotherapeutic agents. Epithelialization of wound
occurs within 48 hours, wound strength is 60 percent of previous strength within
4 months.
HALLMARK SIGNS AND SYMPTOMS



  • Pain from injury to nerves

  • Drainage from injury to tissues and cells migrating to the site of injury

  • Bleeding from injury to blood vessels

  • Foreign body—look for penetrating objects

  • Deeper tissue trauma—assess for nonintact tendons, ligaments, and pieces of
    bone

  • Debris—look for dirt, fragments

  • Signs and symptoms of infection include increased erythema; purulent, foul-
    smelling drainage; and fever

  • Wounds may be accompanied by pain, drainage, bleeding, infection, a for-
    eign body, or deeper tissue trauma. Assessment of the wound, including
    deeper structures if necessary, is imperative.


INTERPRETING TEST RESULTS



  • CBC to assess for leukocytoses for infection.

  • Chemistry to assess hydration status.


TREATMENT



  • Assess circulation if the wound is in a limb. Check distal pulses.

  • Tetanus prophylaxis as needed. A booster is indicated if the last one was not
    within the past ten years.

  • Irrigation of the wound with large amounts of saline to flush away all dirt,
    debris, and foreign bodies.

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