Medical-surgical Nursing Demystified

(Sean Pound) #1

CHAPTER 13 Perioperative Care^489


present, referred to as normal flora. These bacteria may enter the wound and cause
infection. Nosocomial infections can also occur at the surgical site, caused by
bacteria found elsewhere in the hospital. Infection within the surgical wound will
slow approximation of the wound edges, delaying wound healing.


HALLMARK SIGNS AND SYMPTOMS



  • Increase in pain at surgical wound due to inflammatory process early in
    infection

  • Redness at wound edges that spreads if untreated

  • Drainage from wound site due to body’s response to bacterial presence (change
    in color and odor of drainage)

  • Fever due to infection

  • Elevated white blood cell count


INTERPRETING TEST RESULTS



  • Elevated WBC due to body’s response to bacterial presence.

  • Elevated erythrocyte sedementation rate due to inflammation.

  • Culture of wound area will identify organism.

  • Sensitivity test will identify appropriate antibiotic treatment.


TREATMENT



  • Obtain culture and sensitivity test of wound.

  • Administer appropriate antibiotics intravenously.

  • Keep wound site clean and dry.


NURSING DIAGNOSES



  • Risk for infection

  • Impaired skin integrity

  • Impaired tissue integrity

  • Delayed surgical recovery

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