Hello, this is an assignment from the Medical-Surgical Nursing Lab and the teacher wants a nursing note related to caring for a surgical wound (no less than 10 sentences). Please create a real case on an unreal patient. Bibliography: 1. Ignatavicius, D., & Workman, M. (2015). Medical-Surgical Nursing (8th ed.). St Louis, Missouri: Elsevier. ISBN: 9781455772551.
Nursing Note: Caring for a Surgical Wound
Patient Profile:
Patient: Mr. John Doe
Age: 45 years old
Gender: Male
Medical History: No significant medical history
Surgical Procedure: Appendectomy
Surgical Wound: Approximated incision in the right lower quadrant
Surgical Wound Status: Day 2 post-operative
Subjective:
The patient reported mild pain around the surgical site, rated as 3/10 on a numeric pain scale. Patient denies any fever, chills, or discharge from the wound. Patient expresses concerns about wound care and asks about healing progress.
Objective:
Vital signs stable within normal limits. Surgical wound is clean, dry, and intact. Sutures are well-approximated with no signs of dehiscence or infection. Edges of the incision are slightly erythematous but without any drainage or odor. Wound measures approximately 5 cm in length and approximated with staples. No swelling or redness observed around the incision. The patient ambulates without difficulty and denies any signs of systemic infection.
Assessment:
The surgical wound is healing as expected. The mild erythema observed may be indicative of normal inflammatory response and is closely monitored for any signs of infection. Pain appears to be well-controlled with analgesics as evidenced by the patient’s pain rating of 3/10. No other signs or symptoms of complications are noted at this time.
Plan:
1. Continue to assess the surgical wound with each dressing change.
2. Administer prescribed analgesics as needed to maintain pain control.
3. Provide patient education about wound care, emphasizing the importance of keeping the wound clean and dry to prevent infection.
4. Reinforce the need for adherence to post-operative activity restrictions to minimize the risk of wound dehiscence and promote healing.
5. Instruct the patient on signs and symptoms of wound infection to report promptly if observed.
6. Collaborate with the healthcare team to obtain wound culture and sensitivity if warranted by changes in wound appearance or clinical signs of infection.
7. Document wound characteristics, pain rating, and any interventions provided in the patient’s medical record.
8. Ensure proper hand hygiene prior to and after each wound care procedure.
9. Maintain a clean and sterile environment during wound dressing changes to prevent contamination and infection.
10. Monitor the patient’s overall well-being and response to the surgical intervention.
Rationale:
1. Regular assessment of the surgical wound allows for early identification of any changes, facilitating prompt intervention if necessary.
2. Administering analgesics as needed helps to alleviate pain and aid in patient comfort during the healing process.
3. Patient education plays a vital role in optimizing wound care and preventing complications. A well-informed patient is more likely to adhere to the recommended care plan.
4. Reinforcing post-operative activity restrictions reduces the risk of wound disruption and enhances the healing process.
5. Prompt reporting of any signs or symptoms of infection allows for timely intervention and prevents the progression of wound-related complications.
6. Obtaining wound cultures and sensitivities when indicated helps guide targeted treatment if infection is suspected.
7. Accurate documentation is crucial for continuity of care and evaluation of the patient’s progress.
8. Ensuring proper hand hygiene minimizes the risk of introducing pathogens to the surgical wound.
9. Maintaining a clean and sterile environment during dressing changes reduces the risk of infection.
10. Continuous monitoring of the patient’s overall well-being and response to treatment allows for early identification of any adverse events or complications.
In conclusion, Mr. John Doe’s surgical wound is progressing favorably without any signs of complications. With diligent wound care, pain management, and patient education, the risk of infection and other complications can be minimized, promoting optimal healing and recovery.