A patient requires a sterile dressing change for an abdominal incision. How would you determine what is needed in the way of supplies? How would you set up a sterile field? The patient’s wound will heal in 3 phases, explain the phases of wound healing. Differentiate between a wound dehiscence and a wound evisceration? What steps will the nurse take for both
Determining the supplies required for a sterile dressing change for an abdominal incision involves a systematic approach to ensure all necessary items are readily available. Firstly, the type and size of the dressing needed should be determined based on the characteristics of the wound, such as its size, depth, and presence of drainage. The nurse should consult the healthcare provider’s orders for any specific instructions regarding the type or brand of dressing to be used.
In addition to the dressing, other supplies commonly needed for a sterile dressing change include sterile gloves, sterile saline or an antiseptic solution, sterile forceps or applicators for wound cleaning, sterile gauze or sponges for wound packing, adhesive tape or sterile dressings for securing the dressing, and a biohazard bag for disposal of soiled items. It is crucial to ensure that all supplies are within their expiration dates and free from any signs of damage or contamination.
Setting up a sterile field for the dressing change is crucial to prevent infection. The nurse should choose a clean and well-ventilated work area, away from any potential sources of contamination. The work surface should be covered with a sterile drape or towel, and all supplies should be opened on the sterile field. While conducting the dressing change, the nurse must use sterile gloves and avoid touching any non-sterile surfaces or items.
Wound healing is a complex physiological process that occurs in three distinct phases: the inflammatory phase, the proliferative or granulation phase, and the maturation or remodeling phase. The inflammatory phase is the initial stage of wound healing and involves the formation of a blood clot to stop bleeding and the release of inflammatory cells to remove any debris or bacteria. During this phase, the wound may appear red, swollen, and painful.
The proliferative phase is characterized by the formation of granulation tissue, which consists of new blood vessels and connective tissue cells. The wound begins to heal from the bottom up, and collagen is produced to provide tensile strength to the new tissue. In this phase, the wound may appear red and raised, and there may be a slight to moderate amount of drainage.
The final phase of wound healing is the maturation or remodeling phase. During this phase, the newly formed collagen fibers reorganize and align along tension lines. The wound gradually becomes stronger and more resistant to stress. The appearance of the wound at this stage depends on various factors, but it typically becomes flat, lighter in color, and less raised.
Differentiating between wound dehiscence and wound evisceration is crucial in order to determine appropriate nursing interventions. Wound dehiscence refers to the partial or complete separation of the layers of a surgical incision. It typically occurs within the first few days after surgery and is often associated with factors such as poor wound healing, infection, excessive tension on the wound, or disruption of the sutures or staples. Signs of wound dehiscence include a sudden increase in serosanguinous drainage, visible separation of wound edges, and possible protrusion of underlying tissues.
On the other hand, wound evisceration refers to the protrusion of abdominal organs through an open wound. It is a more severe complication than wound dehiscence and requires immediate attention. Risk factors for wound evisceration include obesity, poor nutrition, excessive coughing or vomiting, and improper surgical closure techniques. Signs of wound evisceration include the protrusion of abdominal organs, increased pain or discomfort, and an open wound with visible organs.
For both wound dehiscence and wound evisceration, the nurse should take swift and appropriate actions. The patient should be put in a supine position with the head of the bed slightly elevated to reduce strain on the wound. The nurse should cover the wound with sterile dressings or moist saline gauze, taking care not to apply direct pressure on the exposed organs. The patient should be instructed to avoid any straining or movement that may further compromise the wound. Immediate medical intervention should be sought to ensure that the patient receives the necessary surgical repair and appropriate care for infection prevention.