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4.5 Postoperative Nursing Implications for the Integumentary System

Being knowledgeable of the location of every wound and drainage tube is very important. The practical nurse must practice aseptic techniques in collecting specimens, avoiding accidental contamination of the specimen, and the spread of infection to others.

a. Procedures for Collecting/Submitting a Wound Culture Specimen From a Postoperative Patient.

(1) Wash hands and assemble all equipment.

(a) Antiseptic swabs.

(b) Sterile culturette tube or sterile applicator with a culture medium tube.

(c) Exam gloves.

(d) Sterile gloves.

(e) Sterile dressings, as appropriate.

(f) Waste receptacle.

(2) Verify the physician's order.

(3) Identify and approach the patient, explain what you are going to do, and gain his cooperation.

(4) Provide adequate lighting and for patient's privacy.

(5) Wash your hands.

(6) Position and drape the patient as indicated for the site of the specimen collection.

(7) Put on exam gloves.

(8) Remove patient's wound dressings, if appropriate, and discard.

(9) Remove exam gloves.

(10) Open sterile supplies using aseptic technique.

(11) Apply the sterile gloves.

(12) Cleanse the skin around the area to be cultured with antiseptic swabs to prevent contamination of the specimen by surface bacteria.

(13) Obtain the specimen. The break stick technique or the culturette method may be used.

(a) Break stick technique.

1 Remove the cap from the culture tube and hold the cap in your nondominant hand, maintaining sterility of the inside of the cap.

2 Using sterile applicator, swab the exudate from the site.

3 Insert the swab portion of the applicator into the sterile culture tube.

4 Break off the upper portion of the applicator.

5 Replace the cap on the culture tube.

(b) Culturette method.

1 Remove the cap with the sterile applicator attached from the culturette tube.

2 Swab the exudate from the site.

3 Replace the swab in the culturette tube, securing the cap.

4 Turn the culturette tube cap down.

5 Crush the ampule in the bottom of the tube by squeezing it between your index finger and thumb at midpoint.

6 Push the cap down to bring the swab into contact with the culture medium.

(14) Redress the patient's wound with the appropriate dressing, if necessary.

(15) Remove the sterile gloves.

(16) Label the specimen container.

(17) Reposition the patient comfortably.

(18) Discard equipment or return it to the appropriate area.

(19) Wash your hands.

(20) Complete the laboratory request slip, if not already prepared.

(21) Send the specimen to the laboratory immediately. The specimen can be destroyed if it is not plated to a culture medium at once.

(22) Record procedure in patient's clinical records.

(a) Time, site, and method of specimen collection.

(b) Appearance of the patient's wound site and the specimen collected.

(c) The patient's tolerance of the procedure.

(d) Disposition of the specimen.

(e) All patient teaching done and the patient's apparent level of understanding.

b. Maintain the Postoperative Patient's Wound/Nasogastric Drainage Tubes. The nurse must connect and maintain the tubes to the ordered suction device, must avoid introduction of microorganisms into wound or drainage system, and must also avoid dislodging tubes. The procedures are as follow.

(1) Wash hands and assemble all equipment.

(a) Suction unit (Hemovac, electric or wall vacuum continuous unit, or intermittent suction).

(b) Graduated container.

(2) Verify physician's order.

(3) Identify and approach the patient, explain what you are going to do, and gain his cooperation.

(4) Provide for the patient's privacy and position the patient to facilitate access to the drainage tube.

(5) Provide adequate lighting.

(6) Wash your hands.

(7) Activate the appropriate/ordered tube drainage/suction unit.

(a) Hemovac (wound drainage tube suction) (see Figure 4- 7).


Figure 4-7. Hemovac.

1 Remove the plug cap aseptically and place the portable suction unit upright on a firm surface.

2 Compress the suction unit as flat as possible (see Figure 4-8).


Figure 4-8. Compressing unit to

3 Replace the plug cap immediately (see Figure 4-9).


Figure 4-9. Replace plug in outlet form vacuum. to retain vacuum.

4 Position the suction unit to prevent kinking of the tubes or dropping of the unit.

5 Observe the suction unit for proper compression and patency.

(b) Electric or wall vacuum continuous or intermittent wound/gastrointestinal suction unit (see Figures 4-10 and 4-11).

Figure 4-10. Wound/gastrointestinal  suction wall unit.

 

Figure 4-11. Wound/gastrointestinal suction portable unit.

1 Plug the unit into an electrical outlet or attach to a wall system vacuum.

2 Connect the suction tube to the patient's drainage tube, using aseptic technique.

3 Tape the connection. Ensure that the tubing is not pulling on the drainage tube.

4 Turn the suction unit on "Low" unless specifically ordered differently.

5 Observe the suction system for proper functioning.

(8) Empty the drainage collection device, as necessary.

(a) Hemovac.

1 Remove the plug cap, using aseptic technique.

2 Invert the suction unit over the graduated container and empty the contents (see Figure 4-12).

Figure 4-12. Opening outlet to remove drainage.

3 Return the unit to an upright position and reactivate the unit. Measure and read the drainage and discard.

(b) Electric wall vacuum continuous or intermittent wound section unit.

1 Turn the suction unit off.

2 Empty the drainage bottle.

3 Measure and record the drainage and discard.

4 Reattach the drainage bottle.

5 Turn the suction unit on and observe for proper function.

(9) Discard equipment or return it to the appropriate location.

(10) Wash your hands.

(11) Record procedure and report significant observation to the Charge Nurse.

(a) Type of wound catheter and suction.

(b) Amount, color, characteristics, and odor of drainage.

(c) The patient's reaction to the procedure.

(d) Function of suction system.

(e) Any observations of the wound area or dressing.

(f) All patient teaching done and the patient's apparent level of understanding.

c. Remove Sutures from a Postoperative Patient's Surgical Wound. The nurse must avoid introduction of skin surface contaminants into wound site and interference with wound healing. He must also avoid causing unnecessary pain/discomfort for the patient.

(1) Verify the physician's order.

(2) Wash hands and assemble needed equipment.

(a) Prepackaged suture removal supplies/equipment.

(b) Antiseptic pledgets.

(c) Smooth forceps.

(d) Scissors

(e) Dressings/sterile wipes.

(f) Hydrogen peroxide (as required).

(3) Identify and approach the patient, explain what you are going to do, and gain his cooperation.

(4) Remove the patient's wound dressing to expose suture line.

(5) Cleanse the stitch area carefully and thoroughly with hydrogen peroxide.

(6) Use hydrogen peroxide to remove dried secretions or encrustations, as necessary.

(7) Grasp the knot of each suture with a pair of smooth forceps and gently pull upward to pull stitch away from the skin (see Figure 4-13).

Figure 4-13 Removing suture from wound.

(8) Cut the shortened end of each stitch as close to the skin as possible and pull each stitch free from the wound.

(a) Allows the stitch to be pulled free of wound so that when stitch is removed, only that part of the stitch which is under the skin touches the subcutaneous tissues.

(b) No segment of the stitch that is on the surface of the skin should be drawn below the skin surface. That could introduce skin surface contaminants subcutaneously with risk of infection.

(c) If the suture does not pull free when cut or is embedded into healed suture line, report immediately to the Charge Nurse or to the physician for assistance.

(d) For continuous suture removal, cut the suture at each skin orifice on one side and remove suture from the opposite side. The objective is to avoid subcutaneous contamination.

(9) Pat the suture removal sites with an alcohol sponge.

(10) Reapply dressing as appropriate.

(11) Record procedure and report significant observations to the Charge Nurse.

(a) Wound site condition.

(b) Surface healing.

(c) Evidence of infection.

(d) Poor wound adhesiveness.

Section V. GENERAL NURSING IMPLICATIONS OF THE POSTOPERATIVE PATIENT

 

David L. Heiserman, Editor

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All Rights Reserved

Revised: June 06, 2015