University:
West Coast University
Course:
NURS 122 | Introduction to Medical Surgical Nursing
Academic year:

2022
Views:

178

Pages:

1
Author:

rehinhea0c

ACTIVE LEARNING TEMPLATE: Therapeutic Procedure STUDENT NAME _____________________________________ Incision and Drainage PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________ Description of Procedure Incision and drainage are minor surgical procedures to release pus or pressure built up under the skin, such as from an abscess, boil, or infected paranasal sinus. Indications Localized fluctuant infection that is tender, does not resolve spontaneously on its own, signs of infection like pain, fever, erythema, edema, loss of function or swelling. Outcomes/Evaluation Patient demonstrates understanding of plan to heal tissue and prevent injury. Patient describes measures to protect and heal the tissue, including wound care. Patient's wound decreases in size and has increased granulation tissue. Potential Complications Cellulitis or recollection of pus resulting in bacteremia, septicemia, or gangrene with subsequent amputation Most common complication, pain ACTIVE LEARNING TEMPLATES CONSIDERATIONS Nursing Interventions (pre, intra, post) Informed consent from the patient, explain risks including bleeding, pain and possible scar formation should be relayed. Don PPE Cleanse area collect culture Cover wound with sterile gauze and tape Have patient follow up for removal of packing, if placed, and for evaluation Allow wound to close by secondary intention Client Education Explain procedure to the patient Watch for signs and symptoms of infections (recollection of pus, fever, increased pain and redness, red streaks near the wound, increased swelling) and return to seek medical attention Keep the site clean and dry and covered with a clean gauze until fully healed Medication education Tell the patient to avoid rubbing and scratching. Nursing Interventions Ensure that there are no contraindications to performing the procedure Assess characteristics of the wound, including color, size (length, width, depth), drainage, and odor. Assess changes in body temperature, specifically increased body temperature. Assess the patient's level of pain. Monitor the status of the skin around the wound. THERAPEUTIC PROCEDURE A13