introduction to adult health...
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Perioperative Nursing
Preoperative phase: period of time from decision for surgery until patient
is transferred into operating room
Intraoperative phase: period of time from when patient is transferred into
operating room to admission to post-anesthesia care unit (PACU)
Postoperative phase: period of time from when patient is admitted to PACU
to follow-up evaluation in clinical setting or at home
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Pre Operative Assessment
• Preoperative assessment
• Teaching based on patient’s needs
• Completion of pre op. diagnostic tests.
• Understanding of preoperative orders.
• Discusses advanced-directive document
• Begins discharge planning by assessing patient’s need for postoperative transportation, care
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Pre Operative Assessment
• The patient’s autonomous decision about whether to undergo a surgical procedure
• Should be in writing
• contains the following:
• Explanation of procedure, risks , benefits, alternatives
• Answer all patient questions about procedure
• Patient can withdraw consent
• Any different institutional protocol
Informed consent
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Pre Operative Assessment
• Must be freely given, without coercion
• Patient must be ≥ 18 years
• The nurse may obtain the signature but the physician is responsible to provide explanation
• Patient’s signature must be witnessed by Health care provider.
Voluntary Consent
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Pre Operative Assessment
Incompetent Patient Individual who is not autonomous
Cannot give or withhold consent such as Cognitively impaired , Mentally ill , Neurologically incapacitated (unconscious)
Informed consent is needed in 1. Invasive procedures
2. Procedures requiring sedation or anesthesia
3. A nonsurgical procedure that carries risks such as an arteriography, radiation therapy
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Preoperative Assessment
1. Correct malnutrition, dehydration, hypovolemia, and electrolyte imbalances to avoid the risk of complications
2. Remove dentures (airway obstruction)
3. Assess drug or alcohol use
1. May postpone surgery if patient is intoxicated
2. Insert NGT to prevent aspiration
3. alcohol withdrawal increase mortality.
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Pre-operative assessment
4. Assess the need for breathing exercises, incentive spirometer
5. Assess for respiratory infection (may postpone surgery)
6. Assess tobacco use (stop smoking 4-8 weeks before surgery to reduce pulmonary complications
7. Control Blood pressure.
Preoperative Assessment
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Pre-operative assessment
8. Assess liver function test(LFT) and kidney function test (KFT)
8. Surgery is contraindicated in acute nephritis, acute renal insufficiency with oliguria or anuria (unless lifesaving)
9. Monitor blood glucose before, during and after surgery to avoid hypoglycemia or hyperglycemia
Preoperative Assessment
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Pre-operative assessment
10. Monitor adrenal function If patient on corticosteroids
11. Assess thyroid function.
respiratory failure may develop in hypothyroidism
thyrotoxicosis may develop in hyperthyroidism
12.Assess for allergy
Preoperative Assessment
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Pre-operative assessment
13.Assess for Immunosuppression (common with corticosteroid therapy, renal transplantation, radiation therapy, chemotherapy, AIDS and leukemia).
14.Assess for pre-operative anxiety (fear of death, anesthesia, pain, complications)
15. Assess for previous medication use.
Preoperative Assessment
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Medication Effect
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General Pre-operative Nursing Interventions
Patient teaching
Providing psychosocial interventions
Maintaining patient safety
Managing nutrition, fluids
Preparing bowel
Preparing skin
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Patient teaching
• Deep breathing, coughing, incentive spirometry
• Short breath, exhale from the mouth, cough (prevent atelectasis and pneumonia)
Pre-operative Nursing Interventions
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Patient teachingMobility, active body movement
• Exercise, changing positions
• improve circulation and respiratory function
• Prevent venous stasis
• Leg, feet, shoulder
Pre-operative Nursing Interventions
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Patient teaching• Pain management
– Explain pain scale & Types of pain
• Cognitive Coping strategies– Can help to relieve tension (Distraction)
Providing psychosocial interventions – Reducing anxiety, decreasing fear
Knowing ahead of time about the possible need for a ventilator, drainage tubes, or equipment helps decrease anxiety related to the postoperative period
– Respecting cultural, spiritual, religious beliefs
Pre-operative Nursing Interventions
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Pre-operative Nursing Interventions
Maintaining patient safety – Improve the accuracy of patient identification
– Improve safety of using medications
– Prevent health care–associated pressure ulcers
Managing nutrition, fluids – new recommendations fasting for
• Eight hours after eating fatty food
• Four hours after ingesting milk products
• clear liquids up to 2 hours before an elective procedure
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Pre-operative Nursing Interventions
Preparing bowel
– Enema, Laxatives
– Better visualization
Preparing skin
– Removing hair around the surgical site to decrease bacteria . Use antibacterial soap bath
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Immediate Pre-operative Nursing Interventions
Gown
Remove hairpins, jewelry, make up
Voiding
Administering pre-anesthetic medication – E.g. Diazepam to relieve anxiety
– Keep the side rails up
– On call to OR
maintain medical record
Pre operative checklist
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Immediate Pre-operative Nursing Interventions
Send medical chart with patient to OR
Transporting patient to pre-surgical area 30-60 minutes before the anesthesia
Keep the patient comfortable: Blanket, avoid noise & respond to family needs
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Pre-operative Instructions to Prevent Post-operative complications
• Diaphragmatic breathing
• Coughing
• Leg exercises
• Turning to side
• Getting out of bed
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Intraoperative Nursing Management
DR AHMAD AQEL
Members of the Surgical Team:
Patient
Circulating nurse
Scrub nurse
Surgeon
Registered nurse first assistant
Anesthesiologist, anesthetist
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Circulating Nurse
Verifying consent
Coordinating the team
Ensuring proper temperature, humidity, lighting, function of equipment, and materials
Monitors aseptic practices
Monitors the patient
Ensuring that the second verification of the surgical procedure and site takes place
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Scrub Nurse
Performing a surgical hand scrub
Setting up the sterile tables
Preparing sutures, and special equipment (eg, laparoscope)
Assisting the surgeon; anticipating the instruments required
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The scrub person and the circulator count all needles, sponges, and instruments BEFORE CLOSING the incision
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The Registered Nurse First Assistant
• Handling tissue
• Providing exposure at the operative field
• Suturing
• Maintaining hemostasis
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Anesthetist
Administer anesthesia
Intubates the patient if necessary
Manages any technical problems related to the administration of the anesthetic agent
Supervises the patient’s condition
Assess patient before surgery
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Potential Adverse Effects of Surgery and Anesthesia
Allergic reactions, drug toxicity
Cardiac dysrhythmias
CNS changes, over-sedation, under-sedation
Trauma: laryngeal, oral, nerve, skin, including burns
Hypotension
Thrombosis
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Prevention of Infection
Surgical environment
Unrestricted zone: street clothes are allowed
Semi-restricted zone: attire consists of scrub clothes and caps
Restricted zone: scrub clothes, shoe covers, caps, and masks
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Prevention of infection
Surgical asepsis
Surgical hand and arm scrubbing
Gown, cap, gloves
Antiseptic solutions
Hair removal
Drape
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Environmental controls
Air filters in OR ventilations
Surface cleansing
Room temperature of 20 C to 24 C
Humidity between 30% and 60%
Positive pressure
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Basic Guidelines for Surgical Asepsis
All materials in contact with wound, sterile field must be sterile
Gowns sterile in front from chest to level of sterile field, sleeves from 2 inches above elbow to cuff
Only top of draped tables considered sterile During draping, drape held well above area, placed
from front to back
Items dispensed by methods to preserve sterility e.g. opening package, the edge is unsterile
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Basic Guidelines for Surgical Asepsis
Movement around sterile field must not cause contamination of field At least 1-foot distance from sterile field must be
maintained
When sterile barrier is breached, area is considered contaminated Every sterile field is constantly maintained, monitored
Items of doubtful sterility considered unsterile
Sterile fields prepared as close as possible to time of use
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Intraoperative Complications
Nausea, vomiting
Anaphylaxis
Hypoxia, respiratory complications
Hypothermia
Malignant hyperthermia
Disseminated intravascular coagulation (DIC)
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Nausea and Vomiting
Vomiting >> aspiration >> bronchial spasms >> Pneumonitis and pulmonary edema >> hypoxia
Preoperative antiemetic
If gagging occurred
Patient is turned to the side
The head of the table is lowered
Suction to remove saliva and vomitus
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Hypoxia
Causes: Inadequate ventilation
Occlusion of the airway
Inadvertent intubation of the esophagus
Respiratory depression caused by anesthetic agent
Aspiration
The patient’s position on the operating table
Foreign bodies in the mouth
spasm of the vocal cords
relaxation of the tongue
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Hypoxia
Monitoring
Pulse oximetry: SpO2
Peripheral perfusion
assessing peripheral pulse
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Hypothermia
Core body temperature < 36.6 C
Causes:
low temperature in the OR
infusion of cold fluids
inhalation of cold gases
open body wounds or cavities
decreased muscle activity
pharmaceutical agents used (eg, vasodilators)
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Malignant hyperthermia
Inherited muscle disorder that is chemically induced by anesthetic agents
Result is a hypermetabolic condition that involves altered mechanisms of calcium function in skeletal muscle cells.
Increases muscle contraction (rigidity)
Hyperthermia
Damage to the central nervous system
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Nursing Interventions for the Patient in the Intraoperative Period
Reducing anxiety
Reducing latex exposure
Preventing intraoperative positioning injuries
Protecting patient from injury
Monitoring, managing potential complications
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Protecting the Patient from Injury
Patient identification
Correct informed consent
Verification of records of health history, exam
Results of diagnostic tests
Allergies (include latex allergy)
Monitoring
Safety measures restraints, not leaving a sedated patient
Verification, accessibility of blood
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POST OPERATIVE CARE
Dr Ahmad Aqel
Postoperative Period
The postoperative period
extends from the time the patient leaves the operating room (OR) until the last follow-up visit with the surgeon.
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Phases of Post anesthesia Care
Phases of Post anesthesia care
Phase I, immediate recovery and intensive care is provided.
Phase II, the patient is prepared for self-care or care in the hospital or an extended care setting.
Phase III, the patient is prepared for discharge.
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Admitting the Patient to the PACU
• Special care prevent strain on the incision.
Avoid obstruction of drains or drainage tubes.
Avoid orthostatic hypotension
Remove soiled gown and replaced with a dry gown.
Maintain body temperature and Raise side rails
review post operative orders.
Attach Monitor and apply oxygen
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Nursing Management in the PACU
1. Assessing the Patient Frequent assessments of the patient’s airway, respiratory
function, CV function, skin color, LOC Documents a baseline assessment Checks the surgical site for drainage or hemorrhage and
all tubes are connected and functioning. Check IV fluids or medications currently infusing and
verifies dosage and rate.• Monitor vital signs and documented at least every 15
minutes• Assess pain
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Nursing Management in the PACU
Maintaining a Patent Airway
The primary objective in the immediate postoperative period is to maintain ventilation and thus prevent
Administer supplemental oxygen, assesse respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds
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Nursing Management in the PACU
Nursing alert
• A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable.
• A previously stable blood pressure that shows a down- ward trend of 5 mm Hg at each 15-minute reading should also be reported.
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Nursing Management in the PACU
• Keep oral airway until gag reflex is returned.
• The nurse assists in initiating the use of the ventilator and in the weaning and extubationprocesses if needed.
• If the teeth are clenched, the mouth may be opened manually but cautiously with a padded tongue depressor.
• The head of the bed is elevated 15 to 30 degrees unless contraindicated.
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Nursing Management in the PACU
• minimize the risk of aspiration.
• Suction mucus or vomitus obstructing the pharynx or the trachea with a pharyngeal suction tip or a nasal catheter introduced into the nasopharynx or oropharynx to a distance of 15 to 20 cm (6 to 8 inches).
• Caution is necessary in suctioning the throat of a patient who has had a tonsillectomy or other oral or laryngeal surgery because of risk of bleeding and discomfort.
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Nursing Management in the PACU
Maintaining Cardiovascular Stability
• assess the patient’s mental status; vital signs; cardiac rhythm; skin temperature, color, and moisture; and urine output.
• Central venous pressure, pulmonary artery pressure, and arterial lines are monitored if in place.
• assess the patency of all IV lines. • The primary cardiovascular complications seen in the
PACU include hypotension and shock, hemorrhage, hypertension, and dysrhythmias
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Nursing Management in the PACU
Hypotension and shock
• Hypotension can result from blood loss, hypoventilation, position changes, pooling of blood in the extremities, or side effects of medications and anesthetics.
• If the amount of blood loss exceeds 500 mL (especially if the loss is rapid), replacement is usually indicated
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Nursing Management in the PACU
Shock• The types of shock are classified as hypovolemic,
cardiogenic, neurogenic, anaphylactic, and septic shock.
• The classic signs of hypovolemic shock – pallor; cool, moist skin; rapid breathing; cyanosis of the lips,
gums, and tongue; rapid weak pulse; narrowing pulse pressure; low blood pressure; and concentrated urine.
• Hypovolemic shock can be avoided by the timely administration of IV fluids, blood, blood products, and medications that elevate blood pressure.
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Nursing Management in the PACU
• The primary intervention for hypovolemic shock
– infusion of lactated Ringer’s solution, 0.9% sodium chloride solution, colloids, or blood component therapy
• Oxygen is administered by nasal cannula, face mask, or mechanical ventilation.
• If fluid administration fails to reverse hypovolemic shock, then vasodilator, and corticosteroid medications may be prescribed
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Nursing Management in the PACU
• Place patient in flat position with legs elevated.
• Monitor V/S until the condition stabilize.
• keeps the patient warm
• Implement measures to control Pain
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Nursing Management in the PACU
Hemorrhage
• Monitor patient for S&S OF shock
hypotension; rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin.
The early phase of shock will manifest in
feeling apprehension and decreased cardiac output and vascular resistance. Breathing becomes labored and “air hunger” will be exhibited; the patient will feel cold (hypothermia) and may experience tinnitus.
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Nursing Management in the PACU
• Check the surgical site and incision for bleeding.
• If bleeding is evident– apply sterile gauze pad and a pressure dressing
– Elevate the site of the bleeding to heart level if possible.
– The patient is placed in the shock position (flat on back; legs elevated at a 20-degree angle; knees kept straight).
– If hemorrhage is suspected but cannot be visualized, the patient may be taken back to the OR for emergency exploration of the surgical site.
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Nursing Management in the PACU
Hypertension and dysrhythmias• Hypertension may occur secondary to
sympathetic nervous system stimulation from pain, hypoxia, or bladder distention.
• Dysrhythmias are associated with electrolyte imbalance, altered respiratory function, pain, hypothermia, stress, and anesthetic agents.
• Both hypertension and dysrhythmias are managed by treating the underlying causes
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Nursing Management in the PACU
Relieving pain and anxiety
• administering Opioid analgesics as ordered
• When the patient’s condition permits, a family member is allowed to visit in the PACU to decrease the family’s anxiety and make the patient feel more secure.
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Nursing Management in the PACU
Controlling nausea and vomiting
• Turn patient to one side to promote mouth drainage and prevent aspiration
• Administer medication to control nausea and vomiting as ordered
• (Zofran) is an effective antiemetic with few side effects and is frequently the drug of choice.
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Nursing Management in the PACU
Determining Readiness for Discharge From the PACU
• A patient remains in the PACU until fully recovered from the anesthetic agent.
• Indicators of recovery include
– stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline.
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Modified Aldrete score The Aldrete score is
usually 8 to 10 before discharge from the PACU.
Patients with a score of less than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area
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Nursing Management in the PACU
Preparing the Postoperative Patient for Direct Discharge
• Prior to discharge the patient will require verbal and written instructions and information about follow-up care
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Care of the HospitalizedPostoperative Patient
Receiving the Patient in the Clinical Unit• Prepare all the necessary equipment and supplies
• The PACU nurse reports relevant data about the patient to the receiving nurse
• Usually the surgeon speaks to the family after surgery and relates the general condition of the patient.
• The receiving nurse reviews the postoperative orders, admits the patient to the unit, performs an initial assessment, and attends to the patient’s immediate needs.
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Immediate Postoperative Nursing Interventions
Assess breathing and administer supplemental oxygen, if prescribed.
Monitor vital signs and note skin warmth, moisture, and color.
Assess the surgical site and wound drainage systems. Connect all drainage tubes to gravity or suction as indicated and monitor closed drainage systems.
Assess level of consciousness, orientation, and ability to move extremities.
Assess pain level, pain characteristics (location, quality) and timing, type, and route of administration of last dose of analgesic.
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Immediate Postoperative Nursing Interventions
Administer analgesics as prescribed and assess their effectiveness in relieving pain.
Place the call light, emesis basin, ice chips (if allowed), and bedpan or urinal within reach.
Position the patient to enhance comfort, safety, and lung expansion.
Assess IV sites for patency and infusions for correct rate and solution.
Assess urine output in closed drainage system or the patient’s urge to void and bladder distention.
Reinforce the need to begin deep breathing and leg exercises.
Provide information to the patient and family
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Nursing Management After Surgery
During the first 24 hours after surgery, nursing care of the hospitalized patient on the general medical-surgical unit involves
Frequently assessing the patient’s physiologic status
Monitoring for complications
Managing pain
Implementing measures designed to achieve the long-range goals of independence with self-care
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Nursing Management After Surgery
• The pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours.
• The temperature is monitored every 4 hours for the first 24 hours.
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Nursing Management After Surgery
To assist the postoperative patient in getting out of bed for the first time after surgery, the nurse:
Helps the patient move gradually from the lying position to the sitting position by raising the head of the bed and encourages the patient to splint the incision when applicable.
Positions the patient completely upright (sitting) and turned so that both legs are hanging over the edge of the bed.
Helps the patient stand beside the bed
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Caring for Wounds
First-Intention Healing
• Wounds made aseptically with a minimum of tissue destruction that are properly closed with little tissue reaction by first intention (primary union).
• When wounds heal by first-intention healing, granulation tissue is not visible and scar formation is minimal.
• Postoperatively, many of these wounds are covered with a dry sterile dressing.
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Caring for Wounds
• Second-Intention Healing
• (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been approximated.
• A drainage tube or gauze packing is inserted into the abscess pocket to allow drainage to escape easily.
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Caring for Wounds
Third-Intention Healing
• secondary suture is used for
– deep wounds that either have not been sutured early
– Sutures break down and re-sutured later, thus bringing together two apposing granulation surfaces.
• This results in a deeper and wider scar.
• These wounds are also packed postoperatively with moist gauze and covered with a dry sterile dressing
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