Study Guide Question #1

1. Describe the correct documentation of a surgical wound. (Kozier Pg. 925)

• Apperance- Inspect the color of the wound and surrounding area approximation of wound edges.
• Size- Note size and location of dehiscence, if present.
• Drainage- Observe location, color, consistency, odor, and degree of saturation of dressings. Note number of gauzes saturated or diameter of drainage on guaze.
• Swelling- Observe the amount of swelling; minimal to moderate swellig is normal in early stages of wound healing.
• Pain- Expect severe to moderate postoperative pain for 3 to 5 days; persistent severe pain or sudden onset of severe pain may indicate internal hemorrhaging or infection.
• Drains or Tubes- Inspect drain security and placement, amount and character of drainage, and functioning of collecting apparatus, if present.