AVULSED WOUND LEFT FOOT

PREOPERATIVE PHASE

1. NURSING HISTORY

Chief complaint:: Avulsed Wound to the left foot

History of Present Illness:

The patient is a 28 year old house helper who had shaved some skin off
the left lower leg on a metal object. Wound: A full thickness loss of skin
due to the laceration about 8cm x 3 cm with loss of the skin. It was not
possible to suture the injury without causing a great deal of tension on
the wound.

IMMEDIATE POSTOPERATIVE CARE:

NURSING RESPONSIBILITIES:

Identified nursing problems:

1,RISK FOR INFECTION- At increased risk for being invaded by pathogenic

organisms..

2. IMPAIRED SKIN INTEGRITY- Altered epidermis and/or dermis.

3. RISK FOR INEFFECTIVE TISSUE PERFUSION - At risk for decrease in the
oxygen resulting in the failure to nourish the tissues at the capillary level.

PREOPERATIVE DATA RELATED TO THE SURGERY TO BE PERFORMED

pREOPERATIVE DIAGNOSIS:

AVULSED WOUND LEFT FOOT

ANATOMY & PHYSIOLOGY

the feet are divided into three sections:

 -The forefoot contains the five toes (phalanges) and the five longer
bones (metatarsals).
 -The midfoot is a pyramid-like collection of bones that form the arches of
the feet. These include the three cuneiform bones, the cuboid bone, and
the navicular bone.
 -The hindfoot forms the heel and ankle. The talus bone supports the leg
bones (tibia and fibula), forming the ankle. The calcaneus (heel bone) is
the largest bone in the foot.

pathophysiology

Avulsion occurs if epidermis is damaged.Bleeding occurs and the body’s first

line of defence is breached. Healing is multifactorial.Poor arterial flow leads
to ischemia and impaired healing.Venous hypertension leads to edema and
interferes with healing.Lymphedema often accompanies venous edema.
Lymphedema is rarely acknowledged and poorly understood.Poorly
vascularized tissue leads to slow healing.Entry into fascial plane leads to
infection. Muscles are very vascular and tear easily.Exposed tendons should
be kept moist. They are poorly vascularized and therefore slow to heal. Loss
of tendon means loss of function.Exposed ligaments should be kept moist.
They are poorly vascularized and therefore slow to heal. Loss of ligament
means loss of function.Exposed bone usually leads to osteomyelitis. Bone
(periosteum) should not be allowed to dry out.Joint involvement in wounds
usually leads to osteomyelitis.Appearance of synovium in wounds indicates
exposure to joint cavity.Exposed cartilage should be kept moist. Exposure
leads to osteomyelitis.

MEDICATIONS: ikaw na bahala

PREOPERATIVE NURSING DIAGNOSIS:

1 Anxiety related to the surgical experience (anesthesia, pain) and the

outcome of surgery

2 ’ Risk for Ineffective Therapeutic Management Regiment

related to deficient knowledge of preoperative procedures and protocols
and postoperative expectations

4. FEAR related to perceived threat of the surgical procedure and separation

from support system

PREOPERATIVE CARE:

PSYCHOLOGICAL:

1. Explore the client’s fears, worries and concerns.

2. Encourage patient verbalization of feelings.
3. Provide information that helps to allay fears and concerns of the
patient.
4. Give empathetic support.

HEALTH INSTRUCTIONS:

Teach patient cognitive strategies that may be useful for relieving tension,
overcoming anxiety, and achieving relaxation, including imagery, distraction,
or optimistic affirmations.
PHYSICAL PREPARATION:

DIET: Provide nutritional support as ordered to correct any nutrient deficiency

before surgery to provide enough protein for tissue repair.

GIT :Instruct patient that oral intake of food or water should be withheld 8 to
10 hours before the operation (most common), unless physician allows clear
fluids up to 3 to 4 hours before surgery.

SKIN PREPARATION:Dress patient in a hospital gown that is left untied and

open in the back.

FLUID ADMINISTRATION: encourage fluids by mouth, as ordered, before

surgery, and administer fluids intravenously as ordered.

INTRAOPERATIVE PHASE:

POSITION: supine

SKIN PREP: If hair is to be removed, remove it immediately before

the operation using electric clippers.

ORGAN INVOLVED: NONE

INTRAOPERATIVE PERIOD ACTIVITIES AND CARE

 Send the completed chart with patient to operating room; attach

surgical consent form and all laboratory reports and nurses’
records, noting any unusual last minute observations that may have
a bearing on the anesthesia or surgery at the front of the chart in a
prominent place.
  Take the patient to the preoperative holding area, and keep the area
quiet, avoiding unpleasant sounds or conversation.

POSTOPERATIVE PHASE:

IMMEDIATE POST OPERATIVE

Baseline assessment: monitor VS, note signs of general pallor,cyanosis , cool

skin .

NURSING DIAGNOSIS: Risk for infection: At increased risk for being invaded
by pathogenic organisms.

Goal of care and nursing responsibilities

adequate TISSUE perfusion

-Assist with range-of-motion (ROM) exercises, including active ankle and leg
exercises.Stimulates peripheral circulation; aids in preventing venous stasis to
reduce risk of thrombus formation.

-Encourage and assist with early ambulation. Enhances circulation and return
of normal organ function.