The key difference between preventing and recognizing the occurrence of complications,

including infection, in the acute care setting compared to the home health setting is more

responsibility is placed on the client and/or their family to take action. While there could be a

home health care agency involved in some cases, the client must still always have a good base of

knowledge in what to expect with possible complications as a problem could arise or progress at

any time without the surveillance of a nurse or health care provider. Therefore, recognizing a

deficiency in knowledge, providing education in those areas lacking, and ensuring that a client

may demonstrate the appropriate movements towards proper healing of the surgical wound and

overall health are the main focuses of nursing interventions.

Among the complications, dehiscence and evisceration are two of the most serious.

Dehiscence is the partial or total separation of wound layers as the result of excessive stress on

non-healed wounds, while evisceration is complete separation of the wound with the viscera

protruding through the incision area. The nurse must ensure that a client retains those in order to

understand the importance of avoiding strenuous exercise, heavy lifting, and bearing down hard

with bowel movements, which cause too much stress to the area. It is also important to be aware

of those who are at an increased risk for these complications as it is for hemorrhaging and

infection. These clients especially though should know that an increase of fluid inflow from the

wound between post-operative day four and five could indicate dehiscence. In situations where

it and evisceration occur, the client must use clean bandage supplies to cover the open surgical

area and obtain immediate medical attention.

In addition to those complications, hemorrhage, or excessive bleeding that requires more

dressings or packing and possible surgical treatment, demands rapid care. Clients should seek

that care when blood soaks through bandages over the incision, skin feels cold and clammy, and
tachycardia, tachypnea, dyspnea, oliguria or anuria are present. However, in teaching these signs

and symptoms do not use the medically terminology; explain it in a way that makes sense to

them. The same rules apply in teaching a client about infection signs such as purulent drainage,

or simply put, drainage that is thick, dark yellow/green with a foul odor.

Along with those, a client should be able to relay back other indicators including, pain,

redness, swelling in and around the wound, and an increased temperature, which usually become

apparent within two to seven days. In the case of infection, a client needs to notify their

physician. One of the factors in the treatment that should emphasize the most is that the client

must finish the entire antibiotic prescribed. Being overweight or a smoker, having poorly

controlled diabetes or immune system problems, or having had a surgery that lasts longer than

two hours increases a patient’s risk to develop an infection. All of this information is vital for a

client to avoid more serious results relating to complications and for proper healing of a surgical

wound after leaving an acute care setting.

I choose surgical wound dressing care at home because it is a meticulous skill that needs

to be done correctly in order for the patient to make a full recovery. By maintaining proper

sterility while changing a surgical wound dressing decreases the risk of infection and many other

countless complications. It is important for the patient and his/her family to understand the

procedure of setting up a sterile field and putting on sterile gloves. It’s also a priority that the

patient understands the phases of wound healing in order to correctly assess the wound for

proper healing or for possible complications that need to be reported to their physician. Usually

a surgical dressing change requires saline solution for cleansing, gauze pads to clean and cover

the wound, an ABD pad to hold the gauze in place and cover the wound, and finally tape to

secure the new dressing into place over the wound.

 The steps taken to set up a sterile field are: perform hand hygiene, check expiration dates,

remove sterile drape from package only touching the outer one inch border, lay down the sterile

drape carefully on flat surface, add sterile items by dropping them six inches above the sterile

field avoiding the outer inch border, and maintain sterility of the field. Next is putting on sterile

gloves. Remove the inner package and place the sterile gloves near the work space without

contaminating the sterile field. Use the thumb and forefinger of the non-dominant hand to grasp

the folded cuff of the dominant hand’s glove. Only touch the exposed side of the glove which is

the inside of the glove not the outside. Carefully insert the dominant hand and pull the glove on

again by only touching the inside of the glove. Then take the gloved hand and reach into the cuff

of the other glove touching outside to outside with both gloves and slide the non-dominant hand

into the glove. Adjust the gloves accordingly by only touching outside to outside which is sterile

to sterile in order to maintain the sterility of the gloves.

This procedure in the home differs from being done in an acute care setting because all

the supplies need to be ordered and sent to the home in order to do the prescribed dressing

changes. In an acute care setting those supplies are readily available. It also differs because if

there are any complications they don’t have immediate care or the knowledge to know if

something is wrong unlike an acute care setting where all of the necessary equipment is on hand.

An acute care setting also has professionals to identify any wound problems or complications

sometimes earlier than a patient or patient’s family could recognize at home. The home will also

need to be kept clean and free of any possible dangers that could compromise the patient. In an

acute care setting there is housekeeping to ensure that a patient’s environment is kept clean and

free of hazards.
 There is wound documentation in a home health care agency. The home health nurse will

need to assess the wound’s edges, skin around it, drainage, odor, signs of infection, and

measurements. This gives a reference to track the wound’s healing process and to make sure it is

healing by primary intention. The home health nurse will also want to document dates and times

on dressings changed to maintain a proper healing environment for the surgical wound.

There are various reasons why I chose to talk about pain management of surgical

wounds. First, pain management in wound care is often mismanaged or underestimated by health

care professionals. It is very important for nurses to have an ongoing pain assessment conducted

and for patients in the home care setting to communicate their pain that they are in to health care

professionals. I want to make it very clear to the nursing students in my class and give them the

tools on how to properly manage their patient’s pain.

When visiting a patient in a home health care facility, it is very important to assess their

pain thoroughly. Nurses need to not only listen to what their patients are telling them but also

look at other nonverbal cues such as elevated vital signs and face grimacing. I would ask my

patient to rate their pain based on the numeric rating scale. This would have them rate the

intensity of their pain on a scale from zero to ten. Zero would be no pain; ten would be the worst

pain the patient has ever experienced. This will give the nurse an idea of what type of medicine

needs to be given to relieve this pain. For patients with limited cognitive ability in may be useful

to use the Wong-Baker Faces scale. This scale provides pictures that the patient can pick out to

better describe how bad there pain is. Other important questions to ask are the location and

quality of the pain. Which quadrant is there pain in and what kind of pain is it. Is it a stabbing or

aching pain? Lastly, you want to ask aggravating and alleviating factors of the pain. This for

example would be what makes their pain worse and what makes it better. It is so important to not
only ask questions but also look at how the patient is lying. Are they guarding the area of pain, or

grimacing, increased vital signs are also a huge factor of pain. Many people may not express how

bad there pain is resulting in improper management but it is up to the nurse to assess with her

own eyes the patient’s pain. In a home care setting it is so important to bring a blood pressure

cuff and your stethoscope that way you are able to assess the vital signs and see if the patient is

in distress.

It is very important for a home health nurse to be documenting a thorough pain

assessment. The home health nurse is the only voice for that patient and the only one to see that

they get proper care. A nurse’s documentation tells so much about a visit, especially if they are

in pain. This documentation explains what you felt, saw, and heard during the exam. This

document also serves as a legal document for your patient. It is so important to get as much

information from the patient about their pain. This includes type, intensity, aggravating and

alleviating factors, pain rating, and quality of pain. These all paint a very good picture to be able

for the doctor or you the nurse to assess later and decide if there pain is being managed or not.

There are a couple differences between pain management in the home from pain

management in the hospital. For example, a patient in the home may be persuaded of the

importance of helping their pain with guided imagery, cold or heat, relaxation, spiritual or

emotional counseling. It is easier when patients are comfortable and in their own home for them

to reduce stress resulting in reduced pain. Also in a home setting a doctor may prescribe pain

pills for you such as opioids, Tylenol, or a local anesthetic infusion device. Most meds though

are given orally at home. This differs from the hospital setting because in the hospital setting a

patient may get IV medications that work quicker but don’t last as long. The biggest difference

from the home setting to the hospital setting is the importance of remembering to take your
medication and when to take it. In the hospital, documentation will be done and the nurse will

know when you took the medication and how much you took. In the home setting a patient may

not remember if they took a medication or not. This could result in missed dosages or an over

dose. It is extremely important to track your medications in a logbook to prevent these errors.

Description of procedure is to inform class about how nutrition and proper hydration

effects wound healing as well as what problems arise from deficiencies in certain nutrients.

Proper portion sizes as well as what a balanced meal consists of. Daily requirements and benefits

of different foods, how proper amounts benefit wound healing. Reasons for choosing this topic is

that nutrition is usually the last thing considered when taking care of wounds and as important as

the wound care is itself, eating properly affects healing time infection prevention and overall

recovery which is not usually taken into account. Differences in home than acute care is that an

acute care setting usually offers fixed meals throughout the day giving a full daily meal and

nutrient requirements as well as a dietitian. Home differs that culture and socioeconomic status

highly effect food quality and what is eaten, people also may not know what goes into a balanced

meal. Type of documentation needed is intake and output, maybe counseling from a dietician, a

food pyramid, etc.

Surgical wound care at home has many aspects to it in order for a successful recovery.

These main four subtopics cover everything the patient needs to consider and follow from correct

wound dressings, pain measures, signs and symptoms of infection and complications, and the

proper hydration and nutrition needed to heal.

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