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Summary Procedimientos de fundamentos de enfermería 2

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Procedimientos de fundamentos de enfermería 2

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Laheridaes una pérdida de la integridad de los tejidos blandos, producida
por agentes externos, como un cuchillo, o por agentes internos, como un
hueso fracturado. La pérdida del ambiente estéril del interior hace que Curación
Concepto
pueda producirse una infección. herida
Curación de heridas: serie de maniobras que se realizan para la asepsia
de una herida.




- En todo paciente que es sometido a intervención quirúrgica.
- A todos los pacientes que presentan alguna herida o lesión en tejidos blandos, ya sea superficial o profunda.
- Herida quirúrgica dehiscente o cerrada con datos de infección, salida de material seroso, purulento y/o Indicaciones
serohemático.
- Pie diabetico




-En osteomielitis no tratadas
-Sobre arterias o venas expuestas
-En pacientes con trastornos psiquiátricos Contraindicaciones
-En pacientes que presenten alergia al
-antiseptico.




·Inspeccionar las heridas Medidas de
-Color y temperatura alrededor de la herida control y
-Estado de la sutura y los bordes seguridad
-Presencia de edema
-Salida de material purulento
·Observar las características de los drenes
-Registrar en la historia clínica del drenaje (aspecto, densidad y cantidad)
-Vigilar el drenaje que este siempre permeable, la acumulación se Material y e
convierte en medio de cultivo para el crecimiento de microorganismos

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