Sterile Dressings

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Sterile Dressings

• Chapter 47 Potter Perry
• Chapters 38 39 Perry Potter

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Review
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Wound Assessment in Stable Setting

• Appearance
• Approximation Are wound edges closed? Surgical
  incision should have clean well approximated
  edges
• Is there exudate?
• Is there skin discoloration?
• Are wound edges inflamed and/or swollen?

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Drainage

• Amount color odor consistency
• Type Classifications of drainage
• Serous clear, watery plasma
• Purulent thick, yellow, green, tan or brown
  (pus)
• Sanguineous bright red, indicates active
  bleeding (bloody)
• Sero-sanguineous pale, red, watery mixture of
  serous and sanguineous

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Wound Drains

• Put in place to aid with drainage
• Caution with dressing changes so as not to
  accidentally remove drain
• Types
• Penrose oldest and was most widely used
• Evacuator drainage (self-suction) exerts a
  constant low pressure
• Hemovac
• Jackson-Pratt

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Penrose/Jackson-Pratt
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Hemovac
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Wound Closures

• Staples cause less trauma and provide extra
  strength
• Sutures external internal (internal dissolve
  on their own)
• Steri strips sterile butterfly tape applied
  along both sides of a wound to keep the edges
  closed
• Nurse must note any edema, irritation and
  tightness of closures

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Steri Strips/Staples/Sutures
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Suture Care

• Sutures removed usually 7 days post-op
• Steri-strip usually loosen after a few days and
  are removed easily
• Staples need staple remover

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Assessing the Wound via Palpation

• Observe wound for
• Swelling
• Separation of edges
• Lightly palpate for localized area of tenderness
  or drainage
• May need to culture drainage if present
• Assess for pain

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Document (6 days post op C-section)
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Example

• D- day 6 post-op C-Section surgical incision
  assessed. Incision well approximated, staples
  intact with no inflammation, tenderness or
  exudate noted.

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Document your assessments

• b)
• c)

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Sample for (b)

• D Gaping open wound to lower abdomen noted,
  approximately 10cm in length. Granulation tissue
  noted on wound bed and at wound edges. Small
  amount of purulent drainage noted, no odor
  present.

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Nursing Diagnoses

• Impaired skin integrity related to
• Surgical incision
• Effects of pressure
• Chemical injury
• Secretions (cell/gland) and excretions (waste of
  metabolism)
• Secondary to C-section, appendectomy, etc
• AMB (as manifested) or AEB (as evidenced by)
• Sterile dressing over incision changed OD
• Open pressure ulcer right heel with Tegaderm
  applied
• 2nd degree burns covering anterior aspect of
  thighs bilat
• serosang. drainage from coccyx pressure ulcer

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Goals of Wound Care

• Preventing infection
• Preventing further tissue injury
• Promoting wound healing
• Maintaining skin integrity
• Regaining normal function
• Gaining comfort

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Cleaning Wounds

• Gentle cleansing essential
• Clean with normal saline (unless otherwise
  ordered by physician)

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Wound Dressings

• Purposes of dressings
• Protecting a wound from microorganisms
• Aiding hemostasis pressure dsg prevents bleeding
  eliminates dead space (cavity within a wound)
• Promoting healing by absorbing drainage and
  debriding a wound
• Supporting or splinting a wound

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Types of Dressings

• Woven gauze dressings cause little irritation
  very absorbent (2x2, 4x4)
• Wet to dry - used in treating wound that requires
  debridement
• Nonadherent gauze dressings (telfa) used over
  clean wounds
• Self adhesive temporary, acts as a second
  skin, traps the wounds moisture (Acu-derm,
  Op-site, Tegaderm)

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• Hydrocolloid (HCD) complex formulations of
  colloids, elastomeric and adhesive components
  (Biofilm, Duoderm, Restore, tegasorb)
• The wound contact layer forms a gel as fluid is
  absorbed maintains a moist healing environment
• Occlusive adhesive
• Useful on shallow to moderately deep dermal
  ulcers

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Telfa/Tegaderm/Duoderm
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• Hydrogel dressings water or glycerin based
  (Nu-Gel, ClearSite, IntraSite)
• Used on partial or full thickness wounds, deep
  wounds with exudate, necrotic wounds, burns and
  radiation burns
• Are soothing, reducing pain in the wound
• Debride the wound by softening necrotic tissue

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Hydrogel Dressings
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Changing Dressings

• Must know
• Type of dressing
• Presence of underlying drains or tubing
• Type of supplies needed
• Check physician order
• Solution ordered
• Frequency
• Ointments ordered

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Preparing a Client for Dressing Change

• Administer pain medication prior to dressing
  change if needed
• Describe to client steps of procedure
• Describe normal signs of healing
• Answer any questions

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Wound Care Applying a Dry Dressing

• Review medical orders for dressing change
• Assess size location of wound, type of dsg and
  presence of any drains
• Review previous documentation
• Assess clients comfort, knowledge
• Assess Allergies

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• Gather equipment wash hands
• Close door or curtain
• Position client and drape
• Put disposable bag within reach
• Put on clean gloves
• Remove dressing, pull tape toward suture line.

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• Observe appearance of dressing wound
• Discard dressing and gloves
• Wash hands
• Open sterile dressing tray
• Open cleansing solution pour on gauze
• Put on sterile gloves

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• Cleanse and dry wound
• Apply ointment if ordered
• Apply dry sterile dressings
• Secure dressing (date time on tape)
• Remove gloves
• Assist client into comfortable position

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Basic Skin Cleansing

• Cleanse in a direction from the least
  contaminated area, such as from the wound or
  incision to the surrounding skin
• Use gentle friction when applying solutions
• When irrigating, allow the solution to flow from
  the least to the most contaminated area

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Wound Irrigation

• Cleanses the wound from exudate and debris
• Use 100-150 ml NS
• Sterile technique
• Never occlude wound with the syringe
• Flow directly into the wound not over the
  contaminated area

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• Wound is less contaminated than the surrounding
  skin
• Never cleanse across an incision twice with the
  same gauze
• Drain is highly contaminated move from the
  incision area to the drain site

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Packing a Wound

• Assess the size, depth and shape of wound
• Use appropriate material (as ordered by
  physician)
• Use sterile technique
• Dont pack too tightly (may cause pressure on
  wound bed)

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Securing Wounds

• May use
• Tape
• Ties
• Bandages
• Secondary dressings
• Cloth binders put over a simple dsg to provide
  extra protection support
• Depends on size, location, presence of drainage,
  frequency of changes and activity

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• Inspect dressing
• Assess clients tolerance of the procedure
• Clean supplies and equipment
• Wash hands
• Document (appearance, size, drainage, cleaning
  solution, technique used, what was applied (in
  order), how secured, and how client tolerated
  procedure)

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RESPONSIBLE FOR THE FOLLOWING SKILLS

• Chapter 9 Clinical Nursing Skills and Techniques
  
• (Perry Potter)
• Skill 33-2, p. 666 Preparing a sterile field
• Skill 33-5, p. 672 Open gloving
• First Year skills

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• Chapters 38 39 Clinical Nursing Skills
  Techniques, (Perry Potter)
• Skill 38-2, p. 988 Performing suture staple
  removal
• Skill 38.3, p. 993 Drainage evacuation
• Skill 39.1, p. 1005 Applying a dry dressing

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Video Review

• Cleaning surgical wound and applying a dry
  sterile dressing
• Irrigating a wound using sterile technique
• Unexpected situations

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Infected Surgical WoundRequiring VAC Dressing
(p. 1022)
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After VAC Dressing Change/VAC Reapplied
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Healing!
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Final Lab!

• Urinary Catheter
• Chapter 33