Sterile Dressings

1. Sterile Dressings Chapter 43 Potter & Perry Chapters 37, 38 – Perry & Potter

2. Review

3. 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?

4. 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

5. 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

6. Penrose/Jackson-Pratt

7. Hemovac

8. 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

9. Steri Strips/Staples/Sutures

10. 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

11. 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

12. Document (6 days post op C-section)

13. Document your assessments • b) c)

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

15. Goals of Wound Care • Preventing infection • Preventing further tissue injury • Promoting wound healing • Maintaining skin integrity • Regaining normal function • Gaining comfort

16. Cleaning Wounds • Gentle cleansing essential • Clean with normal saline (unlessotherwise ordered by physician)

17. 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

18. 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)

19. 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

20. Telfa/Tegaderm/Duoderm

21. 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

22. Hydrogel Dressings

23. 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

24. 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

25. 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 client’s comfort, knowledge • Assess Allergies

26. 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.

27. 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

28. 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

29. 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

30. 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

31. 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

32. Packing a Wound • Assess the size, depth and shape of wound • Use appropriate material (as ordered by physician) • Use “sterile technique” • Don’t pack too tightly (may cause pressure on wound bed)

33. 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

34. Inspect dressing • Assess client’s 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)

35. RESPONSIBLE FOR THE FOLLOWING SKILLS Chapter 9: Clinical Nursing Skills and Techniques (Perry & Potter) • Skill 9.2, p. 212: Preparing a sterile field • Skill 9.3, p. 218: Open gloving First Year skills

36. Chapters 37, 38: Clinical Nursing Skills & Techniques, (Perry & Potter) • Skill 37-2, p. 1241: Performing suture & staple removal • Skill 37.3, p. 1247: Drainage evacuation • Skill 38.1, p. 1260: Applying a dry dressing

37. Video Review • Cleaning surgical wound and applying a dry sterile dressing • Irrigating a wound using sterile technique • Unexpected situations

38. Infected Surgical WoundRequiring VAC Dressing (p. 1282)

39. After VAC Dressing Change/VAC Reapplied

40. Healing!

41. Final Lab! Urinary Catheter Chapter 32