Sterile Dressings

Chapter 43 Potter & Perry Chapters 37, 38 – Perry & Potter

Review

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?

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

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

Penrose/Jackson-Pratt

Hemovac

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

Steri Strips/Staples/Sutures

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

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

Document (6 days post op C-section)

Document your assessmentsa) b)

c)

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

Goals of Wound Care

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

Cleaning Wounds

• Gentle cleansing essential

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

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

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)

• 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

Telfa/Tegaderm/Duoderm

• 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

Hydrogel Dressings

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

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

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

• 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.

• 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

• 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

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

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

• 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

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)

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

• 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)

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

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

Video Review

• Cleaning surgical wound and applying a dry sterile dressing

• Irrigating a wound using sterile technique

• Unexpected situations

Infected Surgical WoundRequiring VAC Dressing (p. 1282)

After VAC Dressing Change/VAC Reapplied

Healing!

Final Lab!

Urinary CatheterChapter 32