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Sterile Dressings. Chapter 47 Potter & Perry Chapters 38 & 39 – 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?

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Sterile dressings

Sterile Dressings

Chapter 47 Potter & Perry

Chapters 38 & 39 – Perry & Potter



Wound assessment in stable setting
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
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
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




Wound closures
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



Suture care
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
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 (6 days post op C-section)


Example
Example

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



Sample for b
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.


Nursing diagnoses
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


Goals of wound care
Goals of Wound Care

  • Preventing infection

  • Preventing further tissue injury

  • Promoting wound healing

  • Maintaining skin integrity

  • Regaining normal function

  • Gaining comfort


Cleaning wounds
Cleaning Wounds

  • Gentle cleansing essential

  • Clean with normal saline (unlessotherwise ordered by physician)


Wound dressings
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
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



  • 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



Changing 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
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
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
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
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
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
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
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


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


Video review
Video Review (Perry & Potter)

  • Cleaning surgical wound and applying a dry sterile dressing

  • Irrigating a wound using sterile technique

  • Unexpected situations


Infected surgical wound requiring vac dressing p 1022
Infected Surgical Wound (Perry & Potter)Requiring VAC Dressing (p. 1022)



Healing
Healing! (Perry & Potter)


Final lab

Final Lab! (Perry & Potter)

Urinary Catheter

Chapter 33


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