Sterile dressings
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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?



  • 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

Penrose 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

Steri strips staples sutures

Steri Strips/Staples/Sutures

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)



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

Document your assessments

Document your assessments

  • b)


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)

Sterile dressings

  • 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


Sterile dressings

  • 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

Hydrogel Dressings

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

Sterile dressings

  • 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.

Sterile dressings

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

Sterile dressings

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

Sterile dressings

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

Sterile dressings

  • 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 33-2, p. 666: Preparing a sterile field

  • Skill 33-5, p. 672: Open gloving

    First Year skills

Sterile dressings

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

  • 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 WoundRequiring VAC Dressing (p. 1022)

After vac dressing change vac reapplied

After VAC Dressing Change/VAC Reapplied



Final lab

Final Lab!

Urinary Catheter

Chapter 33

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