Unit 9 Wound Care and Sterile Technique

1. Unit 9 Wound Care and Sterile Technique Metro Community College Nursing Program Nancy Pares, RN, MSN

2. Factors that influence wound healing • Age • Elders: less elastic, drier, circulation impairment longer regeneration • Mobility • Increased pressure leads to breakdown • Nutrition • Poor nutrition, less regeneration, dehydration leads to poor turgor, increase risk of infection

3. Factors affecting skin integritycon’t • Sensation level • Increased risk for pressure and breakdown • Impaired circulation • Decreased O2 supply impacts healing ability, vessel disease, smoking • Medications • Side effects: itching, rashes • Diabetes • Impairs inflammatory response from hypoglycemia; must maintain control of BS

4. Factors cont • Moisture • Leads to maceration • Obesity • Less blood supply in adipose tissue • Fever • Affects moisture and metabolic rate • Infection • Impedes healing • Lifestyle • Tanning, bathing, piercings

5. Classification of wounds • Based on length of time wound existed and the condition of the wound • Open/closed • No breaks in skin vs. true break in skin • Acute/chronic • Short vs. prolonged healing • Clean/contaminated/infected • Uninfected vs. open traumatic vs. evidence of infection

6. Classification cont • Superficial • Epidermis: friction, shearing, burns • Partial • Extend into dermis • Full • Extend into subcutaneous tissue • Penetrating • Involves internal organs

7. Wound drainage • Serous: clear-straw colored, watery • Clean wounds • Sanguinous: bloody • Deep wounds • Serosanguinous: pale pink (mixed) • New wounds • Purulent: yellow or green tinged pus • Purosanguinous: red tinged pus

8. Wound healing process • Regeneration • Same process regardless of injury or tissues • When wound involves only epidermis • No scar • Primary intention • Minimal scarring • Clean, surgical incision; edges well approximated

9. Wound healing • Secondary intention • Extensive tissue loss • Wound not well approximated; heals from inner surface to outer; epithelial tissue may look like sign of infection • Tertiary intention (delayed closure) • Granulating tissue is brought together; initially wound heals by secondary intention then is sutured; moderate scarring

10. Wound healing stages • Inflammatory: cleansing stage lasts 1-5 days • Hemostasis; vasoconstriction, platelets arrive at site, clotting occurs • Inflammation: vasodilatation, phagocytosis, scab formation • Proliferative: granulation stage lasts 5-21 days • Fibroblasts form a bed of collagen • Fills defects and produces new capillaries • Maturation: epitheliazation, begins 2nd or 3rd wk • Contraction of wound edges; scar tissue formation; scar tissue is 80% strong as original tissue.

11. Complications of wound healing • Hemorrhage • Infection • 2-3 days in contaminated wound; 4-5 days post op • Hematoma • Dehiscence: likely during inflammatory phase • Evisceration • Place sterile saline soaked 4x4 over area • Call MD or notify charge/ surgical emergency • Fistula: abnormal passageway often from infection

12. Nursing Assessment • Location • Anatomic terms • Size • Length and width • Appearance • Type, color (Red, yellow black), condition, • Skin around the wound • Drainage • Patient pain

13. Nursing interventions related to wound care • Cleansing and irrigation • Use saline, dilute antimicrobial or commercially prepared cleansers—no hydrogen peroxide, alcohol or iodine; gentle is best; hydrotherapy=debridement • Caring for drainage devices : Vol 2

14. Debridement • Sharp • MD or PT at bedside or OR • Mechanical • Wet to dry dressing-used less • Hydrotherapy • Enzymatic • Topical agent • Autolysis • Uses body out mechanisms

15. Applying wound dressings • Gauze • Transparent • Clear, semi permeable, non absorbent, often used for IV sites • Hydrocolloids/hydrogels • Water loving particles that form a gel with exudate • Absorption • See page 840 table

16. Supporting and immobilizing • Securing dressings • Tape, Montgomery straps • Binders • See 34-6,7 Vol 2 • Important Nursing interventions • Inspect skin, assess and change dressings as ordered • Always ACE wrap distal to proximal • Assess for circulatory impairment

17. Heat and Cold Therapy • Clients at risk • Very old or very young • Sensory impairment • Body areas: highly vascular—fingers, hands, face • Moist heat • Moisture amplifies the treatment; vasodilates, reduces muscle tension • Dry heat • Use with great caution

18. Cold therapy • Vasoconstriction • Decreases edema and inflammation • Acts as a local anesthetic • Slows bacterial growth • Used in the first 24 hrs following injury • R-est • I-ce • C-ompress • E-levate

19. Sterile Technique • Surgical asepsis • Absence of all microorganisms • Slightest break in technique=contamination • Sterile object is only sterile when touched by another sterile object • When in doubt….throw it out…. • Place only sterile objects on a sterile field • Sterile object or field that is out of visual range is contaminated

20. Sterile technique con’t • If exposed to air for a prolonged time=contaminated • Sterile border =field plus 1 inch • Do not reach over a sterile field • Keep hands in front and above waist in field of vision • Procedures which require sterile technique • Injection preparation , catherizations