Sterile Dressings

objectives To assess the wound by both inspection and palpation. To describe the types of wound closure and how to care of the sutures. To know the types of dressings To understand the goals of wound care. To know how to clean a wound. To know what is the purpose and types of wound dressings. To learn how to change a wound dressing .

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 * You 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)

Example 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 b) c)

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.

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

Technique for changing the dressing 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.

Continue, 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

Continue, 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)

Healing!

Thank you