1. Sterile Dressings

2. 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 .

3. 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?

4. 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

5. 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

6. Penrose/Jackson-Pratt

7. Hemovac

8. 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

9. Steri Strips/Staples/Sutures

10. 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

11. 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

12. Document (6 days post op C-section)

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

14. Document your assessmentsb) c)

15. 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.

16. Goals of Wound Care Preventing infection
Preventing further tissue injury
Promoting wound healing
Maintaining skin integrity
Regaining normal function
Gaining comfort

17. Cleaning Wounds Gentle cleansing essential
Clean with normal saline (unless otherwise ordered by physician)

18. 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

19. 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)

20. 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

21. Telfa/Tegaderm/Duoderm

22. 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

23. Hydrogel Dressings

24. 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

25. 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

26. 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

27. 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.

28. 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

29. 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

30. 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

31. Wound Irrigation Cleanses the wound from exudate and debris
Use ml NS
Sterile technique
Never occlude wound with the syringe
Flow directly into the wound not over the contaminated area

32. 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

33. 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)

34. 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

35. 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)

36. Healing!

37. Thank you