Sterile Dressing Change and Wound Management PDF

Sterile Dressing Change and Wound Management NURS 1090   Unit Outcomes  Demonstrate the ability to change a sterile Sterile dressing. Dressing  Explain principles of Change wound management.  Identify types of dressi...

Sterile Dressing Change and Wound Management NURS 1090   Unit Outcomes  Demonstrate the ability to change a sterile Sterile dressing. Dressing  Explain principles of Change wound management.  Identify types of dressings used in wound management.   Absorb drainage  Support or splint the  Protect wound from wound site microorganism  Protect patient from contamination seeing the wound Purposes  Aid in hemostasis  if perceived as  stopping the of flow of blood unpleasant Dressings  Protect wound from  Debride wound mechanical injury  Removal of  Provide moist foreign matter environment for and dead tissue open wounds from a wound   Healing by Primary Intention  Tissue surfaces have been Types of approximated (closed)  Surgical, even edges Wounds:  Sutured, Stapled, Steri-Strips Closed  Minimal or no tissue loss  Incision line, closed fracture   Healing by Secondary Intention  Uneven edges, irregular shape  Considerable tissue loss  Wounds that cannot close completely  Edges may not be together; may be wide open  Burn, pressure ulcer, severe Types of laceration Wounds:  May be touched only with sterile gloves or sterile forceps per CDC Open guidelines  Primary Secondary healing Healing Compare  Wound edges and  Wound edges open Contrast: approximated  Healing time Primary  Healing time longer and shorter  Scarring is greater Secondar  Less scarring  Increased risk for y Wound  Decreased risk infection Healing for infection   Dry sterile: dry gauze sponges  Cover and protect wound  Absorb drainage  Change dressing according to facility Types of policy or if wet (need order from HCP) Dressings  Wet-to-Dry: moist dressing place in wound and allowed to dry  Wound debridement  How often should this type of dressing be changed and why?   Physician’s order  Review chart: nurse’s notes, progress notes, Preparing for lab values, vital signs the Dressing  Example of physician’s order Change  Cleanse abdominal wound with 0.9% Sodium Chloride and apply dry, sterile dressing daily. Dr. Smiley, MD  Universal Steps Preparing for Assess: the Dressing Surgical site, comfort level, Change, cont. allergies Assess for pain/may need to premedicate For surgical wounds, premedication is the primary method of reducing pain  Prepare room Arrange for clean, dry work area, good lighting Preparing for Over bed table at correct the Dressing height Change, cont. Are any supplies available in room? Are they still sterile/usable? Privacy   Gather equipment  Based on type of incision and location  Type of sterile field (towel, glove wrapper, pre-packaged kit)  Dressing supplies Preparing for  Instruments the Dressing  Cleansing solution and container Change, cont.  Normal Saline = 0.9% Sodium Chloride  Other solutions may be ordered  Gloves (clean and sterile)  Disposal bag  Hand Sanitizer   Make patient comfortable; position, privacy, safety  Nurse: body mechanics Implementatio  Patient and nurse: medical asepsis n  Sterile field set up after existing sterile dressing is removed.  Set up disposal bag at foot or side of patient   Remove old dressing  Clean gloves if dry; sterile gloves if saturated  Remove soiled dressings Implementati  Pick up from top of gauze pad on,  do not reach under gauze with thumb  Lift off one layer at a time –carefully and cont. observe  If dressing adheres to wound, moisten with saline  Trash bag–drop items in: keep hand above the trash bag   Immediately following dressing removal  Assess/Observe Characteristics of Wound:  Wound  Edges approximated, intact skin around wound Implementati  Drainage: Color, Odor, Consistency, Amount on, “COCA”  note: COCA is only an acronym for you to cont. remember what to look for, it is not an acceptable abbreviation  Descriptive terms  Erythema (red), warm, pain, edema, purulent exudate, drainage  Remove gloves, perform hand hygiene   Preparing for the sterile dressing change  Set up sterile field (may be done before Implementati or after removing old dressing)  Add supplies on,  dressings, instruments cont.  cleansing agent and sterile cup OFF the field  Apply sterile gloves   Clean to Dirty  Clean in the direction from the Principles LEAST contaminated area of the of wound  Wound that is intact is considered the Cleaning CLEANEST AREA Wounds  Skin is “less” clean; opened areas are less clean Closed  Use gentle friction when applying Wounds cleansing solutions  Keep forceps tips lower than handle   Cleanse wound  Forceps and gauze  CLEAN TO DIRTY – Always clean wound Principles of first Cleaning  If wound is well Wounds: approximated – clean from top to bottom Closed Wounds  ONE STROKE PER STERILE GAUZE PAD  Center (wound), side (skin), side (skin)   Wound Cleansing: 3 steps Principles of Cleaning Wounds: Closed Wounds   Well approximated  Wound edges are closed  Slightly reddened (inflamed) for the first 48 hours – this is a normal expectation  May observe mild edema for first 48 Closed hours – this is a normal expectation Wound – Normal Healing Expectation   At times, the wound Principles of area (or part of it) may Cleaning be left open; usually Wounds: due to infection or inflammation Cleansing an  The opened area would Open be considered “dirtier” Wound  Begin cleansing from least contaminated Cleansing an area to most Incision with contaminated area of an open area wound  Center, side, side using 3 gauze pads   Add dressings to incision/wound  4x4’s, ABD, Tape, Montgomery straps Principles  Remove sterile gloves of  Label dressing with Date, time and Cleaning initials Wounds:  Bag trash  Hand hygiene  Position patient for comfort Cleansing  Rearrange bedside area as needed an Open  Patient safety Wound  “Is there anything else I can do for you?”  Documentation Principles  C O C A: color, odor, consistency, amount of  Condition of wound Cleaning  Edges approximated Wounds:  Drainage or exudate  Hemorrhage? Hematoma? Redness? Pain?  Measurement of wound and stain/drainage Cleansing on old dressing an Open  Type of dressing applied Wound  Reaction of Patient: how was the procedure tolerated?   Wounds can become infected with microorganisms:  During surgery  After surgery  As a result of injury Wound  Bullet or knife wounds Infection  Dirty environment  Surgical wound infections usually occur 2-11 days postoperatively   Wound edges – color changes: bright red, pale  Increased edema/warmth Wound  Increased drainage Infection:  Purulent drainage (yellow, foul smelling) Signs of  Drainage may have strong odor Infection  Edges may begin to separate  Systemic – febrile, tachycardia, increased WBC’s   Comes from fluid and dead phagocytic cells that escape from blood vessels during the inflammatory process  This exudate/drainage is deposited in tissue Wound  Type and amount depends on tissue involved, Infection: intensity & duration of inflammation and presence of organisms  CDC guideline: obtain sterile specimen (wound Exudate/Woun culture) if wound suspected of being infected. d Drainage  Need HCP order Wound Culture  Serous Clear, watery (plasma) Due to mild inflammation Purulent Thick yellow, green, tan, brown Types of Caused by the presence of bacteria Wound Abnormal Drainge Serosanguineous Pale, pink, watery (mixture of clear and red fluid) Common in surgical incisions Sanguineous Bright red (indicates active bleeding); Abnormal Measuring a Wound Measure  Length  Width  Depth  Diameter   Horizontal abdominal incision to RLQ (right lower quadrant) 5 cm in width, edges well Documentati approximated without on: Example inflammation or exudate. 1.2 cm diameter circle of serous drainage present on one 4 x 4 gauze   Drains  Wound Irrigation Wound  Wound packing Manageme  Wet-to-Dry dressing nt  Drainage evacuator (Wound Vac)  Dehiscence  Evisceration   Used when drainage interferes with healing  Drain into dressing Wound  Drainage tube to continuous suction Manageme  Surgical Drains nt: Drains   Cleansing Dressing  Cleanse around  Use sterile instrument drain in a Wound circular motion  Pick up drain with 4x4 Manageme from drain site  Pick up split outward nt: dressing with forceps  Apply dressing Drain Care around drain  Maintain sterility  Don’t drag across skin or contaminate   Purpose Wound To help debride a wound Manageme Cleanse wound nt: Clear the wound for better visualization Wound  Cleanse with sterile solution Irrigation ordered by HCP  Sterile Procedure  Procedure  Remove old dressing Wound  Position patient for flow of fluid Manageme  provide for collection or nt: irrigating solution  Maintain sterility Wound  equipment, solution Irrigation  Irrigate  Reapply sterile dressing   https://www.youtube.com/watch?v=Sk8zbJEm8oE Wound Irrigation ***Note break in sterile technique: Video Nurse drops sterile hand below waist to pour off irrigating fluid  Purposes – Prevent infection Promote healing of wound by secondary intention Wound Absorb drainage Packing Gently debrides wound when removed Sterile procedure packing material instruments sterile gloves  Lightly pack to surface of wound Do not pack too tightly: Overpacking Wound causes too much pressure on wound bed - can impede circulation and delay Packing, healing cont Do not extend packing material over wound edges, on to healthy tissue Reapply sterile dressing Wound Packing Wound Packing Strips   Contact layer applied moist – not wet  Saline, medicated solutions  Dries and absorbs debris Wet to Dry  Mechanically debrides wound Dressings  Removal of dressing gently pulls off debris  May need to pre-medicate – can be painful Wet to Dry Dressings   Cleanse wound prior to packing with solution ordered by HCP  Moisten packing material with solution ordered by HCP Wet to Dry  Press moistened packing material Dressings: (gauze) lightly into wound bed Principles  Too tight packing may cause too much pressure on wound, inhibiting capillary blood flow  Sterile gloves must be worn   Device that assists in wound healing  Closed system Negative Pressure  Uses localized Wound negative pressure Therapy to:  Pull the wound (Wound edges together VAC)  Remove fluid from the area  Stimulates granulation tissue formation   The partial or total separation of a surgical incision or wound closure, usually on abdomen  Often after suture Dehiscence removal  Feels like “pulling”, “tearing” or “giving way” sensation  Risk factors: poor nutritional status, infection, obesity   Protrusion of an internal organ (usually bowel) through a wound or surgical incision, especially in abdominal wall Evisceratio  Preceded by a n sudden discharge of serosanguinous fluid and a “tearing” sensation  Must cover organ with sterile saline saturated dressings and seek treatment   Loss of skin turgor  Skin fragility Factors  Decrease in peripheral circulation and oxygenation Affecting  Slower tissue regeneration Wound  Decrease in absorption of nutrients Healing :  Decrease in collagen Older Adult  Impaired function of immune system  Presence of chronic illnesses  Increased risk for infection   A postoperative patient arrives at an ambulatory care center and states, “I am not feeling well.” Upon assessment, the nurse notes an elevated temperature. An indication that the wound is infected would be Quick Quiz!  A. It has no odor.  B. A culture is negative.  C. The edges reveal the presence of fluid.  D. Purulent drainage is coming from the incision site.