AY2024-25 NUR 1012 - Wound Dressing PDF

NUR 1012 Fundamentals of Nursing I Principle of Asepsis Wound Care AY2024-25 1  Learning Outcomes After this lecture, students will be able to: ❖Describe the types and classification of wounds ❖Describe the phases of wo...

NUR 1012 Fundamentals of Nursing I Principle of Asepsis Wound Care AY2024-25 1  Learning Outcomes After this lecture, students will be able to: ❖Describe the types and classification of wounds ❖Describe the phases of wound healing ❖Identify factors affecting wound healing ❖State the principles of wound care and aseptic technique ❖State the common dressing materials ❖Describe the procedure in wound dressing ❖Describe the procedure for obtaining wound culture ❖Describe the different types of suturing materials ❖Describe the method to remove suture and staple ❖Describe the method to perform irrigation and packing to wound ❖Describe different types of wound drain → 引流 ❖Describe the method to clean the wound drain site ❖Describe the method to remove the wound drain 2  Understand Skin organ Skin Layers of Skin ❖Largest organ in the body Functions ❖Protection from external factors (bacteria, chemicals, temperature) σ ❖Permits sensation of touch, heat, cold ↓ ❖Prevent excessive water loss 有 BV ❖Synthesis of Vitamin D scappleny ❖Excretion (sweat) ∞ - “Cutaneous” refers to skin eindarhery d 3 Tm fatyaerd 心  Understand Skin D 無破損 Intact skin ❖Presence of normal skin and skin layer, not interrupted Wound ❖A break or disruption in the normal integrity of the skin and tissues Wound classification 最初 ❖Onset/Duration 持續 ❖Acute/Chronic ❖Depth of wound T啊 u & msate deptise 以 ❖Pressure - Staging 4 stage. ❖Clean/Contaminated 不乾淨 ( 細菌 ) 4  Types of wounds Abrasion wound Contusion 挫傷 Laceration Hematoma wound 攤裂 腫 cdeep) 下流 Puncture wound Incision wound 8 aftersurger 5 血 皮 山 血  Stages of wound healing ① ❖Bleeding/Hemostasis ❖Inflammation ❖Proliferation 增殖 ❖Remodeling/Maturation 6 血  Stages of wound healing Bleeding/Hemostasis phase ❖Begin immediately after injury ❖Vascular constriction clot ❖Platelet aggregation → ❖Fibrin formation (thrombus) \ s( 會善住 — 7  Stages of wound healing Inflammatory phase ❖Lasts 3 to 6 days ❖Neutrophil infiltration ❖Monocyte infiltration ❖Differentiation to macrophage (Phagocytosis) 8  Stages of wound healing Proliferative phase ❖Lasts from day 3 to day 21 ❖Migration of fibroblasts into the wound -> production of collagen -> increase the tensile strength of wound ❖Capillaries grow across the wound, -> increase blood supply -> granulation tissue is formed 9  Stages of wound healing Remodeling phase ❖Lasts from day 21 to 1 or 2 years ❖Fibroblasts continue to produce collagen ❖Collagen is remodeled ❖Continue to increase tensile strength ❖Vascular maturation and regression 10  Factors affecting wound healing Miistne濕氣 O ❖Infection 位乳 ❖Foreign body death tisse ( ❖Venous sufficiency/Ischemia ❖Age ❖Stress 貸純 tesse damage ❖Comorbidities (diabetes, autoimmune disease) ❖Obesity f 亢 痛消炎藥 ❖Medications (NSAID, chemo agents) ¢❖Alcoholism and smoking 2 o supy 縮 ❖Immunocompromised (cancer, AIDS) ❖Nutrition hotenough poteim 11 牛 皮 血 小 止  Aseptic Principles 12  Concepts Dirty ❖presence of microorganisms in large numbers Clean → 有掂體液 ❖reduced number of microorganisms Sterile 麕 ❖free of microorganisms 13 一  Definition of sterility 麕 An object is sterile when it is free Sterile consumables of all microorganisms Practicality 可 性 ❖A lot of clinical areas ❖A lot of nursing procedures (wound dressing, off drain, urinary catheterization, injections…..) 14 行  Principles of asepsis 記 1. All objects used in a sterile field must be sterile ❖Check the package for intactness, sterilization indicator, dryness, and expiry date. ❖Discard if opened, torn, punctured, wet, or expired. ❖Store in clean, dry areas, off the floor. 2. Sterile objects become unsterile when touched by unsterile objects ❖Handle sterile objects with sterile forceps or gloved hands. ❖Discard sterile objects if they contact unsterile surfaces. ❖If sterility is in doubt, consider the object unsterile. 15  Principles of asepsis , 開祝綠 3. Sterile objects are considered unsterile when out of vision or below the waist or table putundnhand ❖Always keep sterile objects in view; do not turn your back on the sterile field. ❖Always keep sterile gloved hands, and forceps in sight and above the waist or table. 4. Sterile objects become unsterile by prolonged exposure to airborne microorganisms X 換床了哭 X 掃地 ❖An unattended sterile field is considered unsterile. ❖Moving air can carry dust and microorganisms. ❖Keep doors closed and minimize traffic during sterile procedures. ❖Reduce wound exposure time. ❖Do not set up a sterile field in advance for future use. 16  Principles of asepsis 5. Fluid flows in the direction of gravity ❖Hold wet forceps with the tips below the handles and point downwards ❖Always keep the tips of the forceps lower than the wrists dounward ① — 向下 17  Principles of asepsis 濕 6. Moisture passing through a sterile object can draw microorganisms from unsterile surfaces by capillary action. ❖Damp surfaces can attract microorganisms in the air ❖Replace sterile drapes that do not have a sterile barrier underneath when they become moist ❖No dripping from gauze 7. The edges of a sterile field are considered unsterile ❖Place all sterile objects more than 2.5cm inside the edges of the sterile field ❖Do not stand too close to/touch the sterile field ❖Any object that falls outside the edges of the sterile field is considered unsterile 18  Principles of asepsis 8. The skin cannot be sterilized ❖Use sterile gloves or sterile forceps to handle sterile items ❖Perform hand hygiene (to reduce the number of microorganisms) 9. others ❖Do not cross over the sterile field ❖Do not move unsterile objects over the sterile field ❖Always wipe the opening of packages with alcohol before opening ❖Keep hair clean and well-clipped to prevent hair from falling on the sterile field ❖Wear a surgical mask ❖Minimize talking 19  Simple Wound Dressing Solutions 20 。  Cleansing solutions … Normal saline (0.9% sodium chloride/NS) ❖Clean wounds ❖Burn wounds ❖Routine wound cleansing ❖Irrigate wounds (neither donate nor draw fluid from wound bed) 消五 21 小 小  Cleansing solutions Aqueous Hibitane (Chlorhexidine gluconate 0.05%) ❖Gram +ve, gram –ve ❖High anti-microbial activity and low toxicity to tissues 消毒藥 22 水  Cleansing solutions Povidone-iodine intlammation ❖Broad spectrum anti-microbial effect ~ alew F 5 r against bacteria, spores, fungi, virus ❖Rapid bactericidal action ❖Risk of systemic toxicity after prolonged use on large wounds ❖Skin disinfection before the procedure ❖Heavily contaminated wounds 23 Dressing materials 24  Purpose ❖Protect wound from further injury ❖Protect surrounding skin ❖Absorb drainage ❖Maintain a moist environment ❖Prevent, eliminate, or control infection ❖Remove necrotic tissues 25  Types used depends on ❖Location of wound ❖Size of wound ❖Type of wound ❖Amount of exudate 多語多滲液 ❖Purpose Debridement Infected Prevent adhesion ❖Frequency of dressing change 26  彈低 , 透氣 Gauze Transparent film 防 ❖100% cotton ❖Tegaderm/Opsite ❖Wick vertically to draw ❖Transparent & Flexible exudate from wounds ❖Water resistant ❖Stronger than other dressings ❖Effective barrier to external due to their long fibers contamination ❖Non-adherent ❖Breathe off small amounts of fluid ❖Provides a moist environment ❖Adherent 27 小 Mesh film Telfa ❖Vaseline gauze ❖Cotton fabric with a ❖Fine mesh, absorbent gauze perforated seal of polyester impregnated with white petroleum resin (聚酯树脂) ❖Clings and conforms to body ❖Non adherent (polyester resin) contours ❖For light draining wounds ❖Non-adherent ❖Reduce pain and tissue damage during dressing change 28 Melolin 厚 Foam dressings ❖Highly absorbent cotton Allevyn ❖Low adherent perforated film Self-adhesive/non-adhesive Highly permeable, waterproof ❖For light to moderate draining wounds outer film ❖Shiny side goes on the wound For moderate to high draining wounds White side on the wound Can be lifted and repositioned without losing adhesion Can stay on the wound for up to 7 days Provides cushioning 29  for 插候 Alginates ~ 絲 Hydrocolloids slage 2 ❖Fibers of calcium alginate ❖Forms a gel on contact with a formed into loose fleece moist surface ❖Can absorb 15-20 times their ❖Forms a moist environment for own weight wound healing ❖Heavily draining wounds ❖Waterproof ❖Light to moderate draining wounds ❖Leave intact from 4-7 days ❖Also used for skin protection 30 一  殺菌 Hydrogel 打腐 Antimicrobial dressings ❖Encourage moist wound ❖Release a steady amount of silver healing and autolytic (Ag) to the wound debridement ❖Provide anti-microbial activity ❖Loosen and absorb slough ❖Promote wound healing by ❖Dry sloughy wounds or reducing infection (killing bacteria) necrotic wounds ❖Ulcers 31 肉  Wound assessment 32  Location 排激 ❖Anatomical location Which part of body Left/Right Cause ❖To determine the treatment e.g., burn wound e.g., wound sustained due to circulation insufficiency e.g., Wound sustained due to poor control of medical problems 33 又 Type ❖Clean surgical wound ❖Wound sustained due to trauma ❖Pressure injury Size ❖Measure the size ❖Wound edge to wound edge ❖Measure in a straight line ❖Length, width, depth e.g., Depth ❖Use probe/applicator 34 Exudate (drainage) 顏 ⑥→ ” None Serous ❖Dry dressiy幾 ❖Thin, clear fluid (clear yellowish) 液 Serosanguineous Minimal ❖Stains the dressing ❖Thin, mix of serum and blood (blood-tinged to light pink) Moderate Sanguineous ❖Saturates the dressing ❖Blood (Red) Heavy Purulent ❖ Overflow the dressing pus ❖Thick, foul smell (yellowish/greenish) ❖Infected 35 色 Wound bed Granulation Slough Necrotic ❖Red tissue represents ❖Cellular debris ❖Dead tissue presence of granulation ❖Black leathery ❖Yellow, creamy ❖Increased amount of new ❖Gangrene blood vessels ❖Healthy wound bed udras swly & 36 Wound edge Epithelialization ❖Regeneration of epidermis across the wound surface ❖Migration of wound from the edge to the center 37 Undermining ❖Directly under the wound edge ❖Pocket beneath the skin at the wound edge ❖The clock method e.g. 2cm at 4 o’clock e.g. 1.5cm at 7 o’clock Tunneling ❖Extends deeper into the subcutaneous tissue or muscles ❖Results in dead space ❖May result in infection or abscess formation ❖cm/o’clock 38  Surrounding skin/Peri-wound skin Perlench impntat is … 即魁吊 Inflammation ❖Color, temperature, integrity ❖Inflamed Erythematous, warm 重 ❖Macerated Softening and breaking down of skin Extensive exposure to moisture Skin is more vulnerable to other types of Maceration problems Odour 臭味 ? ❖No odour ❖Foul smelling Pain ❖No pain to severe pain ❖Before and during dressing 39 一刀 𤾂 力 心 Wound dressing 40 Assessment ❖Identify the right client 弟 statml ❖Check valid order ❖Check for any allergies (dressing solutions, dressing materials, adhesive tapes) ❖Assess previous dressing procedures and patient response ❖Assess patient 去廊所 ? General condition 食 痛菜 ? Recheck allergies Assess pain level Inform patient Prepare patient →Washroom 41 止 Planning Goal ❖Promote wound healing ❖Maintain asepsis ❖Patient safety ❖Patient comfort Prepare yourself ❖Task delegation ❖Need help ❖Standard precaution+/-infection precaution ❖Adequate information about patient and dressing (clinical judgment) ❖Nurse position for dressing change 42 Planning Prepare patient Prepare equipment ❖ Implied consent ❖Trolley ❖ Administer pain-killers if needed Clean and disinfect the ❖ Patient position trolley with 70% alcohol wipes ❖ Provide privacy Top and bottom shelves and 4 poles Prepare environment Make sure it is dry before ❖ Ward activity placing anything on it ❖ Adequate lighting ❖ Patient warmth ❖ Adjust the position of the patient’s bed rdesset ❖ Side rails ❖ Adequate space ❖ Comfortable working height 43 Planning X 背位架 Prepare equipment ❖Top shelf of trolley Dressing set ❖Bottom shelf of trolley Dressing solution Adhesive tapes Extra gauze Clean kidney dish Clean gloves Disposable ruler Plastic bag Incontinence sheet Alcohol hand rub 44 車 Implementation ❖Move the dressing trolley touching the poles only to the patient’s bedside ❖Check patient identity ❖Provide privacy and warmth ❖Make sure the curtain is not touching the dressing trolley ❖Hand rub ❖Don gloves ❖Remove outer dressing (if there is inner dressing) ❖Loosen dressing (if there is only 1 layer of dressing) ❖Remove gloves ❖Hand rub 45 Implementation ❖Open the dressing set Place the dressing set in a way so that the first flap of the wrapper opens away from you Pinch the first flap on the outside of the wrapper and open it away from yourself Touch only the outside of the wrapper, maintain sterility of the inside Repeat for the other 3 sides Open the innermost flap the last and towards you 46 Implementation ❖Arrange the contents of the dressing set Pick up one forcep at the handle (DO NOT touch any other surface or objects on the sterile field) Use that forcep to arrange all the contents of the dressing set on the sterile field in an orderly manner ❖Add in extras Add in extra gauze if needed (Peel open and hold 6”/15cm above the sterile field and let the materials fall on the sterile field without being in the 2.5cm edges) 47 Implementation ❖Pour dressing solution Check for name, concentration, expiry date, color, sedimentation, open date/time Open cap. DO NOT touch the inside of the cap For newly opened lotions, write down the date and time of opening Pour dressing solution (Hold 6”/15cm above the sterile field and from the side) Avoid splashing Replace cap ❖Prepare all dressing materials Squeeze excess solution from the gauze using 2 forceps Always point the tip of the forceps DOWNWARDS 48 Implementation ❖Wear disposable gloves or use one forcep to remove and discard the old dressing ❖Measure wound size ❖+/- Hand rub or discard the forcep ❖Maximize sterile field Grasp 2 corners of the drape Lift the drape off the sterile field and open it Lay the drape on a clean and dry surface beside the wound Minimize moving the drape once it is in place 49 Implementation ❖Clean the wound 1st forcep as dressing forcep (touch the patient) 2nd forcep for transfer (do not touch patient) The 2 forcep tips should NOT touch during transfer One swab once, in one direction (top to bottom) From clean (less contaminated) to dirty (contaminated) If there is more than one wound, start with clean wound first Ensure no dripping Observe each returned gauze before Disposal Clean at least 2.5cm beyond the wound margin 50 Implementation X 描北 ❖Clean the wound Dry skin properly (maintain wound bed moist as this will facilitate wound healing) Cover with appropriate wound dressing materials Secure dressing to cover all sides of the dressing ❖Provide education Do not take off the cover of the dressing Do not wet the dressing If the dressing becomes loose/wet ->inform Adequate nutrition for wound healing 51 Implementation ❖Aftercare Patient safety Environment Throw away the disposable and used materials (soiled dressing in BLACK bag and heavily soiled dressing in RED bag) Put away the other materials Disinfect the trolley with 70% alcohol wipes after use For reusable items – perform general cleansing and send for sterilization For infectious cases – wrap used set and items in plastic bag labelled with “DANGER OF INFECTION” 52 Implementation ❖Documentation Location, size, stage, type, color of exudate, wound bed, wound edge, surrounding skin, any inflammation/infection, type and number of dressing materials used Fill in the wound chart ❖Evaluation Wound condition (any change) Client’s tolerance Need for further assessment and dressing (any change) 53 ❖Documentation sample NS dressing was performed on the left forearm abrasion wound. Wound size 3cm x 2cm. Minimal amount of serous discharge stained on one gauze. Surrounding skin is pinkish and dry. Covered with 2 pieces of gauze and mefix. The procedure was completed uneventfully with nil complaints. Education given. The client shows understanding. --------------- STN Chan Tai Man/RN Chan Siu Man 54 55 Wound Culture 56 Purpose ❖Identify the microorganisms causing the infection ❖Identify the antibiotic that is sensitive to the organism ❖Evaluate the antibiotic therapy ❖Wound culture/swab x C/ST (Culture and Sensitivity Test) Equipment ❖Clean gloves ❖Usually done with wound dressing procedure ❖0.9% NS ❖Culture swab 57 Implementation ❖Open sterile dressing pack 拎 smble ❖Clean wound with NS until all exudate had been removed ❖Absorb excess solution ❖Collect the culture using zig-zag/Levine method aflatmat ❖DO NOT use pooled exudate/pus for culture ❖DO NOT touch the surrounding skin using the swab ❖Return the swab to the culture tube ❖DO NOT touch the inside/outside of the culture tube ❖Secure the cap firmly 58  Covid 臭液 β 售 cullnelube 59 Wound Closure 60 Purpose ❖Holds the tissues and skin together ❖Close the wound Choice ❖Location of wound ❖Nature of wound ❖Age 61 Absorbable sutures ❖Made of material that is digested by the body’s enzymes or broken down by the water in tissue fluids ❖Used beneath the skin (attaches the tissues) ❖Disappears in several days Non-absorbable sutures ☆ 繼針 ❖Made of material that is not digested by body’s enzymes or broken down by water in tissue fluids ❖Used on skin ❖Needs to be removed (7-10 days post-op) 62 Staples ❖Stainless steel ❖For superficial wounds ❖For flat surfaces X Sterile strips 坐針 ❖Adhesive strips in various widths ❖Loosen in 5-7 days or can be removed when they are no longer adherent to the skin 63 Medical glue ❖Special medical glue to close wounds ❖Can be used alone, with stitches or tapes. ❖Forms a protective waterproof cover over the wound ❖Comes off by itself 64  Remove Sutures/Staples 65 ❖Aseptic technique ❖Extra equipment needed Scissors Staple remover Artery forcep/Dissecting forcep d 66 Assessment ❖Check valid order (R/O all/alternate sutures/staples) ❖Check for any allergies (dressing solutions, dressing materials, adhesive tapes) ❖Identify right client Assess patient ❖General condition ❖Recheck allergies ❖Assess pain level ❖Inform patient ❖Prepare patient Washroom 67 Planning Goal ❖Off sutures/staples/wound healing ❖Asepsis ❖Patient safety ❖Patient comfort Prepare yourself ❖Task delegation ❖Need help ❖Standard precaution+/-infection precaution ❖Adequate information about patient and dressing (clinical judgment) ❖Nurse position for dressing change 68 Planning Prepare patient Prepare equipment ❖Trolley ❖Implied consent Clean and disinfect the ❖Patient position trolley with 70% alcohol wipes ❖Provide privacy Top and bottom shelves and Prepare environment 4 poles Make sure it is dry before ❖Ward activity placing anything on it ❖Adequate lighting ❖Patient warmth ❖Adjust the position of the patient’s bed Side rails Adequate space Comfortable working height 69 Planning Prepare equipment ❖Top shelf of trolley Dressing set ❖Bottom shelf of trolley Dressing solution Scissors/Staple remover/Forceps Adhesive tapes Extra gauze Clean kidney dish Disposable gloves Plastic bag Incontinence sheet 70 Implementation ❖Move the dressing trolley touching the poles only to the patient’s bedside ❖Check patient identity ❖Provide privacy and warmth ❖Make sure the curtain is not touching the dressing trolley ❖Hand rub ❖Don gloves Remove outer dressing (if there is an inner dressing) Loosen dressing (if there is only 1 layer of dressing) ❖Remove gloves ❖Hand rub 71 Implementation ❖Open the dressing set Place the dressing set in a way so that the first flap of the wrapper opens away from you Pinch the first flap on the outside of the wrapper and open it away from yourself Touch only the outside of the wrapper, maintain sterility of the inside Repeat for the other 3 sides Open the innermost flap the last and towards you ❖Arrange the contents of the dressing set Pick up one forcep at the handle (DO NOT touch any other surface or objects on the sterile field) Use that forcep to arrange all the contents of the dressing set on the sterile field in an orderly manner 72 Implementation ❖Add in extras Add in extra gauze if needed (Peel open and hold 6”/15cm above the sterile field and let the materials fall on the sterile field without being in the 2.5cm edges) Sterile scissors/Staple remover/Forceps ❖Pour dressing solution Check for name, concentration, expiry date, color, sedimentation, open date/time Open cap. DO NOT touch inside of the cap For newly opened lotions, write down date and time of opening Pour dressing solution (Hold 6”/15cm above the sterile field and from the side) Avoid splashing Replace cap 73 Implementation ❖Prepare all dressing materials Squeeze excess solution from the gauze using 2 forceps Always point the tip of the forceps DOWNWARDS ❖Wear disposable gloves or use one forcep to remove and discard the old dressing ❖+/- Hand rub or discard the forcep ❖Count the number of sutures/staples before removal ❖Maximize sterile field Grasp 2 corners of the drape Lift the drape off the field and open it Lay the drape on a clean and dry surface beside the wound Minimize moving the drape once it is in place Place a piece of sterile gauze near the wound 74 Implementation ❖Clean the wound Clean the wound before removal of sutures/staples 1st forcep as dressing forcep (touch the patient) 2nd forcep for transfer (do not touch patient) The 2 forcep tips should NOT touch during transfer One swab once, in one direction From clean (less contaminated) to dirty (contaminated) If there is more than one wound, start with clean wound first Ensure no dripping Observe each gauze before disposal Remove sutures/staples Clean the wound after removal of sutures/staples Dry skin properly and assess wound healing Cover with appropriate wound dressing materials Secure dressing to cover all sides of the dressing Count the number of sutures/staples after removal (should be exactly equal to the count before removal) 75 Implementation l泳 ❖Removal of staples 插卸插像數針 Place the lower prongs of the staple remover under the staple Depress the handle of the staple remover When both ends of the staple are visible, move the staple away from the incision site (Prevent skin scratching with sharp pointed ends of the staple) DO NOT lift the staple remover when squeezing the handles Place removed staples on the gauze Remove intermittent staples and check that the wound edges are healed Look for any problem areas (gap, overlap) 76 Implementation ❖Removal of sutures Grasp the tip of the knot with forcep Gently lift upward on the suture Slip the tip of the scissors under the suture Snip/Cut the suture close to the skin Gently tug/pull on the thread until it slips through the skin and out Place removed sutures on the gauze Remove intermittent sutures and check that the wound edges are healed Look for any problem areas (gap, overlap) Inspect the wound that all sutures are removed and no parts are left in the wound 77 Implementation ❖Provide education Do not take off the cover of the dressing Do not wet the dressing If the dressing becomes loose/wet ->inform Adequate nutrition for wound healing ❖Aftercare Patient safety Environment Throw away the disposable and used materials (soiled dressing in BLACK bag and heavily soiled dressing in RED bag) Put away the other materials Disinfect the trolley with 70% alcohol wipes after use For reusable items – perform general cleansing and send for sterilization For infectious cases – wrap used set and items in a plastic bag labelled with “DANGER OF INFECTION” 78  Implementation 10 ❖Documentation Location, type, exudate, wound edge, surrounding skin, any inflammation/infection, how many sutures were removed, wound union, type and number of dressing materials used ❖Documentation sample 5 staples removed from left forearm wound. The wound was cleansed with normal saline. Nil discharge. The wound healed well. No gap. Surrounding skin healthy. It was covered with 2 gauzes and micropores. Education was given to the client, and understanding was shown. -------------------------------STN Chan Tai Man/RN Chan Siu Man 79 一一一 Evaluation educathon ❖Wound condition/healing pam e pundd ❖Client’s tolerance ❖Need for further assessment and dressing (any problem with closure/healing of the wound) 80 Wound Packing 81 Wound Packing Purpose ❖Wound packing prevents premature closure. ❖Packing material absorbs drainage, promoting inside-out healing. ❖Without packing, the wound may close at the top, trapping fluid and bacteria, leading to infection and impaired healing. Implementation prentto ≥ ❖Count the packing materials ❖Ribbon gauze/gauze ❖Moisten the packing material and squeeze excess fluid out ❖Loosely pack the wound cavity just until the wound surface and edges are covered ❖Loose packing prevents too much pressure on the wound bed which could impede wound healing ❖NO need to cut the packing material. Packed materials should be in its original size ❖Leave a tail of packing material outside the wound 82  Wound Irrigation 83 Wound Irrigation 沖洗 ❖Purpose Remove foreign material, decrease bacterial contamination of the wound, remove cellular debris or exudate from the wound ❖Implementation Sterile syringe 30-60ml, angio-catheter Sterile receiver Sterile gloves Place a waterproof drape on the bed under the wound Hold the syringe 2.5cm above the wound to be cleaned Use continuous pressure to flush the wound and continue irrigating until the returned solution becomes clear Dry the wound Pack/Cover the wound 84 Drain Care 85  3 ~U po 防 勢 ❖Purpose Inserted near/into the wound to drain out fluid in a closed area to prevent delayed wound healing. Without a drain, the collection of fluid could cause infection and impede wound healing ❖Types of drains Open drainage system X 滲液 Removes drainage from the wound and deposits onto the skin Care is needed to ensure that these drains are not dislodged Dressing should be changed whenever it is saturated Assess the condition of the surrounding skin Penrose drain, Corrugated drain No suction 86 日 水 Drain care 狗引流 87 ❖Types of drains Closed drainage system Drain is sutured in place and connected to a collection device via a closed system Prevent microorganisms from entering the wound Allows for measurement of drainage Can have vacuum applied Jackson-Pratt (JP) drain, Redivac, Heamovac 88  Drain Care Redivac Drain Minivac Drain 胞 β 89 大 骨  Drain care Haemovac Drain 深液 90 大 Drain care ❖Principles Keep the reservoir below the level of the wound Do not place on the floor Secure the tubing with a loop to reduce the risk of inadvertently pulling out from the body and minimize tension in the tubing causing discomfort Keep the drainage system patent (no kinking, twisting, no clot inside the tubing) Monitor the nature and amount of drainage Handle with aseptic technique 91 Drain care ❖Dressing Assess the drainage and drain site condition Check for suction Ensure patency Aseptic technique One swab once Clean at least 3cm away from the exit site Keyhole gauze DO NOT pull on the tubing Inspect the position of the drain Inspect surrounding skin 92 Drain care ❖Removal of drain Identify the correct drain for removal Note the drainage and amount Release the suction Drain site dressing Remove the anchoring stitch Hold the drain close to the skin With another hand, hold the gauze in position over the drain site Pull the drain gently in a rotating manner Apply gentle pressure over the drain site and check for leaking Withhold and inform the doctor if resistance is felt or the patient has excessive pain Check the integrity of the drain after removal Assess the patient for any discomfort Document 93 References Berman, A.T., Synder, S., & Frandsen, G. (2016). Kozier and Erb’s fundamentals of nursing: Concepts, process and practice (10th ed.). Hoboken, New Jersey: Pearson Education Doyle, G.R., & McCutcheon, J.A. (2015). Clinical proedures for safer patient care. Retrieved from https://opentextbc.ca/clinicalskills/ Lippincott Williams & Wilkins. (2023). Wound care made incredibly visual (2nd ed.). Philadelphia, PA: Wolters Kluwer Health. Lynn, P. (2015). Taylor’s clinical nursing skills: A nursing process approach (14th ed.). Philadelphia, PA: Wolters Kluwer. Perry, A. G., & Potter, P. A. (2018). Clinical nursing skills and techniques (8th ed.). St. Louis, MO: Elsevier Smith, S.F., Duell, J., Martin, B.C., Aebersold, M. L., & Gonzales, L. (2017). Clinical nursing skills: Basic to advanced skills (9th ed.). Boston, MA: Pearson. Taylor, C. R., Lillis, C., Lynn, P., & LeMone, P. (2015). Fundamentals of nursing: the art and science of person-centered nursing care (8th ed.). Philadelphia, PA: Wolters Kluwer Health. 94 THE END 95