2SKILL 43-7 INTRODUCTIONWhen caring for a patient with a wound, assess the condition of the wound and observe for the development of infection.Localized inflammation, tenderness, and warmth at the wound site and purulent drainage are signs and symptoms of wound infection.Identification of the causative organism confirms an infection and provides guidelines for accurate treatment.A specimen of wound drainage is analyzed to determine the type and number of pathogenic microorganisms.
3SKILL 43-7 INTRODUCTIONAlways collect a wound culture sample from fresh exudate from the center of a wound after removing old drainage.Resident colonies of bacteria on the skin grown in wound exudate and may not be the true causative organisms of infection.Use separate techniques to collect specimens for measuring aerobic versus anaerobic microorganisms.Aerobic organisms grow in superficial wounds expose to the air.Anaerobic organisms grow deep within body cavities, where oxygen is not normally presents.
4ASSESSMENT1. Assess patient’s understanding of need for wound culture and ability to cooperate with the procedure.2. Assess patient for signs of fever, chills, or excessive thirst. Note in medical laboratory results if the White Blood Cell (WBC) count is elevated.3. Ask patient about extent and type of pain at wound site using a scale of 0 to 10. If patient requires analgesic before dressing changes, give medication 30 minutes before beginning procedure to reach peak effect – Pain at wound site often increases with infection.
5ASSESSMENT – CONT’D4. Determine when dressing change is scheduled. Perform wound assessment as part of actual procedure.5. Review health care provider’s order for aerobic or anaerobic cultureSpecimens are taken from different sites and placed in different containers, depending on type of culture.6. Perform hand hygiene and apply clean gloves. Remove old dressings covering wound. Fold soiled sides of dressing together and dispose properly. Remove gloves. Apply sterile gloves to palpate wound. Observe for swelling, separation of wound edges, inflammation, and drainage. Palpate gently along wound edges and note tenderness or drainage. Remove and discard gloves.
6PLANNING 1. Expected outcomes following completion of procedure: Wound culture does not reveal bacterial growth.Culture swab is not contaminated by bacteria from the skin.Patient discusses purpose and procedure for specimen collection.2. Determine if analgesia is necessary. Administer analgesic 30 minutes before dressing change and/or specimen collection.3. Explain reason for wound culture and how it will be collected.4. Explain that patient may feel tickling sensation when wound is swabbed.
7IMPLEMENTATION 1. Close bedside curtains or door to room. 2. Identify patient using two identifiers.3. Perform hand hygiene and apply clean gloves.4. Clean area around wound edges with antiseptic swab. Wipe from edges outward. Remove old exudate.5. Discard swab and remove and dispose of soiled gloves in appropriate receptacle. Perform hand hygiene.6. Open packages containing sterile culture tube and dressing supplies. Apply sterile gloves.
8IMPLEMENTATION – CONT’D 7. OBTAIN CULTURES:A. Aerobic Culture:1. Take swab from culture tube, insert tip into wound in area of drainage, and rotate swab gently.Remove swab and return to culture tube (wrap outside of ampule with gauze to prevent injury to your fingers).Crush ampule of medium and push swab into fluid.
9IMPLEMENTATION – CONT’D OBTAIN CULTURES – CONT’DB. Anaerobic Culture:1. Take swab from special anaerobic culture tube, swab deeply into draining body cavity, and rotate gently. Remove swab and return to culture tubeOR2. Insert tip of syringe (without needle) into wound and aspirate 5 to 10 mL of exudate. Attach 19-gauge needle, expel all air, and inject drainage into special culture tube.
10IMPLEMENTATION – CONT’D 8. Remove and dispose of gloves. Perform hand hygiene.9. Place correct specimen label on each culture tube. Verify identifiers in front of patient. Note: Indicate on specimen if patient is receiving antibiotics.10. Send specimens to laboratory immediately.11. Clean wound per health care provider’s order. Apply new sterile dressing using aseptic technique. Secure dressing with tape or ties.12. Remove and dispose of gloves and soiled supplies in appropriate receptacle according to agency policy. Perform hand hygiene.13. Help patient to a comfortable position.
11EVALUATION1. Obtain laboratory report for results of culture – the report indicates if pathogenic organisms are identified.2. Observe character of wound drainage – Characteristics can reveal abnormal status and infection.3. Observe edges of wound for redness and bleeding – Indicates trauma to healing tissue.4. Ask patient about purpose of wound culture – validates learning.
12UNEXPECTED OUTCOMES 1. Wound cultures reveal heavy bacterial growth. Monitor patient for fever, chills, or excessive thirst, which indicate systemic infection.Inform health care provider of findings.2. Wound culture is contaminated from superficial skin cells.Monitor patient for fever and pain.Repeat collection of specimen as ordered.3. Patient describes increased pain.Provide analgesia.Notify health care provider.
13RECORDING & REPORTING SPECIAL CONSIDERATIONS – TEACHING: Record types of specimens obtained, source, and time and date sent to laboratory and describe appearance of wound and characteristics of drainage in nurses’ notes.Report any evidence of infection to charge nurse and health care provider.Record patient’s tolerance of procedure and response to analgesics.SPECIAL CONSIDERATIONS – TEACHING:Instruct patient to inform you if procedure causes pain or if you need to stop because unable to tolerate pain.Teach patient to assess status of wound for changes and signs and symptoms of infection.
14END OF SKILL This is the end of your skill Your book has not provided a video for this skill.In order to pass this skill, you will need to go into the nursing skills lab and practice, practice, practice.