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 dressingsTo 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 edgesIs there exudate?Is there skin discoloration?Are wound edges inflamed and/or swollen?
4 Drainage Amount – color – odor – consistency Type: Classifications of drainageSerous – clear, watery plasmaPurulent – 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 drainTypes:Penrose – oldest and was most widely usedEvacuator drainage (self-suction) exerts a constant low pressureHemovacJackson-Pratt
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
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 injuryPromoting wound healingMaintaining skin integrityRegaining normal functionGaining 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 microorganismsAiding hemostasis –pressure dsg prevents bleeding & eliminates dead space (cavity within a wound)Promoting healing by absorbing drainage and debriding a woundSupporting or splinting a wound
19 Types of DressingsWoven gauze dressings – cause little irritation & very absorbent (2x2, 4x4)Wet to dry - used in treating wound that requires debridementNonadherent gauze dressings (telfa) – used over clean woundsSelf – 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 environmentOcclusive & adhesiveUseful on shallow to moderately deep dermal ulcers
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 burnsAre soothing, reducing pain in the woundDebride the wound by softening necrotic tissue
24 Changing Dressings Must know: Type of dressing Presence of underlying drains or tubingType of supplies neededCheck physician orderSolution orderedFrequencyOintments ordered
25 Preparing a Client for Dressing Change Administer pain medication prior to dressing change if neededDescribe to client steps of procedureDescribe normal signs of healingAnswer any questions
26 Wound Care – Applying a Dry Dressing Review medical orders for dressing changeAssess size & location of wound, type of dsg and presence of any drainsReview previous documentationAssess client’s comfort, knowledgeAssess Allergies
27 Technique for changing the dressing Gather equipment & wash handsClose door or curtainPosition client and drapePut disposable bag within reachPut on clean glovesRemove dressing, pull tape toward suture line.
28 Continue, Observe appearance of dressing & wound Discard dressing and glovesWash handsOpen sterile dressing trayOpen cleansing solution – pour on gauzePut on sterile gloves
29 Cleanse and dry woundApply ointment if orderedApply dry sterile dressingsSecure dressing (date & time on tape)Remove glovesAssist client into comfortable position
30 Basic Skin CleansingCleanse in a direction from the least contaminated area, such as from the wound or incision to the surrounding skinUse gentle friction when applying solutionsWhen 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 NSSterile techniqueNever occlude wound with the syringeFlow 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 gauzeDrain – 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 & supportDepends on size, location, presence of drainage, frequency of changes and activity
35 Inspect dressingAssess client’s tolerance of the procedureClean supplies and equipmentWash handsDocument (appearance, size, drainage, cleaning solution, technique used, what was applied (in order), how secured, and how client tolerated procedure)