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Sterile Dressings Chapter 43 Potter & Perry Chapters 37, 38 – Perry & Potter.

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Presentation on theme: "Sterile Dressings Chapter 43 Potter & Perry Chapters 37, 38 – Perry & Potter."— Presentation transcript:

1 Sterile Dressings Chapter 43 Potter & Perry Chapters 37, 38 – Perry & Potter

2 Review

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 *Nurse 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 Document your assessments a) b) c)

14 Nursing Diagnoses Impaired skin integrity related to: – Surgical incision – Effects of pressure – Chemical injury – Secretions (cell/gland) and excretions (waste of metabolism) AMB (as manifested) or AEB (as evidenced by): – Sterile dressing over incision changed OD – Open pressure ulcer right heel with duoderm applied – 2 nd degree burns covering anterior aspect of thighs bilat – serosang. drainage from coccyx pressure ulcer

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

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

17 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

18 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)

19 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

20 Telfa/Tegaderm/Duoderm

21 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

22 Hydrogel Dressings

23 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

24 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

25 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

26 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.

27 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

28 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

29 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

30 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

31 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

32 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)

33 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

34 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)

35 RESPONSIBLE FOR THE FOLLOWING SKILLS Chapter 9: Clinical Nursing Skills and Techniques (Perry & Potter) Skill 9.2, p. 212: Preparing a sterile field Skill 9.3, p. 218: Open gloving First Year skills

36 Chapters 37, 38: Clinical Nursing Skills & Techniques, (Perry & Potter) Skill 37-2, p. 1241: Performing suture & staple removal Skill 37.3, p. 1247: Drainage evacuation Skill 38.1, p. 1260: Applying a dry dressing

37 Video Review Cleaning surgical wound and applying a dry sterile dressing Irrigating a wound using sterile technique Unexpected situations

38 Infected Surgical Wound Requiring VAC Dressing (p. 1282)

39 After VAC Dressing Change/VAC Reapplied

40 Healing!

41 Final Lab! Urinary Catheter Chapter 32


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