Sterile Dressings

Sterile Dressings

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 dressings• To 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 .

Wound Assessment in Stable SettingWound 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?

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

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

Penrose/Jackson-Pratt

Hemovac

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

Steri Strips/Staples/Sutures

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

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

Document (6 days post op C-section)

Example

• D- day 6 post-op C-Section surgical incision assessed. Incision well approximated, staples intact with no inflammation, tenderness or exudate noted.

Document your assessmentsa) b)

c)

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.

Goals of Wound Care

• Preventing infection• Preventing further tissue injury• Promoting wound healing• Maintaining skin integrity• Regaining normal function• Gaining comfort

Cleaning Wounds

• Gentle cleansing essential

• Clean with normal saline (unless otherwise ordered by physician)

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

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)

• 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

Telfa/Tegaderm/Duoderm

• 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

Hydrogel Dressings

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

Preparing a patient for Dressing Change

• Administer pain medication prior to dressing change if needed

• Describe to patient steps of procedure

• Describe normal signs of healing

• Answer any questions

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 patient’s comfort, knowledge• Assess Allergies

Technique for changing the dressing

• Gather equipment & wash hands• Close door or curtain• Position patiient and drape• Put disposable bag within reach• Put on clean gloves• Remove dressing, pull tape toward suture line.

Continue,

• 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

• Cleanse and dry wound • Apply ointment if ordered• Apply dry sterile dressings• Secure dressing (date & time on tape)• Remove gloves• Assist patient into comfortable position

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

Wound Irrigation• Cleanses the wound

from exudate and debris

• Use 100-150 ml NS• Sterile technique• Never occlude wound

with the syringe• Flow directly into the

wound not over the contaminated area

Continue,

• 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

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)

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

• 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)

Healing!

Thank you