Professional Documents
Culture Documents
Review
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
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
Example
D- day 6 post-op C-Section surgical incision assessed. Incision well approximated, staples intact with no inflammation, tenderness or exudate noted.
c)
Nursing Diagnoses
Impaired skin integrity related to: Surgical incision Effects of pressure Chemical injury Secretions (cell/gland) and excretions (waste of metabolism)
Secondary to: C-section, appendectomy, etc AMB (as manifested) or AEB (as evidenced by): Sterile dressing over incision changed OD Open pressure ulcer right heel with Tegaderm applied 2nd degree burns covering anterior aspect of thighs bilat serosang. drainage from coccyx pressure ulcer
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
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.
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 client into comfortable position
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
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 Dont 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 clients 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)
Skill 33-2, p. 666: Preparing a sterile field Skill 33-5, p. 672: Open gloving
First Year skills
Chapters 38 & 39: Clinical Nursing Skills & Techniques, (Perry & Potter)
Skill 38-2, p. 988: Performing suture & staple removal Skill 38.3, p. 993: Drainage evacuation Skill 39.1, p. 1005: Applying a dry dressing
Video Review
Cleaning surgical wound and applying a dry sterile dressing Irrigating a wound using sterile technique Unexpected situations
Healing!
Final Lab!
Urinary Catheter Chapter 33