Download Slide 1 - Amazon S3

Chapter 24
Wound Care and Irrigation
Patient-Centered Care
• Wound assessment is the first essential step in planning
wound care
• Discuss the importance of wound assessments with patient
and family.
• Consider cultural beliefs and practices.
• Maintain patient privacy during assessment and wound care.
• Value and apply patient expertise in wound management.
– Include care providers in wound management.
Safety
• Use proper infection control practices to reduce the risk of
wound infection.
– Surgical wounds usually require sterile technique.
– Chronic wounds often use clean technique.
• Prevent tissue injury when measuring wounds.
• Irrigate wounds gently.
• User correct instruments when removing staples or stitches.
Procedural Guideline 24.1
Performing a Wound Assessment
• Assess wound status and phase of healing.
• Frequency depends on condition of wound, health care
setting, and agency policy.
– Use agency-approved assessment tool.
– Assess pain at wound site.
– Measure dimensions: Undermining, tissue loss, tissue type,
exudate, periwound skin.
• Reapply dressing per order.
• Record findings and compare to previous data.
Skill 24.1 Performing Irrigation
• Cleanse surgical or chronic wounds using prescribed irrigating
solution.
– Position patient so solution flows away from wound.
– Use appropriate syringe or equipment to minimize tissue trauma and
provide gentle irrigation.
– Apply slow, continuous pressure with syringe and/or catheter.
– Use pulsatile high-pressure lavage per provider order.
• Reapply appropriate dressing and label.
Skill 24.2 Managing Drainage Evacuation
• Drainage devices apply suction to remove and collect
drainage and facilitate wound healing.
– They are inserted into wounds through the suture line or a small
stab wound near the surgical site.
– Number drainage devices when more than one exists.
• Empty and reset drainage devices when more than onehalf full.
– Maintain asepsis when opening and closing system.
– Measure and record volume and characteristics.
– Reestablish vacuum by compressing or reattaching to suction.
Skill 24.3 Removing Staples and Sutures
• Remove sutures or staples per provider order when surgical
healing is adequate.
– Sutures and staples usually removed in 7 to 10 days
– Retention sutures left in longer (14 days or more)
• Cleanse incision with antiseptic swabs.
• Remove staples without scratching skin.
• Remove suture with forceps after snipping.
– Never snip both ends of a suture.
– Identify type of suturing (e.g., interrupted, continuous).
• Determine that all sutures are removed.
• Cleanse incision with antiseptic.
• Apply steri-strips according to policy or order.
A, Staple extractor placed under staple. B, Removal of interrupted
sutures.
Skill 24.4 Negative-Pressure Wound Therapy
• Dressings are typically changed every 48 hours.
• Remove old dressing.
– Protect periwound skin.
• Cleanse or irrigate wound per order or policy.
– Perform wound assessment.
• Reapply proper size wound dressing.
– Count and document number of dressings or packing.
• Apply transparent covering.
• Reconnect to device.
– Reestablish negative pressure per orders or policy.
Chapter 26
Dressings, Bandages, and Binders
Patient-Centered Care
• Acute and chronic wounds can cause pain, distress, and
financial burden on patients and families.
– Consider individual patient needs, including socioeconomic needs.
• Patients and families often care for wounds at home.
– Initiate teaching as soon as possible.
– Provide opportunities for patient and family participation.
Safety
• Wounds may be colonized with bacteria.
– Colonization does not interfere with wound healing.
• Monitor for signs of infection.
– Wound infection interferes with wound healing.
• Follow precautions to prevent introduction or spread of
bacteria.
– Wear personal protective equipment.
– Follow agency isolation protocols for colonized or infected
patients.
Skill 26.1 Applying a Dressing
(Dry and Moist-to-Dry)
• Dry dressings
– For wounds healing by primary intention
– Not used for debriding wounds
• Moist-to-dry dressings
– Commonly use isotonic solutions
– Mechanically debride wounds
• Provide pain medication if needed.
• Remove tape by pulling toward dressing.
• Remove dressing one layer at a time
– If dry dressing sticks, moisten with normal saline.
Skill 26.1 Applying a Dressing
(Dry and Moist-to-Dry) (cont’d)
• Observe wound characteristics.
• Prepare and maintain sterile field during dressing.
– Clean wound from least to most contaminated area.
– Gently pack moist-to-dry dressing.
• Ensure that all dead space is loosely packed.
• Do not leave moist gauze in contact with surrounding skin.
– Blot dry sterile wound with sterile gauze to dry skin.
• Cover with secondary dressing.
• Secure with tape or Montgomery straps.
Skill 26.2 Applying a Pressure Bandage
• Pressure bandages temporarily control excessive bleeding.
• Locate external bleeding site.
– Apply immediate manual pressure with gloved hand and dry gauze.
– Obtain assistance from second person to prepare gauze compress and
tape strips.
– Tape compress with overlapping strips.
• Keep firm pressure on site while taping.
• Avoid tourniquet effect.
• Observe dressing for control of bleeding.
Procedural Guideline 26.1
Applying a Transparent Dressing
• Occlusive or moisture-retentive dressings cover and
encapsulate wounds.
• Remove old dressing.
– Pick up ends and slowly pull back parallel to wound.
– Do not pull upward.
• Cleanse and dry wound per orders.
• Inspect wound characteristics.
• Apply new dressing.
– Do not stretch film.
– Avoid wrinkles.
– Smooth and adhere dressing with fingers.
Skill 26.3 Applying a Hydrocolloid, Hydrogel,
Foam, or Absorption Dressing
• Hydrating dressings maintain a moist, insulated environment.
– Apply wafers, granules, paste, or gel as prescribed.
– Ensure contact with any undermined areas.
– Cover with moisture-retentive dressing.
• Absorbent dressings wick exudate away.
– Cut foam sheet to extend 2.5 cm (1 inch) onto periwound skin.
– Check instructions for which side faces wound bed.
– Cover with secondary dressing.
Procedural Guideline 26.2
Applying Gauze and Elastic Bandages
• Use to wrap or secure hard-to-cover areas or exert
pressure over a body part.
• Apply from distal point toward proximal boundary,
stretching slightly.
• Alternate ascending and descending turns.
• Ensure that bandage is snug but not tight.
– Check primary dressing or splint for correct position.
– Secure with tape or clips.
• Assess tightness and routinely evaluate distal circulation.
Procedural Guideline 26.3
Applying an Abdominal and Breast Binder
• Binders fit a specific body part to support a wound, reduce or
prevent edema, protect surrounding skin, or decrease pain.
– Ensure correct fit to decrease risk of wound injury or interference with
respirations or mobility.
• Routinely assess patient’s ability to breathe deeply and cough
when binder is in use.
• Routinely remove binder to assess underlying dressings, skin,
and wound characteristics.