Chapter 24

1. Chapter 24 Wound Care and Irrigation

2. 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.

3. 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.

4. 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.

5. 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.

6. 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 one-half full. Maintain asepsis when opening and closing system. Measure and record volume and characteristics. Reestablish vacuum by compressing or reattaching to suction.

7. 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.

8. A, Staple extractor placed under staple. B, Removal of interrupted sutures.

9. 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.

10. Chapter 26 Dressings, Bandages, and Binders

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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.