Showing posts with label Physical Treatments. Show all posts
Showing posts with label Physical Treatments. Show all posts

UNDERSTANDING VACUUM-ASSISTED CLOSURE THERAPY

Posted by Admin in Thursday, February 24, 2011

Vacuum-assisted closure (VAC) therapy, also called negative pressure wound therapy, is an option to consider when a wound fails to heal in a timely manner. VAC therapy encourages healing by applying localized subatmospheric pressure at the site of the wound. This reduces edema and bacterial colonization and stimulates the formation of granulation tissue.

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VACUUM-ASSISTED CLOSURE THERAPY

Posted by Admin in Tuesday, February 22, 2011

Vacuum-assisted closure (VAC) therapy, also known as negative pressure wound therapy, is used to enhance delayed or impaired wound healing. The VAC device applies localized subatmospheric pressure to draw the edges of the wound toward the center. It's applied after a special dressing is placed in the wound or over a graft or flap; this wound packing removes fluids from the wound and stimulates growth of healthy granulation tissue. (See Understanding vacuum-assisted closure therapy.)
VAC therapy is indicated for acute and traumatic wounds, pressure ulcers, and chronic open wounds, such as diabetic ulcers, meshed grafts, and skin flaps. It's contraindicated for fistulas that involve organs or body cavities, necrotic tissue with eschar, untreated osteomyelitis, and malignant wounds. This therapy should be used cautiously in patients with active bleeding, in those taking anticoagulants, and when achieving wound hemostasis has been difficult.

Equipment
Waterproof trash bag • goggles • gown, if indicated • emesis basin • normal saline solution • clean gloves • sterile gloves • sterile scissors • linen-saver pad • 35-ml piston syringe with 19G catheter • reticulated foam • fenestrated tubing • evacuation tubing • skin protectant wipe • transparent occlusive air-permeable drape • evacuation canister • vacuum unit.

Preparation of equipment
Assemble the VAC device at the bedside per manufacturer's instructions. Set negative pressure according to the physician's order (25 to 200 mm Hg).

Implementation
  • Check the physician's order, and assess the patient's condition.
  • Explain the procedure to the patient, provide privacy, and wash your hands. Put on goggles—and a gown, if necessary—to protect yourself from wound drainage and contamination.
  • Place a linen-saver pad under the patient to catch any spills and avoid linen changes. Position the patient to allow maximum wound exposure. Place the emesis basin under the wound to collect any drainage.
  • Put on clean gloves. Remove the soiled dressing and discard it in the waterproof trash bag. Attach the 19G catheter to the 35-ml piston syringe and irrigate the wound thoroughly using the normal saline solution.
  • Clean the area around the wound with normal saline solution; wipe intact skin with a skin protectant wipe and allow it to dry well. Remove and discard your gloves.
  • Put on sterile gloves. Using sterile scissors, cut the foam to the shape and measurement of the wound. More than one piece of foam may be necessary if the first piece is cut too small.
  • Carefully place the foam in the wound. Next, place the fenestrated tubing into the center of the foam. The fenestrated tubing, embedded into the foam, delivers negative pressure to the wound.
  • Place the transparent occlusive air permeable drape over the foam, enclosing both the foam and the tubing. Remove and discard your gloves.
  • Connect the free end of the fenestrated tubing to the evacuation tubing connected to the evacuation canister.
  • Turn on the vacuum unit.
  • Make sure the patient is comfortable.
  • Properly dispose of drainage, solution, linen-saver pad, and trash bag, and clean or dispose of soiled equipment and supplies according to facility policy and Centers for Disease Control and Prevention guidelines.

Special considerations
  • Change the dressing every 48 hours. Try to coordinate dressing change with the physician's visit so he can inspect the wound.
  • Measure the amount of drainage every shift.
  • Adjust the negative pressure setting according to the physician's orders.
  • Audible and visual alarms alert you if the unit is tipped greater than 45 degrees, the canister is full, the dressing has an air leak, or the canister becomes dislodged.

Complications
Care and cleaning of wounds may temporarily increase the patient's pain. They also increase the risk for infection.

Documentation
Document the frequency and duration of therapy, the amount of negative pressure applied, the size and condition of the wound, and the patient's response to treatment.




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USING A CLOSED-WOUND DRAINAGE SYSTEM

Posted by Admin in Monday, February 14, 2011

The portable closed-wound drainage system draws drainage from a wound site, such as the chest wall postmastectomy (shown at left), by means of a Y tube. To empty the drainage, remove the plug and empty it into a graduated cylinder. To reestablish suction, compress the drainage unit against a firm surface to expel air and, while holding it down, replace the plug with your other hand (as shown in the center). The same principle is used for the Jackson-Pratt bulb drain (shown at right).









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IRRIGATING A DEEP WOUND

Posted by Admin in Friday, January 7, 2011

When preparing to irrigate a wound, attach a 19G needle or catheter to a 35-ml piston syringe. This setup delivers an irrigation pressure of 8 psi, which is effective in cleaning the wound and reducing the risk of trauma and wound infection. To prevent tissue damage or, in an abdominal wound, intestinal perforation, avoid forcing the needle or catheter into the wound.


Irrigate the wound with gentle pressure until the solution returns clean. Then position the emesis basin under the wound to collect any remaining drainage.

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WOUND IRRIGATION

Posted by Admin in Saturday, December 25, 2010

Irrigation cleans tissues and flushes cell debris and drainage from an open wound. Irrigation with a commercial wound cleaner helps the wound heal properly from the inside tissue layers outward to the skin surface; it also helps prevent premature surface healing over an abscess pocket or infected tract. Performed properly, wound irrigation requires strict sterile technique. After irrigation, open wounds usually are packed to absorb additional drainage. Always follow the standard precaution guidelines of the Centers for Disease Control and Prevention (CDC).

Equipment
Waterproof trash bag • linen-saver pad • emesis basin • clean gloves • sterile gloves • goggles • gown, if indicated • prescribed irrigant such as sterile normal saline solution • sterile water or normal saline solution • soft rubber or plastic catheter • sterile container • materials as needed for wound care • sterile irrigation and dressing set • commercial wound cleaner • 35-ml piston syringe with 19G needle or catheter • skin protectant wipe.

Preparation of equipment
Assemble all equipment in the patient's room. Check the expiration date on each sterile package and inspect for tears. Check the sterilization date and the date that each bottle of irrigating solution was opened; don't use any solution that's been open longer than 24 hours.
Using aseptic technique, dilute the prescribed irrigant to the correct proportions with sterile water or normal saline solution, if necessary. Let the solution stand until it reaches room temperature, or warm it to 90° to 95° F (32.2° to 35° C).
Open the waterproof trash bag, and place it near the patient's bed. Position the bag to avoid reaching across the sterile field or the wound when disposing of soiled articles. Form a cuff by turning down the top of the trash bag to provide a wide opening, which will keep instruments or gloves from touching the bag's edge, thus preventing contamination.

Implementation
  • Check the physician's order, and assess the patient's condition. Identify the patient's allergies, especially to povidone-iodine or other topical solutions or medications.
  • Explain the procedure to the patient, provide privacy, and position the patient correctly for the procedure. Place the linen-saver pad under the patient to catch any spills and avoid linen changes. Place the emesis basin below the wound so that the irrigating solution flows from the wound into the basin.
  • Wash your hands thoroughly. If necessary, put on a gown to protect your clothing from wound drainage and contamination. Put on clean gloves.
  • Remove the soiled dressing; then discard the dressing and gloves in the trash bag.
  • Establish a sterile field with all the equipment and supplies you'll need for irrigation and wound care. Pour the prescribed amount of irrigating solution into a sterile container so you won't contaminate your sterile gloves later by picking up unsterile containers. Put on sterile gloves, gown, and goggles, if indicated.
  • Fill the syringe with the irrigating solution; then connect the catheter to the syringe. Gently instill a slow, steady stream of irrigating solution into the wound until the syringe empties. (See Irrigating a deep wound, page 202.) Make sure the solution flows from the clean to the dirty area of the wound to prevent contamination of clean tissue by exudate. Also make sure the solution reaches all areas of the wound.
  • Refill the syringe, reconnect it to the catheter, and repeat the irrigation.
  • Continue to irrigate the wound until you've administered the prescribed amount of solution or until the solution returns clear. Note the amount of solution administered. Then remove and discard the catheter and syringe in the waterproof trash bag.
  • Keep the patient positioned to allow further wound drainage into the basin.
  • Clean the area around the wound with normal saline solution; wipe intact skin with a skin protectant wipe and allow it to dry well to help prevent skin breakdown and infection.
  • Pack the wound, if ordered, and apply a sterile dressing. Remove and discard your gloves and gown.
  • Make sure the patient is comfortable.
  • Properly dispose of drainage, solutions, and trash bag, and clean or dispose of soiled equipment and supplies according to facility policy and CDC guidelines. To prevent contamination of other equipment, don't return unopened sterile supplies to the sterile supply cabinet.


Special considerations
  • Try to coordinate wound irrigation with the physician's visit so that he can inspect the wound.
  • Use only the irrigant specified by the physician because others may be erosive or otherwise harmful.
  • Remember to follow your facility's policy and CDC guidelines concerning wound and skin precautions.
  • Irrigate with a bulb syringe if the wound is small or not particularly deep or if a piston syringe is unavailable. However, use a bulb syringe cautiously because this type of syringe doesn't deliver enough pressure to adequately clean the wound.
Home care
If the wound must be irrigated at home, teach the patient or a family member how to perform this procedure using strict aseptic technique. Ask for a return demonstration of the proper technique. Provide written instructions. Arrange for home health supplies and nursing visits, as appropriate. Urge the patient to call the physician if he detects signs of infection.

Complications
Wound irrigation increases the risk of infection and may cause excoriation and increased pain. Pressure over 15 psi causes trauma to the wound and directs bacteria back into the tissue.
Documentation
Record the date and time of irrigation, amount and type of irrigant, appearance of the wound, sloughing tissue or exudate, amount of solution returned, skin care performed around the wound, dressings applied, and the patient's tolerance of the treatment.

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TRAUMATIC WOUND MANAGEMENT

Posted by Admin in Monday, December 20, 2010

Traumatic wounds include abrasions, lacerations, puncture wounds, and amputations. In an abrasion, the skin is scraped, with partial loss of the skin surface. In a laceration, the skin is torn, causing jagged, irregular edges; the severity of a laceration depends on its size, depth, and location. A puncture wound occurs when a pointed object, such as a knife or glass fragment, penetrates the skin. Traumatic amputation refers to the removal of part of the body, a limb, or part of a limb.
When caring for a patient with a traumatic wound, first assess his ABCs—airway, breathing, and circulation. It may seem natural to focus on a gruesome injury, but a patent airway and pumping heart take first priority. Once the patient's ABCs are stabilized, you can turn your attention to the traumatic wound. Initial management concentrates on controlling bleeding, usually by applying firm, direct pressure and elevating the extremity. If bleeding continues, you may need to compress a pressure point. Assess the condition of the wound. Management and cleaning technique usually depend on the specific type of wound and degree of contamination.

Equipment
Sterile basin • normal saline solution • sterile 4″ × 4″ gauze pads • sterile gloves • clean gloves • sterile cotton-tipped applicators • dry sterile dressing, nonadherent pad, or petroleum gauze • linen-saver pad • optional: scissors, towel, goggles, mask, gown, 50-ml catheter-tip syringe, surgical scrub brush, antibacterial ointment, porous tape, sterile forceps, sutures and suture set, hydrogen peroxide.
Preparation of equipment
Place a linen-saver pad under the area to be cleaned. Remove any clothing covering the wound. If necessary, cut hair around the wound with scissors to promote cleaning and treatment.
Assemble needed equipment at the patient's bedside. Fill a sterile basin with normal saline solution. Make sure the treatment area has enough light to allow close observation of the wound. Depending on the nature and location of the wound, wear sterile or clean gloves to avoid spreading infection.

Implementation
  • Check the patient's medical history for previous tetanus immunization and, if needed and ordered, arrange for immunization.
  • Administer pain medication, if ordered.
  • Wash your hands.
  • Use appropriate protective equipment, such as a gown, a mask, and goggles, if spraying or splashing of body fluids is possible.
For an abrasion
  • Flush the scraped skin with normal saline solution.
  • Remove dirt or gravel with a sterile 4″ × 4″ gauze pad moistened with normal saline solution. Rub in the opposite direction from which the dirt or gravel became embedded.
  • If the wound is extremely dirty, you may use a surgical brush to scrub it.
  • With a small wound, allow it to dry and form a scab. With a larger wound, you may need to cover it with a nonadherent pad or petroleum gauze and a light dressing. Apply antibacterial ointment if ordered.
For a laceration
  • Moisten a sterile 4″ × 4″ gauze pad with normal saline solution. Clean the wound gently, working outward from its center to about 2″ (5 cm) beyond its edges. Discard the soiled gauze pad and use a fresh one as necessary. Continue until the wound appears clean.
  • If the wound is dirty, you may irrigate it with a 50-ml catheter-tip syringe and normal saline solution.
  • Assist the physician in suturing the wound edges using the suture kit, or apply sterile strips of porous tape.
  • Apply the prescribed antibacterial ointment to help prevent infection.
  • Apply a dry sterile dressing over the wound to absorb drainage and help prevent bacterial contamination.
For a puncture wound
  • If the wound is minor, allow it to bleed for a few minutes before cleaning it.
  • For a larger puncture wound, you may need to irrigate it before applying a dry dressing.
  • Stabilize any embedded foreign object until the physician can remove it. After he removes the object and bleeding is stabilized, clean the wound as you'd clean a laceration or deep puncture wound.
For an amputation
  • Apply a gauze pad moistened with normal saline solution to the amputation site. Elevate the affected part, and immobilize it for surgery.
  • Recover the amputated part, and prepare it for transport to a facility where microvascular surgery is performed.
Special considerations
  • When irrigating a traumatic wound, avoid using more than 8 psi of pressure. High-pressure irrigation can seriously interfere with healing, kill cells, and allow bacteria to infiltrate the tissue.
  • To clean the wound, you may use normal saline or hydrogen peroxide (its foaming action facilitates debris removal). However, peroxide should never be instilled into a deep wound because of the risk of embolism from the evolving gases. Be sure to rinse your hands well after using hydrogen peroxide.
  • Avoid cleaning a traumatic wound with alcohol because alcohol causes pain and tissue dehydration. Also, avoid using antiseptics for wound cleaning because they can impede healing. In addition, never use a cotton ball or cotton-filled gauze pad to clean a wound because cotton fibers left in the wound can cause contamination.
  • After a wound has been cleaned, the physician may want to debride it to remove dead tissue and reduce the risk of infection and scarring. If this is necessary, pack the wound with gauze pads soaked in normal saline solution until debridement.
  • Observe for signs and symptoms of infection, such as warm red skin at the site or purulent discharge. Be aware that infection of a traumatic wound can delay healing, increase scar formation, and trigger systemic infection, such as septicemia.

  • Observe all dressings. If edema is present, adjust the dressing to avoid impairing circulation to the area.
Complications
Cleaning and care of traumatic wounds may temporarily increase the patient's pain. Excessive, vigorous cleaning may further disrupt tissue integrity.

Documentation
Document the date and time of the procedure, wound size and condition, medication administration, specific wound care measures, and patient teaching.

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RECOGNIZING DEHISCENCE AND EVISCERATION

Posted by Admin in Saturday, November 27, 2010

In wound dehiscence (top), the layers of the surgical wound separate. In evisceration (bottom), the viscera (in this case, a bowel loop) protrude through the surgical incision.


Wound dehiscence



Evisceration of bowel loop

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TYPES OF ADHESIVE SKIN CLOSURES

Posted by Admin in Sunday, November 14, 2010

Steri-Strips are used as a primary means of keeping a wound closed after suture removal. They're made of thin strips of sterile, nonwoven, porous fabric tape.

Butterfly closures consist of sterile, waterproof adhesive strips. A narrow, nonadhesive “bridge” connects the two expanded adhesive portions. These strips are used to close small wounds and assist healing after suture removal

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WOUND DEHISCENCE AND EVISCERATION MANAGEMENT

Posted by Admin in Saturday, November 6, 2010

Although surgical wounds typically heal without incident, occasionally the edges of a wound may fail to join or may separate even after they seem to be healing normally. This development, called wound dehiscence, may lead to an even more serious complication: evisceration, in which a portion of the viscera (usually a bowel loop) protrudes through the incision. Evisceration, in turn, can lead to peritonitis and septic shock. (See Recognizing dehiscence and evisceration.) Dehiscence and evisceration are most likely to occur 6 to 7 days after surgery. By then, sutures may have been removed and the patient can cough easily and breathe deeply—both of which strain the incision. Some wound dehiscence may be managed conservatively using a medical approach, such as sterile dressing application and wound monitoring.
  • NURSING ALERT Wound evisceration requires quick intervention to prevent potentially fatal shock; the wound is usually closed in the operating room.
Several factors can contribute to these complications. Poor nutrition—either from inadequate intake or a condition such as diabetes mellitus—may hinder wound healing. Chronic pulmonary or cardiac disease can also slow healing because the injured tissue doesn't get needed nutrients and oxygen. Localized wound infection may limit closure, delay healing, and weaken the incision. Also, stress on the incision from coughing or vomiting may cause abdominal distention or severe stretching. A midline abdominal incision, for instance, poses a high risk of wound dehiscence.
Equipment
Two sterile towels • 1 L of sterile normal saline solution • sterile irrigation set, including a basin, solution container, and 50-ml catheter-tip syringe • several large abdominal dressings • sterile, waterproof drape • linen-saver pads • sterile gloves.
If the patient will return to the operating room, also gather the following equipment: I.V. administration set and I.V. fluids • equipment for nasogastric (NG) intubation • sedative, as ordered • suction apparatus.
Implementation
  • Provide reassurance and support to ease the patient's anxiety. Tell him to stay in bed. If possible, stay with him while someone else notifies the physician and collects the necessary equipment.
  • Place a linen-saver pad under the patient to keep the sheets dry when you moisten the exposed viscera.
  • Using sterile technique, unfold a sterile towel to create a sterile field. Open the package containing the irrigation set, and place the basin, solution container, and 50-ml syringe on the sterile field.
  • Open the bottle of normal saline solution and pour about 400 ml into the solution container. Also pour about 200 ml into the sterile basin.
  • Open several large abdominal dressings, and place them on the sterile field.
  • Put on the sterile gloves, and place one or two of the large abdominal dressings into the basin to saturate them with saline solution.
  • Place the moistened dressings over the exposed viscera. Then place a sterile, waterproof drape over the dressings to prevent the sheets from getting wet.
  • Moisten the dressings every hour by withdrawing saline solution from the container through the syringe and then gently squirting the solution on the dressings.
  • When you moisten the dressings, inspect the color of the viscera. If it appears dusky or black, notify the physician immediately. With its blood supply interrupted, a protruding organ may become ischemic and necrotic.
  • Keep the patient on absolute bed rest in low Fowler's position (no more than 20 degrees' elevation) with his knees flexed. This prevents injury and reduces stress on an abdominal incision.
  • Don't allow the patient to have anything by mouth to decrease the risk of aspiration during surgery.
  • Monitor the patient's pulse, respirations, blood pressure, and temperature every 15 minutes to detect shock.
  • If necessary, prepare the patient to return to the operating room. After gathering the appropriate equipment, start an I.V. infusion, as ordered.
  • Insert an NG tube and connect it to continuous or intermittent low suction, as ordered.
  • Depending on the circumstances, some of these procedures may not be done at the bedside. For instance, NG intubation may make the patient gag or vomit, causing further evisceration. For this reason, the physician may choose to have the NG tube inserted in the operating room with the patient under anesthesia.
  • Continue to reassure the patient while you prepare him for surgery. Make sure he has signed a consent form and that the operating room staff has been informed about the procedure.
  • Administer preoperative medications to the patient, as ordered.
Special considerations
  • The best treatment is prevention. If you're caring for a postoperative patient who's at risk for poor healing, make sure he receives an adequate supply of protein, vitamins, and calories. Monitor his dietary deficiencies, and discuss any problems with the physician and the dietitian.
  • When changing wound dressings, always use sterile technique. Inspect the incision with each dressing change, and if you recognize the early signs of infection, start treatment before dehiscence or evisceration can occur. If local infection develops, clean the wound as necessary to eliminate a buildup of purulent drainage. Make sure bandages aren't so tight that they limit blood supply to the wound.
Complications
Infection, which can lead to peritonitis and, possibly, septic shock, is the most severe and most common complication of wound dehiscence and evisceration. Caused by bacterial contamination or by drying of normally moist abdominal contents, infection can impair circulation and lead to necrosis of the affected organ.
Documentation
Note when the problem occurred, the patient's activity preceding the problem, his condition, and the time the physician was notified. Describe the appearance of the wound or eviscerated organ; amount, color, consistency, and odor of any drainage; and nursing actions taken. Record the patient's vital signs, his response to the incident, and the physician's actions.
Finally, make sure you change the patient care plan to reflect nursing actions needed to promote proper healing.

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SKIN STAPLE AND CLIP REMOVAL

Posted by Admin in Monday, November 1, 2010

Skin staples or clips may be used instead of standard sutures to close lacerations or surgical wounds. Because they can secure a wound more quickly than sutures, they may substitute for surface sutures when cosmetic results aren't a prime consideration, such as in abdominal closure. When properly placed, staples and clips distribute tension evenly along the suture line with minimal tissue trauma and compression, facilitating healing and minimizing scarring. Because staples and clips are made from surgical stainless steel, tissue reaction to them is minimal. Usually, physicians remove skin staples and clips, but some facilities permit qualified nurses to perform this procedure.
Skin staples and clips are contraindicated when wound location requires cosmetically superior results or when the incision site makes it impossible to maintain at least a 5-mm distance between the staple and underlying bone, vessels, or internal organs.
Equipment
Waterproof trash bag • adjustable light • clean gloves, if needed • sterile gloves • sterile gauze pads • sterile staple or clip extractor • povidone-iodine solution or other antiseptic cleaning agent • sterile cotton-tipped applicators • optional: butterfly adhesive strips or Steri-Strips, compound benzoin tincture or other skin protectant.
Prepackaged, sterile, disposable staple or clip extractors are available.
Preparation of equipment
Assemble all equipment in the patient's room. Check the expiration date on each sterile package and inspect for tears. Open the waterproof trash bag, and place it near the patient's bed. Position the bag to avoid reaching across the sterile field or the wound when disposing of soiled articles. Form a cuff by turning down the top of the bag to provide a wide opening, then preventing contamination of instruments or gloves by touching the bag's edge.
Implementation
  • If your facility allows you to remove skin staples and clips, check the physician's order to confirm the exact timing and details for this procedure.
  • Check for patient allergies, especially to adhesive tape and povidone-iodine or other topical solutions or medications.
  • Explain the procedure to the patient. Tell him that he may feel a slight pulling or tickling sensation but little discomfort during staple removal. Reassure him that because his incision is healing properly, removing the supporting staples or clips won't weaken the incision line.
  • Provide privacy, and place the patient in a comfortable position that doesn't place undue tension on the incision. Because some patients experience nausea or dizziness during the procedure, have the patient recline if possible. Adjust the light to shine directly on the incision.
  • Wash your hands thoroughly.
  • If the patient's wound has a dressing, put on clean gloves and carefully remove it. Discard the dressing and the gloves in the waterproof trash bag.
  • Assess the patient's incision. Notify the physician of gaping, drainage, inflammation, and other signs of infection.
  • Establish a sterile work area with all the equipment and supplies you'll need for removing staples or clips and for cleaning and dressing the incision. Open the package containing the sterile staple or clip extractor, maintaining asepsis. Put on sterile gloves.
  • Wipe the incision gently with sterile gauze pads soaked in an antiseptic cleaning agent or with sterile cotton-tipped applicators to remove surface encrustations.
  • Pick up the sterile staple or clip extractor. Then, starting at one end of the incision, remove the staple or clip. (See Removing a staple.) Hold the extractor over the trash bag, and release the handle to discard the staple or clip.
  • Repeat the procedure for each staple or clip until all are removed.
  • Apply a sterile gauze dressing, if needed, to prevent infection and irritation from clothing. Then discard your gloves.
  • Make sure the patient is comfortable. According to the physician's preference, inform the patient that he may shower in 1 or 2 days if the incision is dry and healing well.
  • Properly dispose of solutions and the trash bag, and clean or dispose of soiled equipment and supplies according to facility policy.
Special considerations
  • Carefully check the physician's order for the time and extent of staple or clip removal. The physician may want you to remove only alternate staples or clips initially and to leave the others in place for an additional day or two to support the incision.
  • When removing a staple or clip, place the extractor's jaws carefully between the patient's skin and the staple or clip to avoid patient discomfort. If extraction is difficult, notify the physician; staples or clips placed too deeply within the skin or left in place too long may resist removal.
  • If the wound dehisces after staples or clips are removed, apply butterfly adhesive strips or Steri-Strips to approximate and support the edges, and call the physician immediately to repair the wound. (See Types of adhesive skin closures.)
  • You may also apply butterfly adhesive strips or Steri-Strips after removing staples or clips even if the wound is healing normally to give added support to the incision and prevent lateral tension from forming a wide scar. Use a small amount of compound benzoin tincture or other skin protectant to ensure adherence. Leave the strips in place for 3 to 5 days.
Home care
If the patient is being discharged, teach him how to remove the dressing and care for the wound. Instruct him to call the physician immediately if he observes wound discharge or any other abnormal change. Tell him that the redness surrounding the incision should gradually disappear and that after a few weeks, only a thin line will be visible.

Documentation
Record the date and time of staple or clip removal, number of staples or clips removed, appearance of the incision, dressings or butterfly strips applied, signs of wound complications, and the patient's tolerance of the procedure.

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REMOVING A STAPLE

Posted by Admin

Position the extractor's lower jaws beneath the span of the first staple (as shown below).


Squeeze the handles until they're completely closed; then lift the staple away from the skin (as shown below). The extractor changes the shape of the staple and pulls the prongs out of the intradermal tissue.

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METHODS FOR REMOVING SUTURES

Posted by Admin

Removal techniques depend on the type of sutures to be removed. The illustrations below show removal steps for four common suture types. Keep in mind that for all suture types, it's important to grasp and cut sutures in the correct place to avoid pulling the exposed (thus contaminated) suture material through subcutaneous tissue.
Plain interrupted sutures
Using sterile forceps, grasp the knot of the first suture and raise it off the skin. This will expose a small portion of the suture that was below skin level. Place the rounded tip of sterile curved-tip suture scissors against the skin, and cut through the exposed portion of the suture. Then, still holding the knot with the forceps, pull the cut suture up and out of the skin in a smooth continuous motion to avoid causing the patient pain. Discard the suture. Repeat the process for every other suture, initially; if the wound doesn't gape, you can then remove the remaining sutures as ordered.



Plain continuous sutures
Cut the first suture on the side opposite the knot. Next, cut the same side of the next suture in line. Then lift the first suture out in the direction of the knot. Proceed along the suture line, grasping each suture where you grasped the knot on the first one.



Mattress interrupted sutures
If possible, remove the small, visible portion of the suture opposite the knot by cutting it at each visible end and lifting the small piece away from the skin to prevent pulling it through and contaminating subcutaneous tissue. Then remove the rest of the suture by pulling it out in the direction of the knot. If the visible portion is too small to cut twice, cut it once and pull the entire suture out in the opposite direction. Repeat these steps for the remaining sutures, and monitor the incision carefully for infection.



Mattress continuous sutures
Follow the procedure for removing mattress interrupted sutures, first removing the small visible portion of the suture, if possible, to prevent pulling it through and contaminating subcutaneous tissue. Then extract the rest of the suture in the direction of the knot.

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SUTURE REMOVAL

Posted by Admin in Sunday, October 31, 2010

The goal of this procedure is to remove skin sutures from a healed wound without damaging newly formed tissue. The timing of suture removal depends on the shape, size, and location of the sutured incision; the absence of inflammation, drainage, and infection; and the patient's general condition. Usually, for a sufficiently healed wound, sutures are removed 7 to 10 days after insertion. Techniques for removal depend on the method of suturing, but all require sterile procedure to prevent contamination. Although sutures usually are removed by a physician, in many facilities, a nurse may remove them on the physician's order.
Equipment
Waterproof trash bag • adjustable light • clean gloves, if the wound is dressed • sterile gloves • sterile forceps or sterile hemostat • normal saline solution • sterile gauze pads • antiseptic cleaning agent • sterile curve-tipped suture scissors • povidone-iodine pads • optional: adhesive butterfly strips or Steri-Strips and compound benzoin tincture or other skin protectant.
Prepackaged, sterile suture-removal trays are available.
Preparation of equipment
Assemble all equipment in the patient's room. Check the expiration date on each sterile package and inspect for tears. Open the waterproof trash bag, and place it near the patient's bed. Position the bag properly to avoid reaching across the sterile field or the suture line when disposing of soiled articles. Form a cuff by turning down the top of the trash bag to provide a wide opening and prevent contamination of instruments or gloves by touching the bag's edge.


Implementation
  • If your facility allows you to remove sutures, check the physician's order to confirm the details for this procedure.
  • Check for patient allergies, especially to adhesive tape and povidone-iodine or other topical solutions or medications.
  • Tell the patient that you're going to remove the stitches from his wound. Assure him that this procedure typically is painless, but that he may feel a tickling sensation as the stitches come out. Reassure him that because his wound is healing properly, removing the stitches won't weaken the incision.
  • Provide privacy, and position the patient so he's comfortable without placing undue tension on the suture line. Because some patients experience nausea or dizziness during the procedure, have the patient recline if possible. Adjust the light to have it shine directly on the suture line.
  • Wash your hands thoroughly. If the patient's wound has a dressing, put on clean gloves and carefully remove the dressing. Discard the dressing and the gloves in the waterproof trash bag.
  • Observe the patient's wound for possible gaping, drainage, inflammation, signs of infection, and embedded sutures. Notify the physician if the wound has failed to heal properly. The absence of a healing ridge under the suture line 5 to 7 days after insertion indicates that the line needs continued support and protection during the healing process.
  • Establish a sterile work area with all the equipment and supplies you'll need for suture removal and wound care. Open the sterile suture-removal tray, maintaining sterility of the contents, and put on sterile gloves.
  • Using sterile technique, clean the suture line to decrease the number of microorganisms present and reduce the risk of infection. The cleaning process should also moisten the sutures sufficiently to ease removal. Soften them further, if needed, with normal saline solution.
  • Proceed according to the type of suture you're removing. (See Methods for removing sutures.) Because the visible part of a suture is exposed to skin bacteria and considered contaminated, be sure to cut sutures at the skin surface on one side of the visible part of the suture. Remove the suture by lifting and pulling the visible end off the skin to avoid drawing this contaminated portion back through subcutaneous tissue.
  • If ordered, remove every other suture to maintain some support for the incision. Then go back and remove the remaining sutures.
  • After removing sutures, wipe the incision gently with gauze pads soaked in an antiseptic cleaning agent or with a povidone-iodine pad. Apply a light sterile gauze dressing, if needed, to prevent infection and irritation from clothing. Then discard your gloves.
  • Make sure the patient is comfortable. According to the physician's preference, inform the patient that he may shower in 1 or 2 days if the incision is dry and heals well.
  • Properly dispose of the solutions and trash bag, and clean or dispose of soiled equipment and supplies according to your facility's policy.
Special considerations
  • Be sure to check the physician's order for the time of suture removal. Usually, you'll remove sutures on the head and neck 3 to 5 days after insertion; on the chest and abdomen, 5 to 7 days after insertion; and on the lower extremities, 7 to 10 days after insertion.
  • If the patient has interrupted sutures or an incompletely healed suture line, remove only those sutures specified by the physician. He may want to leave some sutures in place for an additional day or two to support the suture line.
  • If the patient has both retention and regular sutures in place, check the physician's order for the sequence in which they are to be removed. Because retention sutures link underlying fat and muscle tissue and give added support to the obese or slow-healing patient, they usually remain in place for 14 to 21 days.
  • Be particularly careful to clean the suture line before attempting to remove mattress sutures. This decreases the risk of infection when the visible, contaminated part of the stitch is too small to cut twice for sterile removal and must be pulled through tissue. After you have removed mattress sutures this way, monitor the suture line carefully for subsequent infection.
  • If the wound dehisces during suture removal, apply butterfly adhesive strips or Steri-Strips to support and approximate the edges and call the physician immediately to repair the wound.
  • Apply butterfly adhesive strips or Steri-Strips after any suture removal, if desired, to give added support to the incision line and prevent lateral tension on the wound from forming a wide scar. Use a small amount of compound benzoin tincture or other skin protectant to ensure adherence. Leave the strips in place for 3 to 5 days, as ordered.
Home care
If the patient is being discharged, teach him how to remove the dressing and care for the wound. Instruct him to call the physician immediately if he observes wound discharge or any other abnormal change. Tell him that the redness surrounding the incision should gradually disappear and only a thin line should show after a few weeks.
Documentation
Record the date and time of suture removal, type and number of sutures, appearance of the suture line, signs of wound complications, dressings or butterfly strips applied, and the patient's tolerance of the procedure.

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HOW TO PUT ON STERILE GLOVES

Posted by Admin

Using your nondominant hand, pick up the opposite glove by grasping the exposed inside of the cuff.


Slip the gloved fingers of your dominant hand under the glove of the loose glove to pick it up.


Pull the glove onto your dominant hand. Be sure to keep your thumb folded inward to avoid touching the sterile part of the glove. Allow the glove to come uncuffed as you finish inserting your hand, but don't touch the outside of the glove.


Slide your nondominant hand into the glove, holding your dominant thumb as far away as possible to avoid brushing against your arm. Allow the glove to come uncuffed as you finish putting it on, but don't touch the skin side of the cuff with your other gloved hand.

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TAILORING WOUND CARE TO WOUND COLOR

Posted by Admin in Sunday, October 24, 2010

Promote healing in any wound by keeping it moist, clean, and free of debris. For open wounds, use wound color to guide the specific management approach and to assess how well the wound is healing.
Red wounds
Red, the color of healthy granulation tissue, indicates normal healing. When a wound begins to heal, a layer of pale pink granulation tissue covers the wound bed. As this layer thickens, it becomes beefy red. Cover a red wound, keep it moist and clean, and protect it from trauma. Use a transparent dressing (such as Tegaderm or Op-site), a hydrocolloidal dressing (such as DuoDerm), or a gauze dressing moistened with sterile normal saline solution or impregnated with petroleum jelly or an antibiotic.
Yellow wounds
Yellow is the color of exudate produced by microorganisms in an open wound. When a wound heals without complications, the immune system removes microorganisms. However, if there are too many microorganisms to remove, exudate accumulates and becomes visible. Exudate usually appears whitish yellow, creamy yellow, yellowish green, or beige. Dry exudate appears darker.
If your patient has a yellow wound, clean it and remove exudate, using irrigation; then cover it with a moist dressing. Use absorptive products (for example, Debrisan beads and paste) or a moist gauze dressing with or without an antibiotic. You may also use hydrotherapy with whirlpool or high-pressure irrigation.
Black wounds
Black, the least healthy color, signals necrosis. Dead, avascular tissue slows healing and provides a site for microorganisms to proliferate.
You should debride a black wound. After removing dead tissue, apply a dressing to keep the wound moist and guard against external contamination. As ordered, use enzyme products, surgical debridement, hydrotherapy with whirlpool or irrigation, or a moist gauze dressing.
Multicolored wounds
You may note two or even all three colors in a wound. In this case, classify the wound according to the least healthy color present. For example, if your patient's wound is both red and yellow, classify it as a yellow wound.

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SURGICAL WOUND MANAGEMENT

Posted by Admin in Saturday, October 23, 2010

When caring for a surgical wound, you carry out procedures that help prevent infection by stopping pathogens from entering the wound. Besides promoting patient comfort, such procedures protect the skin surface from maceration and excoriation caused by contact with irritating drainage. They also allow you to measure wound drainage to monitor fluid and electrolyte balance.
The two primary methods used to manage a draining surgical wound are dressing and pouching. Dressing is preferred unless caustic or excessive drainage is compromising your patient's skin integrity. Usually, lightly seeping wounds with drains and wounds with minimal purulent drainage can be managed with packing and gauze dressings. Some wounds, such as those that become chronic, may require an occlusive dressing.
A wound with copious, excoriating drainage calls for pouching to protect the surrounding skin. If your patient has a surgical wound, you must monitor him and choose the appropriate dressing.
Dressing a wound calls for sterile technique and sterile supplies to prevent contamination. You may use the color of the wound to help determine which type of dressing to apply. (See Tailoring wound care to wound color, page 188.) Be sure to change the dressing often enough to keep the skin dry. Always follow standard precautions set by the Centers for Disease Control and Prevention (CDC).
Equipment
Waterproof trash bag • clean gloves • sterile gloves • gown and face shield or goggles, if indicated • sterile 4″ × 4″ gauze pads • large absorbent dressings, if indicated • sterile cotton-tipped applicators • sterile dressing set • povidone-iodine swabs • topical medication, if ordered • adhesive or other tape • soap and water • optional: forceps; skin protectant; nonadherent pads; collodion spray or acetone-free adhesive remover; sterile normal saline solution; graduated container; and Montgomery straps, a fishnet tube elasticized dressing support, or a T-binder.
For a wound with a drain
Sterile scissors • sterile 4″ × 4″ gauze pads without cotton lining • sump drain • ostomy pouch or another collection bag • sterile precut tracheostomy pads or drain dressings • adhesive tape (paper or silk tape if the patient is hypersensitive) • surgical mask.
For pouching a wound
Collection pouch with drainage port • sterile gloves • skin protectant • sterile gauze pads.
Preparation of equipment
Ask the patient about allergies to tapes and dressings. Assemble all equipment in the patient's room. Check the expiration date on each sterile package, and inspect for tears.
Open the waterproof trash bag, and place it near the patient's bed. Position the bag to avoid reaching across the sterile field or the wound when disposing of soiled articles. Form a cuff by turning down the top of the trash bag to provide a wide opening and to prevent contamination of instruments or gloves by touching the bag's edge.
Implementation
  • Explain the procedure to the patient to allay his fears and ensure his cooperation.
Removing the old dressing
  • Check the physician's order for specific wound care and medication instructions. Note the location of surgical drains to avoid dislodging them during the procedure.
  • Assess the patient's condition.
  • Identify the patient's allergies, especially to adhesive tape, povidone-iodine or other topical solutions, or medications.
  • Provide privacy, and position the patient as necessary. To avoid chilling him, expose only the wound site.
  • Wash your hands thoroughly. Put on a gown and a face shield, if necessary. Then put on clean gloves.
  • Loosen the soiled dressing by holding the patient's skin and pulling the tape or dressing toward the wound. This protects the newly formed tissue and prevents stress on the incision. Moisten the tape with acetone-free adhesive remover, if necessary, to make the tape removal less painful (particularly if the skin is hairy). Don't apply solvents to the incision because they could contaminate the wound.
  • Slowly remove the soiled dressing. If the gauze adheres to the wound, loosen the gauze by moistening it with sterile normal saline solution.
  • Observe the dressing for the amount, type, color, and odor of drainage.
  • Discard the dressing and gloves in the waterproof trash bag.
Caring for the wound
  • Wash your hands. Establish a sterile field with all the equipment and supplies you'll need for suture-line care and the dressing change, including a sterile dressing set and povidone-iodine swabs. If the physician has ordered ointment, squeeze the needed amount onto the sterile field. If you're using an antiseptic from an unsterile bottle, pour the antiseptic cleaning agent into a sterile container so you won't contaminate your gloves. Then put on sterile gloves. (See How to put on sterile gloves.)
  • Saturate the sterile gauze pads with the prescribed cleaning agent. Avoid using cotton balls because they may shed fibers in the wound, causing irritation, infection, or adhesion.
  • If ordered, obtain a wound culture; then proceed to clean the wound.
  • Irrigate the wound, if ordered, using the specified solution.
  • Pick up the moistened gauze pad or swab, and squeeze out the excess solution.
  • Working from the top of the incision, wipe once to the bottom and then discard the gauze pad. With a second moistened pad, wipe from top to bottom in a vertical path next to the incision (as shown below).
  • Continue to work outward from the incision in lines running parallel to it. Always wipe from the clean area toward the less clean area (usually from top to bottom). Use each gauze pad or swab for only one stroke to avoid tracking wound exudate and normal body flora from surrounding skin to the clean areas. Remember that the suture line is cleaner than the adjacent skin and the top of the suture line is usually cleaner than the bottom because more drainage collects at the bottom of the wound.
  • Use sterile, cotton-tipped applicators for efficient cleaning of tight-fitting wire sutures, deep and narrow wounds, and wounds with pockets. Because the cotton on the swab is tightly wrapped, it's less likely than a cotton ball to leave fibers in the wound. Remember to wipe only once with each applicator.
  • If the patient has a surgical drain, clean the drain's surface last. Because moist drainage promotes bacterial growth, the drain is considered the most contaminated area. Clean the skin around the drain by wiping in half or full circles from the drain site outward.
  • Clean all areas of the wound to wash away debris, pus, blood, and necrotic material. Try not to disturb sutures or irritate the incision. Clean to at least 1″ (2.5 cm) beyond the end of the new dressing. If you aren't applying a new dressing, clean to at least 2″ (5 cm) beyond the incision.
  • Check to make sure the edges of the incision are lined up properly, and check for signs of infection (heat, redness, swelling, induration, and odor), dehiscence, and evisceration. If you observe such signs or if the patient reports pain at the wound site, notify the physician.
  • Wash skin surrounding the wound with soap and water, and pat dry using a sterile 4″ × 4″ gauze pad. Avoid oil-based soap because it may interfere with pouch adherence. Apply any prescribed topical medication.
  • Apply a skin protectant, if needed.
  • If ordered, pack the wound with gauze pads or strips folded to fit, using a sterile forceps. Avoid using cotton-lined gauze pads because cotton fibers can adhere to the wound surface and cause complications. Pack the wound, using the wet-to-damp method. Soaking the packing material in solution and wringing it out so that it's slightly moist provides a moist wound environment that absorbs debris and drainage. However, removing the packing won't disrupt new tissue. Don't pack the wound tightly; doing so will exert pressure and may damage the wound.
Applying a fresh gauze dressing
  • Gently place sterile 4″ × 4″ gauze pads at the center of the wound, and move progressively outward to the edges of the wound site. Extend the gauze at least 1″ (2.5 cm) beyond the incision in each direction, and cover the wound evenly with enough sterile dressings (usually two or three layers) to absorb all drainage until the next dressing change. Use large absorbent dressings to form outer layers, if needed, to provide greater absorbency.
  • Secure the dressing's edges to the patient's skin with strips of tape to maintain the sterility of the wound site (as shown on page 191). Or secure the dressing with a T-binder or Montgomery straps to prevent skin excoriation, which may occur with repeated tape removal necessitated by frequent dressing changes. (See How to make Montgomery straps.)
  • Make sure the patient is comfortable.
  • Properly dispose of the solutions and trash bag, and clean or discard soiled equipment and supplies according to your facility's policy. If your patient's wound has purulent drainage, don't return unopened sterile supplies to the sterile supply cabinet because this could cause cross-contamination of other equipment.

Dressing a wound with a drain
  • Use commercially precut gauze drain dressings or prepare a drain dressing by using sterile scissors to cut a slit in a sterile 4″ × 4″ gauze pad. Fold the pad in half; then cut inward from the center of the folded edge. Don't use a cotton-lined gauze pad because cutting the gauze opens the lining and releases cotton fibers into the wound. Prepare a second pad the same way.
  • Gently press one drain dressing close to the skin around the drain so that the tubing fits into the slit. Press the second drain dressing around the drain from the opposite direction so that the two dressings encircle the tubing.
  • Layer as many uncut sterile 4″ × 4″ gauze pads or large absorbent dressings around the tubing as needed to absorb expected drainage. Tape the dressing in place, or use a T-binder or Montgomery straps.
Pouching a wound
  • If your patient's wound is draining heavily or if drainage may damage surrounding skin, you'll need to apply a pouch.
  • Measure the wound. Cut an opening 3/8″ (1 cm) larger than the wound in the facing of the collection pouch (as shown below).

  • Apply a skin protectant as needed. (Some protectants are incorporated within the collection pouch and also provide adhesion.)
  • Make sure the drainage port at the bottom of the pouch is closed firmly to prevent leaks. Then gently press the contoured pouch opening around the wound, starting at its lower edge, to catch any drainage (as shown below).
  • To empty the pouch, put on gloves and a face shield or mask and goggles to avoid any splashing. Then insert the pouch's bottom half into a graduated biohazard container, and open the drainage port (as shown below). Note the color, consistency, odor, and amount of fluid. If ordered, obtain a culture specimen and send it to the laboratory immediately. Remember to follow the CDC's standard precautions when handling infectious drainage.
  • Wipe the bottom of the pouch and the drainage port with a gauze pad to remove any drainage that could irritate the patient's skin or cause an odor. Then reseal the port. Change the pouch only if it leaks or fails to adhere. More frequent changes are unnecessary and only irritate the patient's skin.

Special considerations
  • If the patient has two wounds in the same area, cover each wound separately with layers of sterile 4″ × 4″ gauze pads. Then cover each site with a large absorbent dressing secured to the patient's skin with tape. Don't use a single large absorbent dressing to cover both sites because drainage quickly saturates a pad, promoting cross-contamination.
  • When packing a wound, don't pack it too tightly because this compresses adjacent capillaries and may prevent the wound edges from contracting. Avoid overlapping damp packing onto surrounding skin because it macerates the intact tissue.
  • To save time when dressing a wound with a drain, use precut tracheostomy pads or drain dressings instead of custom-cutting gauze pads to fit around the drain. If your patient is sensitive to adhesive tape, use paper or silk tape because it is less likely to cause a skin reaction and peels off more easily than adhesive tape. Use a surgical mask to cradle a chin or jawline dressing; this provides a secure dressing and avoids the need to shave the patient's hair.
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  • If ordered, use a collodion spray or similar topical protectant instead of a gauze dressing. Moisture- and contaminant-proof, this covering dries in a clear, impermeable film that leaves the wound visible for observation and avoids the friction caused by a dressing.
  • If a sump drain isn't adequately collecting wound secretions, reinforce it with an ostomy pouch or another collection bag. Use waterproof tape to strengthen a spot on the front of the pouch near the adhesive opening; then cut a small “Xâ€� in the tape. Feed the drain catheter into the pouch through the “Xâ€� cut. Seal the cut around the tubing with more waterproof tape; then connect the tubing to the suction pump. This method frees the drainage port at the bottom of the pouch so you don't have to remove the tubing to empty the pouch. If you use more than one collection pouch for a wound or wounds, record drainage volume separately for each pouch. Avoid using waterproof material over the dressing because it reduces air circulation and promotes infection from accumulated heat and moisture.
  • Because many physicians prefer to change the first postoperative dressing themselves to check the incision, don't change the first dressing unless you have specific instructions to do so. If you have no such order and drainage comes through the dressings, reinforce the dressing with fresh sterile gauze. Request an order to change the dressing, or ask the physician to change it as soon as possible. A reinforced dressing shouldn't remain in place longer than 24 hours because it's an excellent medium for bacterial growth.
  • For the recent postoperative patient or a patient with complications, check the dressing every 15 to 30 minutes or as ordered. For the patient with a properly healing wound, check the dressing at least once every 8 hours.
  • If the dressing becomes wet from the outside (for example, from spilled drinking water), replace it as soon as possible to prevent wound contamination.
  • If your patient will need wound care after discharge, provide appropriate teaching. If he'll be caring for the wound himself, stress the importance of using aseptic technique, and teach him how to examine the wound for signs of infection and other complications. Also show him how to change dressings, and give him written instructions for all procedures to be performed at home.
Complications
A major complication of a dressing change is an allergic reaction to an antiseptic cleaning agent, a prescribed topical medication, or adhesive tape. This reaction may lead to skin redness, rash, excoriation, or infection.
  • NURSING ALERT Take care when removing adhesive tape to prevent skin tears, especially in elderly patients.
Documentation
Document the date, time, and type of wound management procedure; amount of soiled dressing and packing removed; wound appearance (size, condition of margins, presence of necrotic tissue) and odor (if present); type, color, consistency, and amount of drainage (for each wound); presence and location of drains; additional procedures, such as irrigation, packing, or application of a topical medication; type and amount of new dressing or pouch applied; and the patient's tolerance of the procedure.
Document special or detailed wound care instructions and pain management steps on the care plan. Record the color and amount of drainage on the intake and output sheet.

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