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PAYWARD

MARY ANN S. ZUNIEGA

BSN 3B

WOUND CARE

Sterile Dressing Application

Application process:

Personal protective equipment (PPE)

Wear the following PPE when performing this procedure:

• Gown
• Sterile gloves
• Mask

Supplies and equipment

Supplies:

• Medicated ointment and/or solutions as Equipment:


ordered by a physician
• Dressings and applicators as needed • Appropriate containers for medicated
Examples: 4x4s, 2x2s, Kerlex ointment and/or solutions
• Plastic disposal bag and red bio-hazard bag • Instrument set if needed
• Tap Antiseptic solution Example: Scissors and forceps
Examples: Cliniscrub, 4-oz. Plastic bottle • Sterile basin
• Sterile saline

Preparing

Action

1. Gather the Supplies, PPE, Equipment.


2. Make the necessary arrangements to maintain privacy during the procedure.
3. Explain the procedure to the patientPosition the dressing set on the table.
4. Position the dressing set on the table.
5. Wash your hands with antiseptic solution.
6. Open the dressing set without touching the contents.
7. Leave the dressing set on the open wrapper.
8. Open the sterile supplies and pour the necessary solutions.

Reason: The wrapper provides a sterile environment for the dressing set.

Note: Dressing changes should take place in the examination room.

Removing existing dressing

Action

1. Loosen the tape on the patient's existing dressing.


2. Put on sterile gloves.
3. Remove the dressing, using forceps, if required
4. Place the used dressing and forceps in a plastic bag.
5. Does the wound require cleaning?If yes, go to Step 6.If no, go to Step 8.
6. Clean the wound with a sterile applicator using a circular motion beginning at the center of the
wound and extending outward.
7. Place the used applicator(s) in a plastic bag.Caution: Do not touch the wound site with a used
applicator(s).
8. Observe the wound for complications. Examples: Discoloration, edema, purulent drainage

Applying the sterile dressing

Action

1. Apply the sterile dressing.


2. Remove your gloves and place them in a plastic bag.
3. Tape the new dressing in place.
4. Double-bag the contaminated articles closing each bag securely.
5. Place these bags inside a red plastic bag outside of the room.
6. Wash your hands using the proper technique.
7. Clean up the treatment room and complete the charge tickets for materials used.
8. Document the following in the patient's record:

• Name of person performing the procedure


• Time of procedure
• Description of the wound
Example: Absence or presence of edema, discoloration, and/or drainage
• Patient's reaction to dressing change

9. Report any unusual findings to the physician.

Educating the patient

Action

Instruct the patient to keep his/her hands off of the wound.


Instruct the patient to report the following about the wound site to a nurse or physician:

• Tenderness
• Pain
• Redness
• Swelling

9. Is the patient returning home or to a halfway house?If yes, instruct the patient and/or family how to
change the dressing.If no, you have completed this procedure.

What is wound drainage?


Wound drainage provides a way for unnecessary body fluids or air to flow out of the body from a wound.

What is a wound drain?


After surgery, some patients require wound drains such as the one pictured above. The wound drain is inserted
while the patient is in the operating room receiving general anesthesia. The purpose of the drain is to remove
fluid and/or blood from the surgical site. This helps the healing process. Not all patients need wound drains
following surgery. Wound drains are usually made of plastic. One end is placed within the wound to be drained
and the other end is connected to a suction collection device. The fluid may be collected in a drainage bag,
plastic bulb, and plastic carton or onto a dressing.

How long is a wound drain used?


That depends on the type of surgery and the amount of fluid or blood draining from the wound. The surgeon
closely evaluates the wound drain daily and decides when it should be removed. The nurses check on the drain
frequently and empty it when necessary.
Does the wound drain hurt?
No. Usually the patient does not know that the wound drain is present unless they are told. The wound drain
may sting when it is removed.

What happens if the patient rolls on it?


Normally nothing happens. Occasionally it may become blocked. However, the nurses assess the drain
frequently to make sure that this does not happen.

Are there any potential complications associated with use of a wound drain?
wound drains are usually not associated with significant complications.

Drain instructions

Drain care is a clean procedure. Supplies do not need to be sterile, but you must wash your hands thoroughly
with soap and warm water before performing drain care.

• Perform drainage care twice a day.


Discard the drainage once in the morning and once in the evening.
Try to empty the drain at the same time each day.
• Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup.
• Record the amount of drainage fluid on the record sheet.
• Dispose of the drainage fluid in a toilet or rinse it down a sink.
• Reestablish drain suction.

Various types of suction devices are used on wound drain systems. Prior to your discharge from the
hospital, a nurse will specify which type of drain and suction device you have and will instruct you on
proper drain care for your wound.

Types of drains

Jackson-Pratt

This oval-shaped suction system is about the size and shape of a large lemon. To re-establish suction, squeeze
the drain in the palm of your hand with your fingers until the inside walls of the drain touch. While maintaining
pressure, replace the plug. Slowly release your grip to re-establish suction. The drain should remain concave or
somewhat flat. It should not be fully inflated. If the drain is not flat, the suction is not working.

Fig. 1 Fig. 2 Fig. 3

A Jackson-Pratt drain prior to emptying (Figure 1) Empty drainage fluid into a measuring cup and record the
amount of fluid. (Figure 2) While maintaining pressure, replace the plug. Slowly release your grip to re-
establish suction. (Figure 3)

Hemovac

A Hemovac is a round drain with springs inside that must be compressed to establish proper suction. To re-
establish suction, squeeze the drain on both sides until the drain appears to be flat. While maintaining suction,
replace the plug and release your grip.
Fig. 4 Fig. 5

Fig. 6

A Hemovac drain prior to emptying. (Figure 4) Empty drainage fluid into a measuring cup and record the
amount of fluid. (Figure 5) While maintaining pressure, replace the plug. Slowly release your grip to re-
establish suction. (Figure 6)

Davol

This suction device has a rubber bulb on top of the drain that acts as pump to inflate the balloon in the drainage
bottle. To re-establish suction, squeeze the rubber bulb with a continuous pumping motion until the balloon in
the drainage bottle is completely inflated. Quickly replace the plug in the drain before the balloon deflates. The
inflated balloon inside the drainage bottle creates the suction.

Fig. 8
Fig. 9
Fig. 7

A Davol drain prior to emptying. (Figure 7) Empty draining fluid into a measuring cup and record the amount
of fluid. (Figure 8) Squeeze the rubber bulb until the balloon in the drainage bottle is completely inflated.
Quickly replace the plug in the drain before the balloon deflates. (Figure 9)

Correcting problems with the drain

If the drain tube becomes temporarily obstructed or is not draining properly, you may:

• Bend the tubing over your fingers.


• Gently squeeze the tube between your thumb and index finger, moving your fingers along the tubing
toward the suction bottle, to help dislodge the obstruction or blood clot.

Call your physician if any of the following occur:

• The drainage suddenly stops (The drainage should decrease gradually, not abruptly.)
• There's a sudden change in the color of the drainage.
The drainage should gradually change from blood to a straw-colored fluid.
Call if the drainage becomes bloody again or changes to a milky white fluid.
• There's an increase in redness or swelling around the insertion site of the drain.
• You are unable to re-establish suction in the drainage system.

Directions for suture line care

Suture (incision) line care also is a clean procedure. Supplies do not need to be sterile, but you must wash your
hands thoroughly before performing the procedure.

• Suture line care should be done twice a day (morning and evening after emptying the drain).
• In a basin or cup, mix 1 part hydrogen peroxide with 2 parts saline solution or distilled water (For
example, mix 1/8 cup of hydrogen peroxide with 1/4 cup of saline solution or distilled water.)
• Moisten the cotton-tipped applicators with the diluted hydrogen peroxide mixture.
• Using the moistened cotton-tipped applicator:
* Gently wipe over the suture line and once down each side.
* Wipe once down the middle of the incision, gently removing drainage and crusting.
If crusting is difficult to remove, do not remove it.
• After cleaning the suture line, swab a generous amount of antibiotic ointment on a cotton-tipped
applicator. Gently and evenly spread the ointment on the suture line.

Signs of infection at the suture line

The following are signs indicating that there may be an infection at or around the suture line. Notify your
physician if you experience any of the following:

• An increase in redness, tenderness, or swelling of the suture line.


• Drainage from the suture line. (Occasionally, a small amount of bloody or clear yellow-tinged fluid may
drain. Notify your physician if it persists or if it changes in consistency.)
• A marked or sudden increase in pain not relieved by the pain medication.
• White pimples or blisters at or around the incision line.

General signs and symptoms of infection

• A persistent elevation of body temperature greater than 100.5 degrees Fahrenheit. (You should take your
temperature daily, at the same time each day.)
• Sweats or chills.
• Skin rash.
• Persistent sore throat, scratchy throat or pain when swallowing.
• Persistent sinus drainage, nasal congestion, headaches, or tenderness along the upper cheekbones.
• Persistent dry or moist cough that lasts more than two days.
• White patches in your mouth or on your tongue.
• Nausea, vomiting or diarrhea.
• Trouble urinating: pain or burning, constant urge or frequent urination.
• Bloody, cloudy or foul-smelling urine.

Hemovac Autotransfusion System

The safe solution in wound drainage and reinfusion

The Hemovac Autotransfusion System (H.A.S.® Autotransfusion System) from Zimmer improves safety for
the hospital staff and the patient. A complete system, the H.A.S. product provides everything needed for post-
operative salvage of the patient’s own blood and for continued wound drainage after reinfusion: a collection
unit, wound drainage tubing and an autotransfusion evacuator designed to minimize risk of spreading infection.
As an infection control system, the H.A.S. product reduces the staff’s exposure to blood and body fluids.

The Hemovac Autotransfusion System is a fully integrated, completely portable system that does not depend on
external sources such as wall suction or batteries to operate. And because wall suction is not needed, the risk of
hemolysis is greatly reduced. The system’s low, gentle suction helps ensure the overall quality of blood to be
reinfused.

Easy set up for easy use

The Hemovac Autotransfusion System has a minimal number of steps for assembly and operation. All
connectors are identified for easy assembly. Just two quick attachments, compress the evacuator and drainage
can begin. No batteries or other equipment are needed. Once drainage and reinfusion are completed, the entire
system can be safely discarded.

For safety and convenience

Superior design and thorough testing have made Hemovac the dependable name in wound drainage for more
than three decades. This same expertise has been applied to reinfusion of the patient’s own blood. Special
attention is always given to the details designed to make the process safer and less complicated.
• A large 230 micron gross filter with an internal spring helps reduce clots and keeps blood flowing feely
into the bottle.
• The system operates from any position during wound drainage which is especially convenient during
patient transportation.
• The safety of a dual trocar drain assembly.
• Vents in the collection bag minimize retention of wound air, leaving good quality shed blood more room
for reinfusion into the patient.
• A choice of three drain sizes, or none at all, is designed to accommodate any reinfusion and wound
drainage need.

Discharge Instructions: Caring for Your Hemovac Drainage Tube

You have been discharged with a Hemovac drainage tube. The tube was placed in your incision to remove fluid
and is attached to a drain or collection device. It will help healing and reduce the risk of infection. Expect to see
fluid and blood in the drain. You may also feel some burning and pulling from the stitch that holds the tube in
place. Your drain will be removed when the fluid leaking from it is less than 2 tablespoons each day. There is a
bandage at the site where the tube is placed. This is to protect the open area from infection. Your stitches will be
taken out 7 to 14 days after surgery. Here's what you need to do to care for your Hemovac drainage tube.

General Guidelines

• Don’t sleep on the same side as the tube.


• Secure the tube and bag inside your clothing. This will prevent the tube from being pulled out.
• Tape plastic wrap over the bandage and tube site when you shower.

Empty the Drain

Empty your drain at least twice a day. Empty it more often if needed.

• Lift the cork. The drain will expand.


• Turn the drain upside down.
• Drain the fluid into a measuring cup.
• Record the amount of fluid each time you empty the drain. Share this information with your doctor on
your next visit.
• Place the empty drain on a hard surface and press down until it is flat.
• Close the cork device.

Change the Dressing

Change the dressing around the tube every day.

• Wash your hands.


• Remove the old bandage.
• Wash your hands again.
• Wet a cotton swab (Q-tip) and clean around the incision and tube site. Use normal saline solution (salt
and water).
• Put a new bandage on the incision and tube site. Make the bandage large enough to cover the whole
incision area.
• Tape the bandage in place.

Follow-Up

Make a follow-up appointment as directed by our staff.


When to Call Your Doctor

Call your doctor right away if you have any of the following:

• Pain, swelling, or fluid around the tube


• Redness or warmth around the incision or fluid draining from the incision
• Nausea and vomiting
• Fever above 100°F or chills
• An incision that does not heal; stitches that become infected or loose
• A tube that falls out
• A foul smell from the incision site

• Drainage that changes from light pink to dark red

IRRIGATING WOUNDS

RESPONSIBILITY STATEMENT: Licensed staff may perform wound irrigation.

EQUIPMENT LIST:
Gloves, face shield, gown Sterile normal saline
Plastic bag Syringe 30-35 ml
Incontinent pads 18-19 gauge angiocath
Waterproof drape for patient Gauze 4x4’s
Sterile basin

SUPPORTIVE EVIDENCE:
Irrigation is a method of wound cleaning by removing wound debris mechanically with pressurized fluids.
Irrigation pressures below 4 pounds per square inch (psi) may not adequately cleanse the wound.
Optimum irrigation pressure of 8-12 psi effectively cleanses the wound, reduces wound trauma and wound
infection.
Irrigation pressures over 15 psi can cause wound trauma and drive bacteria into the tissue.

Wound Cleansing Principles


1. Cleanse wounds initially and at each dressing change.
2. Use minimal mechanical force when cleansing the wound with gauze, cloth, or sponges.
3. Use Normal Saline to cleanse wounds. Do not cleanse wounds with skin cleansers or antiseptic agents as
they are cytotoxic to normal tissue.
4. Use enough irrigation pressure to enhance wound cleansing without causing trauma to the wound bed.
Methods Of Irrigation Include:
1. High pressure irrigation : Fluid delivered at 8-12 pounds per square inch (psi)
• A 30-35ml syringe and an 18-19
gauge angiocatheter
2. Lower pressure irrigation (6psi and under)
• Saline squeeze bottle (250ml) with
irrigation cap delivers 4.5psi
• Piston Irrigation Syringe (60ml) with
catheter tip delivers 4.2 psi
• Bulb syringe delivers 2 psi
• Spray bottle (Ultra Klenz) delivers
1.2
Normal Saline Bullets (30cc) psi is unknown.

CONTENT:
Any wound irrigation that requires squirting, spraying, or pressure release of fluid requires personal protective
equipment that includes gloves, gown, mask with eye shield to prevent exposure to debris and aerosolization of
microorganisms. Splash shield devices will still require wearing of gowns, and face protection due to splash
potential.

Procedure Steps Key Points


Topic: High Pressure Irrigation

Rational: to cleanse and debride the slough from


the wound bed. Debris, slough, and wound contamination can prevent
healing.

Preparation
1. Perform hand hygiene and collect supplies. Maintain aseptic environment by performing hand hygiene
Place only those supplies to be used for the and wearing protective equipment.
irrigation next to the patient. Do not allow Protect environment, equipment, and other supplies from
irrigation spray to contaminate dressing contamination by irrigation spray aerosolization by
supplies or equipment. covering or removing supplies, etc
2. Put on gown, gloves, mask with eye shield. Delivering fluid under pressure to the wound bed can cause
3. Position patient to a position in which the aerosolization/dissemination of wound bacteria over a wide
irrigating solution will flow by gravity from area, exposing the patient and caregiver to potential
the upper end of the wound to the lower end. contamination.
4. Place incontinent pad under wound site.
5. Place waterproof drape over the client.
6. Position plastic bag or trash can. Place debris or waste in plastic bag.
7. Remove dressing
Cleaning Wound (Optional)
8. Clean wound from the center of the wound Prevents the introduction of microorganisms to other
outward, using circular strokes. wound areas.
9. Use a separate gauze/swab for each stroke, Provides adequate force to remove debris without
and discard each gauze/swab after use. damaging healthy tissue or inoculating the underlying
10. Assess the wound and drainage. tissue with bacteria.

High Pressure Irrigation


11. Fill 30-35 ml syringe with sterile saline for
irrigation. Use 30 cc NS bullets/fish or 250cc A steady stream provides adequate force to remove debris
NS for irrigation poured into sterile basin. without damaging healthy tissue or inoculating the
underlying tissue with bacteria.
12. Apply steady pressure with 18-19-gauge
angiocatheter over the surface of the wound.
Hold catheter close to wound. Water piks are not used for wound irrigation in GHC
13. Use sterile gauze to gently absorb or remove facilities as psi may damage tissue and increase
fluid and debris. aerosolization of bacteria.
14. When wound is adequately cleaned, dispose
incontinent pads and other disposable
supplies in plastic sack.
Prevent touching clean items with contaminated items.
15. Remove gloves and protective equipment.
16. Perform hand hygiene.
DOCUMENTATION:
Record in the medical record:
• Date and time
• Wound location (e.g., lower aspect of abd incision)
• Note method of wound cleaning (e.g., High pressure irrigation with a 35ml syringe and 19 gauge
angiocather)
• Appearance, size, depth of cleaned wound bed