1 Handbook of Dermatology Surgery-Seven Steps to Success. Leslie Plauntz, RN, BA, DNC Clinical Nurse Specialist Division of Plastic Surgery Sunnybrook Health Sciences Center Discuss: Objectives Factors Affecting Wound Healing Preoperative Screening Surgical Complications Wound Closure Understand: Local Anesthetics Suture Choice Describe: Practical Dressing Tips Basic Principles and Techniques of Dermatologic Surgery Necessary knowledge for nurses working in a surgical unit. Presentation is based on a: Case Study: We will follow a patient through her consultation, preassessment, surgical experience, and wound closure
2 Best Option for Treatment 1. Imiquimod 5% ( Aldara)-6 weeks 2. Cryosurgery 3. MOHS or removal under frozen sections 4. Nothing right now-come back in the spring 5. Electrodesiccation and curettage (ED&C) 6. Radiation -92% cure rate Correct Answer: MOHS or frozen sections-99% cure rate Step 1 Understanding Factors Affecting Wound Healing Stages of Wound Healing 1. Inflammatory (Days 1-4) Following skin injury or skin incision the wound fills with: a. Platelets-participate in forming fibrin clot -provides hemostasis- support for wound healing b. Neutrophils-gone in 72 hrs.-rids wound of bacteria c. Macrophages-main function-wound debridement, secrete cytokines (growth factors for tissue formation)
3 Proliferation ( Days 4-Week 3) a. Re-epithelialization: Epidermal cells migrate, reattach to basement membrane b. Granulation Tissue Formation: Collagen and fibroblastic stage, rapid gain of tensile strength in wound (day 4-5) Maturation/Remodeling Phase (3 weeks onwards) Maturation by intermolecular cross-linking of collagen leads to flattening of the scar, dynamic, ongoing, peak tensile strength at 60 days-80% of preliminary strength Note:Scar has 5% of strength at 2 weeks 30% at 3 week 40% at 4 weeks Mature Scar never attains more than 70-80% of original strength Surgical Factors Affecting Wound Healing Wound Closure: wounds left to heal by secondary intention are slower to heal Wound Depth: superficial wounds heal faster than deep wounds Anatomic Location: face heals faster vs. other areas, chest worst location for scaring Proper Homeostasis: to avoid hematomas, higher chance of infection Good Flap Design: use anatomic landmarks to close wounds - undermine to relieve wound tension Dressings: provide absorption, protection, immobilization, compression Debridement: remove clots, debris, necrotic tissue, irrigate before closing wound Local Factors Affecting Wound Healing Surgical Technique: rough handling of tissue, poor approximation of wound edges, excessive tension on the wound, excessive bleeding Infection: wound infection -tissue should be debrided (high bacterial counts lead to wound dehiscence) Foreign body reaction: foreign bodies provide source of infection -tetnus update every 10 yrs.-especially with burns (decreases body immunity) Radiation: radiated skin heals poorly-large risk of wound break down
4 Patient Factors Affecting Wound Healing Disease states: diabetes, vascular diseases,malnutrition Smoking-vasoconstriction Vitamin deficiencies: Vit C ( important for collagen synthesis), Vit A( reverses effects of steroids), Vit E ( antioxidant) Mineral deficiencies : zinc ( deficiency causes impaired epithelial, fibroblast production) Coagulation disorders: liver disease, blood thinners Medications: glucocorticoids, immunosuppressant's, (prednisone) Aging:have a slower healing process through all wound stages Anatomical Factors Affecting Wound Outcome Important to have good knowledge of facial anatomy Know the danger areas to avoid: Facial Nerve Main Arteries Facial Nerves Facial Nerve(Cranial Nerve 7)-motor supply to facial expressions Starts in the skull, enters through parotid gland and divides into 5 branches: TEMPORAL(raises eyebrow) easily cut crosses zygomatic arch BUCCAL MARGINAL MANDIBULAR(responsible for smile) CERVICAL ZYGOMATIC
5 Nerve Danger Areas Mid -Pupillary Line Facial Anatomy Important Structures Identifies location of foramina out of which 3 sensory nerves emerge 1. supraorbital (anesthetizes forehead and frontal scalp), 2. infraorbital (anesthetizes lower eyelid, medial cheek, upper lip, nasal sidewall), 3. mental nerve (anesthetizes chin, lower lip) Anterior Border of Masseter Muscle Masseter muscle -controls chewing: originates on the zygoma. Can be felt in middle of the cheek by clenching teeth.(feel pulse) Lower edge of mandible and anterior border of masseter crossing, is where facial artery enters face
6 Nose: Tip, Dorsum, Sidewall, Ala, Glabella Ear: Helix, Antihelix, Tragus, Concha Lip: Philtrum, Vermillion Border, Nasolabial Fold Facial Structures Facial Anatomy Summary Factors Affecting Wound Healing A well planned excision is essential Follow good wound closure techniques Knowledge of wound healing, anatomy, local anesthesia, instrumentation, closure material, suture techniques, and dressing material ensure successful excisional biopsy results
7 Step 2 Preassessment of The Surgical Patient Ethel has chosen to have Mohs surgery. Why do patient s need preassessment prior to surgery? Preoperative Screening Medical Evaluation: Allergies, medications (interactions, anticoagulants, preoperative antibiotic therapy) Recommendations for blood thinners: ASA, Plavix : Discontinue 5-7 days before, restart 1-2 days after (may depend on patient and physician s preference) New blood thinners: eg. Xarelto-Discontinue 1-2 days prior to major surgery, restart as soon as hemostasis is obtained Perioperative Anticoagulation Management Consider risks vs. benefits of with holding medication (warfarin, coumadin) Stop 4-5 days prior (has long lasting effect) in low risk patients Restart in 24 hours (takes several days to reach blood thinning effect) High risk patients are given a bridging therapy (heparin IV-is short acting, started 3 days prior, for 4-6 days after until warfarin takes effect)
8 Preoperative Screening Diabetes: risk of slower wound healing and chance of infection Hypertension: increases chance of bleeding Cardiovascular disease: valvular heart disease-prosthetic valves have a greater risk for endocarditis, may require prophylactic antibiotics. Identify patients with pacemakers Role of Antibiotics in Skin Surgery Infective Endocarditis: few guidelines for skin procedures At Risk: prosthetic heart valve, history of infective endocarditis, congenital heart disease Antibiotics: Keflex 1-2 grams, Clindamycin 600 mg. (1-2 hrs pre-op) Prevention Joint Infection: high risk if surgery is 2 years following surgery-use mainly in high-risk patients where perforation of the mucosa occurs Prophylaxis Antibiotics- Mohs Clean procedure rather than sterile Higher risk of infection: nose (1.7%), ears, mucosal surfaces, below the knees Rate infection rises with: large defects, flaps (2.4%), multiple stages (0.8%), high-tension, surgery of multiple sites Overall for Mohs: 0.7% Use of antibiotics should be individualized to each patient Ref: Winstanley, D.The Role of Antibiotics in Cutaneous Surgery: emedicine Clinical Procedures. Mar 26, 2009
9 Preoperative Screening Organ transplants/artificial joints:rheumatoid arthritis, immunosuppressed- may require prophylactic antibiotics Herpes simplex virus: history of requires antiviral prophylaxis Pregnancy: Lidocaine is safe in low doses, does cross placenta, excessive amounts can cause fetal central nervous system and cardiac depression Preoperative Screening Allergies: Local anesthetics:allergies are rare (usually sensitivity to paraben preservatives). Allergy testing recommended for true allergies Adhesive/skin preparations/latex: Latex allergies a rising concern Antibiotics: Note allergies. Some medication may cause localized sensitizations not true allergies Medications:Include recreational drugs, alcohol, barbiturates, vitamin supplements, herbal medications Tell your patients to:stop smoking! Preoperative Screening Review the following with all patients: Psychosocial: family support, need for homecare Past medical history: previous surgeries, current health status Past family history: sickle cell, malignant hypothermia, prophyria Infectious diseases:mrsa, HIV, hepatitis
10 Preoperative Screening Preoperative testing: blood work, chest x-ray, ECG Physical examination: height, weight, blood pressure, cardiovascular assessment Day of surgery: review assessment data, medications, physical status, baseline BP, respiration, pulse, allergies, pre-operative blood tests Nurses hold a key role in health assessment and monitoring of patients during surgery Short Checklist Patient: Pacer/joint replaced/prosthetic heart valve Blood thinners Allergies or anaesthesia problems Patient expectations, personality, etc Nurse: Were all risks and benefits explained? All documentation done re: allergies? Does the patient understand the procedure? Step 3 Local Anesthesia
11 Types of Local Anesthesia 1. Topical: EMLA 5% cream: applied under occlusive dressing min prior (duration 4 hrs), topical xylocaine 2. Infiltrative: direct injection into site 3 Tumescent: uses large volumes of dilute anesthetic (Lidocaine 0.05%, Epinephrine 1:1000, NaHCO310meq/l), liposuction, hair transplants 4. Field (ring) block: reduces amount of anesthetic needed in large areas such as scalp, inject at all levels where nerves run 5. Nerve block: Small amounts needed to anesthetize large areas, may take a longer time to act Local Anesthesia Lidocaine: with or without epinephrine, (with lasts longer ) duration 1-2 hrs, onset 5-10 min (0.5%, 1%, 2%) Bupivicaine (Marcaine): slower onset, lasts 3-6 hrs Toxic Effects: pain, bruising, direct nerve damage, take care around vessels (e.g. superficial temporal) Local Anesthesia Side Effects of Epinephrine: 1. Pain due to acidity of solution 2. Vasoconstriction if used on penis (digits) 3. Delayed post-operative healing 4. Vasovagal (place patient in trendelenburg, cool cloth) 5. Systemic CNS reaction (as little as 2 cc's can cause tachycardia) palpitation, sweating, headache, chest pain
12 Allergy To Epinephrine? Impossible! Symptoms: racing heart, shaking uncontrollably, breaking out in a cold sweat, rapid breathing, hyperventilating, dizziness, tingling fingers and toes Signs of adrenaline rush!! Why? Epinephrine accidently injected into a vein? Some people more sensitive True Allergy? Local Anesthesia Symptoms include: pruritis, urticaria, erythema, facial swelling, nausea, vomiting, sneezing, dyspnea, cyanosis, laryngeal swelling Most are not allergic, may be vasovagal Good pre-screening history is essential! Why? Local Anesthetics- Allergy? Cocaine 1 st local anesthetic-1860-from coca bush-andes ( chewed the leaf) Introduced to Europe and N. America 1880 s Cocaine contains esters! ( Novocain, Procaine-developed in 1904 s)- Lidocaine in 1943 Now- most local anesthetics contain amides NOT esters ( esters only used for topical anesthesia in dentistry, or topical cocaine for mucosal anesthesia)
13 Local Anesthesia Classes of anesthetics: Amide or Ester Procaine (ester) cross reacts with methylparabens used in multidose vials of Lidocaine as a preservative. Amides and Esters- can be given safely using Lidocaine without methylparaben preservatives ( single dose vials) Type1 allergy to amides: Referral for drug testing before surgery! Very rare! Pregnancy and Breast Feeding Local anesthetics can cross placenta Fetal liver is less able to metabolize Small procedures (biopsies) have negligible risk Local anesthetics can cross into breast milk-avoid large procedures Epinephrine can cause placental ischemia-dilute and use small amount Psychogenic, Vasovagal Local Anesthesia Characteristics: hypotension, low pulse rate, sweating, pallor, lightheadedness and nausea Management:react quickly, make the correct diagnosis, put patient in trendelenburg, cool compress, monitor closely, talk to your patient!
14 Recommended Dosage: For Lidocaine 1% (10mg.ml) Local Anesthesia Without Epinephrine: Adult: 4.5mg/kg (300mg or 30cc in 70kg adult) WithEpinephrine: Adult: 7.0mg/kg (500mg or 50cc in 70kg adult) Toxic level low Blood level Lidocaine Toxicity Symptoms 3 mic/ml Tinnitus, light head, nausea, metallic taste in mouth med 9 Tremor, slurred speech, seizures Treatment D/C, trendelenburg, O2 D/C, diazepam 5-10 mg slowly high 12+ Arrest, coma D/C, cardiac life support Local Anesthesia Injection Techniques: 1. Use 30 gauge needle when possible 2. Use longer needles (fewer needle sticks) 3. Use long-acting anesthetic if long case 4. Allow 5-7 minutes for vasoconstrictor effect 5. Insert needle through already anesthetized skin 6. Inject slowly (smallest possible amounts)- skin distortion hurts
15 Injection Techniques con t 7. In areas with little distention (fingers, nose) use nerve blocks 8. Use topical anesthetics e.g. Emla 9. Buffer fresh Lidocaine with epinephrine-burning sensation partly related to low ph required to preserve solution Mixture: Add 1 ml. of 8. 4% Sodium bicarbonate to 10 cc s of Lidocaine with epinephrine 1:1000,000(epinephrine decays in buffered solution, use within one week) Summary-Local Anesthesia Regardless of injection technique the nurse plays the biggest role in patient comfort and safety through: Pre-operative screening Proper positioning during surgery Offering explanations Hand holding Being alert to fear, pain, anxiety, signs of vasovagal, and allergic reactions! Step 4-Understanding Sutures and Needle Selection
16 Suture Selection Dependent on anatomic site Surgeon s preference Suture characteristics Factors to Consider When Choosing a Suture Suture type and size: choose smallest needle (less foreign body reaction, less track marks) Suture color: important in hair bearing areas Cost: balanced against possible benefit Strength of suture consistent with wound size Characteristics of an Ideal Suture Easy to handle Forms secure knots (no fraying, cutting) High tensile strength Absorbed with minimal tissue reaction Causes minimal tissue injury or tissue reaction Sterile Resistant to infection
17 Suture Size Suture Size: refers to diameter of the suture (denoted as zeros) More zeros describes suture size, the smaller the resultant strand diameter (eg. 3-0 is largerthan 5-0, not smaller) Smaller the suture, less tensile strength Types of Sutures Absorbable: break down in the body over time, used internally: Polyglycolic Acid, Polyglactin 910, Catgut Non-Absorbable: placed internally when under pressure or movement (heart) or external wound closure: Polypropylene, Nylon, Polyester, Silk, Stainless Steel Sutures are either Natural(silk, catgut) or Synthetic Types of Sutures Absorbable Sutures: Derived from sub mucosal layer of bovine small intestine. Used for rapidly healing tissue, ligating blood vessels. Include collagen, plain surgical gut, fast-absorbing surgical gut, chromic surgical gut. Examples: Vicryl(absorbed in days) used in soft tissue approximation, e.g. Dexon 11 Monocryl(absorbed in days), used in soft-tissue approximations and subcuticular closure Polysorb (absorbed between days), high initial strength in tissue PDS11(minimal for the first 90 days, complete at 6 months) provides extended wound support and mild tissue reaction
18 Types of Sutures Non-Absorbable Sutures Include: Surgical silk, surgical cotton, surgical steel Include: Nylon Polyester Fiber (Mersielene/Surgidac, Ethibond) Polybutester Suture(Novafil), Prolene, Surgipro 11 Surgical Silk: made from raw silk of silkworms (can absorb after 2 yrs), causes an acute inflammatory reaction Surgical Cotton: Made of long, staple cotton fibers. Nonabsorbable (becomes encapsulated in tissue) Surgical Steel: Made of stainless steel, flexible, fine size, holds knots well (used in orthopedic, thoracic closures) Sutures are based on material structure. Multifilament are braided sutures-provide better knot security Monofilament provide better passage through tissue -provide less tissue reaction-used for infected wounds to prevent harboring bacteria in suture strands
19 Surgical Needles Ideal Needle: High quality stainless steel Smallest diameter possible Stable in the grasp of the needle holder Capable of minimal tissue damage Sharp enough to penetrate tissue with minimal resistance Sterile, corrosion-resistant to prevent infection Needle Selection Main consideration is to minimize trauma Taper Needle: sharp tip but no sharp edge, used for tissues that are easy to penetrate, used for tendon and deep tissue closer Cutting Needles: reserved for tough tissue Blunt-point Needles: used to dissect friable tissue. Points rounded and blunt (used in liver and kidneys) Types of Needles Cutting Needle skin and dermis are sutured with cutting needles-sharp edges, better at penetrating tough tissue Conventional:sharp edge on inner side of curve Reverse Cutting: flat surface on anterior of curve-better for skin closure
20 Needles should be grasped 1/3 to 1/2 of the distance from the swaged area Needle should be placed securely When assisting the physician pass the needle holder pointing in the direction it is to be used Selection and Use of Needle holders Suture Tips Open only sutures that are needed for the procedure to keep cost down Straighten sutures gently, never crush or rub Draw nylon sutures between gloved fingers to remove packing memory Discard all used needles in sharps container Suture Removal Face: 5-7 days (to prevent railroad tracking) Head and Trunk: days Removing Sutures Plain Interrupted Grasp suture tails or knot with forceps-lift off skin to expose small portion of suture-cut suture below the knot with forceps pull suture up and out of skin.
21 Removing Sutures Plain Continuous: Cut first suture on side opposite the knot-cut the same side of the next suture in line-continue cutting along the loops of suture until the end of the suture line removing the suture as you go along-cut the last suture below the knot to remove the final knot Removing Sutures Mattress interrupted sutures: Remove the small, visible portion of the suture opposite the knot by cutting it where it is visible 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, cut the suture below the knot on the opposite side and remove the suture Alternate Types of Wound Closure
22 Steri-strips: Used over wounds post surgery to increase stability of wound. Used post suture removal to help with scarring Staples Advantages: saves time, aids in wound eversion, no tracking so less chance of bacteria entrance into the skin Disadvantages: cosmetic appearance while in, unpleasant, more expensive, limited use on face, uncomfortable for patient Staples
23 Cyanoacrylate-Skin Glue When skin glue is not used? Wounds with uneven jagged edges Deep wounds Moist wounds Bleeding wounds Infected wounds Wounds under tension Skin Glue When is skin glue used? Pediatric lacerations- reduces fear and pain Skin grafts (burn patients) Over subcuticular sutures Rapid and effective for well-aligned wounds under no tension Handling of Surgical Biopsies
24 Biopsy Types Punch - used to obtain a small sample of tissue for diagnosis (2-6 mm in diameter size) Incisional Biopsy -used to remove tissue for diagnosis but entire lesion may not be removed Excisional Biopsy -used to excise entire lesion, often with wide margins Handling of Biopsy Specimens 1. Minimize trauma to specimen (forceps, scissors, cautery) 2. Use correct preservative: formalin, fresh tissue for lymphoma protocol, muscle biopsies 3. Complete pathology requisition in detail with accurate description of lesion and history 4. Label specimen bottle with name, specimen location 5. Orientate the lesion with sutures if required and document on pathology requisition Step 5 The Reconstructive Ladder- Closing the Surgical Wound
25 The reconstructive ladder: Definitions Free tissue transfers Distant tissue transfers Skin graft Direct tissue closure Local tissue transfers Allow wound to heal by secondary closure Step One- Wound Closure Secondary closure: Simplest, question cosmetic results Allow wound to heal Contraindications: by secondary closure Large defects Poorly vascularized defect (>3 weeks healing) Undesirable esthetic consequences. Exposed vessels, nerves, tendons, viscera, or bone Step 2- Wound Closure Primary closure: Direct approximation of edges within hours of wound creation Most cosmetically pleasing results Contraindications: Excessive tension on the skin Infected wound Direct tissue closure
26 Step 3-Wound Closure Grafts: Commonly used. Contraindications: Exposed vessels, nerves, viscera Bare tendon Bare bone Radiation damaged tissue Infected wounds Skin graft Classification of Skin Grafts Split Thickness: Includes epidermis and part of dermis. Varies from thin to thick. Thin has higher percentage of take. Used in large areas of skin loss. Harvested by free hand or dermatome Full Thickness:Includes epidermis and dermis. Slower to vascularize, less likely to take. Used on fingers to avoid contracture Take initially by diffusion of nutrition from recipient site. Revascularization in 3-5 days Continued Grafts: By species: Autograft graft from one place to another on the same individual. Allograft (homograft) graft from one individual to another of the same species. Xenograft (heterograft) graft from one individual to another of a different species. Synthetic skin substitutes. e.g. Integra
27 Optimal Take: Bed well vascularized Contact between graft and recipient bed Staples, sutures, splinting and appropriate dressing (pressure) are used to prevent collections, or movement Recipient site: clean (to prevent infection) Post-operative Care Graft failure: Blood Collection. Movement Bolster Infection Protection Moist environment Dressing Types: Bolster Primary use is to promote take of Skin Grafts Function: 1. Maintain constant wound opposition 2. Prevents fluid from collecting beneath graft 3. Maintains skin graft adherence to wound 4. Prevents hematoma and seroma formation 5. Protects skin graft from trauma
28 Wound Closure-Flaps A flap is tissue transferred from one site to another with vascular supply intact. Types: 1. Rotation, transposition: All have a common pivot point and an arc through which the flap rotates 2. Advancement Flaps: single, pedicle, V-Y advancement Step 6 Understanding Surgical Complications What is a Complication? Any negative outcome as perceived by either the surgeon or the patient Early recognition and prompt intervention are the best ways to avert complications!
29 Complications They do happen!!! Prior to signing the consent form all possible surgical risks, benefits and expected surgical outcomes should be discussed with the patient or patient s family. Avoiding Complications Well-informed Patient! Verbal and written pre- and post-operative instructions Patient anticipated results are realistic Clear explanations of procedure by physician and nursing staff Consultation: Talk to your patient Are the patient s expectations appropriate? Do they understand the entire procedure and possible side effects or risks? Is the patient asking appropriate questions?
30 Avoiding Complications Well-informed Staff : Complete and accurate medical history Good surgical technique and post-op care Staff equipped to handle: MI, arrhythmia, anaphylaxis, syncope, allergic reactions, cardiac events Staff trained in CPR, cardiac resuscitation and airway support available Normal Post-operative Symptoms Swelling and bruising- occurs in first days post-op Numbness- can last several months Discomfort and pain (initially)-increased pain, look for another reason Crusting along incision lines Itching- as wound heals Redness may stay red for many month, fade to pink Early Surgical Complications Contact Dermatitis- topical antibiotic? Hypergranulation-normal or complication? Suture complications: railroad tracking, stitch abscess, deep suture reactions, sutures unravel, retained permanent sutures Increased pain-not normal! (look for another cause) Edema Nerve Damage
31 Hematoma Nursing Implications Identify Patient risk factors: history of ASA, anticoagulants, history of bleeding, nutritional or alcohol problems Be aware of the effect of epinephrine on the surgical site Use of precise electrodessication during surgery Use of pressure dressings
32 Flap Necrosis Treatment: Treat underlying problem first: e.g. hematoma-drain if necessary Most often left to heal with no intervention Delay debridement: area of involvement is often smaller than seen on the skin Note: Pressure dressing can make or break a flap. Avoid crushing a flap with a tight pressure dressing
33 Infection Signs and Symptoms : Erythema at wound site Warmth- increased redness Swelling Cellulitis-redness and swelling Lymphangitis Fever Drainage Pain-increase in pain Cellulitis
34 Treatment of Infection If caught early may only require oral antibiotics, close follow up Late stages-may lead to cellulits, systemic symptoms (IV antibiotics) May require opening wound, irrigating, packing Prevention of Dehiscence Good surgical technique Good hemostasis Wound: site, size, age of patient, medical conditions, closure tension, trauma Good post operative wound care instructions Leave sutures in longer or remove alternate if under tension Treatment of Dehiscence Clean wound well Dehiscence within hrs (if no signs infection) can be resutured Treat the underlying cause Good ongoing wound care until closed Leave wound to heal be secondary intention, VAC therapy?
35 Delayed Post-Operative Surgical Complications Scar: hypertropic vs. keloid scar, prolonged hyper or hypo pigmentation, prolonged erythema Nerve: reduced or altered sensations, partial or complete loss of muscle function. Motor nerve deficit Contracture- around joint spaces Seroma Usually arise when deep dead space has not been obliterated and serum collects Can be difficult to remove Management: needle removal of fluid, pressure dressings (may need serial drainage). Often absorbs on its own over time
36 Dog Ears Treatment: advise patient that dog ears will shrink in time-do nothing for several months If they persist in bothering the patient, can be excised under local anesthesia. Problem: Makes the incision line longer Suture Spitting Absorbable sutures dissolve by inflammation. The process, depending on the suture starts around 4-6 wks. Sutures buried close to the surface of the skin will try to escape through the wound when this happens Treatment: Cleanse the area, open the little area of fluid, remove the suture if visible, apply topical antibiotic and small dressing. Wound will heal quickly once the suture is removed
37 Summary Surgical Complications Every suture is a foreign body which can increase the chance of infection Infected wounds should be followed closely Reassure your patient, answer questions Nurses can reduce fear associated with surgical complications and help prevent complications through good pre-operative and post operative teaching! Finally! Document, document, document! When in doubt -have the patient seen, notify the physician! Educate your patients on what to look for. Obtain home nursing support for elderly patients with large wounds. Ensure the patient has all emergency contact phone numbers as well as the nurse s! Step 7 Understanding Wound Dressings
38 Role of Wound Dressings 1. Absorb wound drainage 2. Protect the wound from trauma 3. Provide pressure on the wound 4. Speed up epidermalization of the wound 5. Reduce pain and provide comfort 6. Allow patients to function at home Pressure Dressings 1. Provide hemostasis to prevent hematomas 2. Helps eliminate dead space within sutured wounds to prevent seromas 3. Minimize wound seepage 4. Reduce swelling, especially on lower legs 5. Splint the wounds and immobilize wound edges Components of Pressure Dressing Contact layer: Non sticky -gooey gauze types of dressings e.g. vaseline, adaptec, jelonet Absorbent layer: Store wound secretions e.g. gauze pads, eye pads, cotton balls Outer layer: Holds everything in place, firm comfortable pressure, e.g. gauze, coban, ace wrap, surgiflex, elastoplast, hypafix, tape
39 Dressing Application Dressing application is an art. It takes time, repetition, experience and imagination! Difficult Areas to Dress: Nose, Ears, Scalp, Fingers, Medial Canthus of eye Dressing Application Nose: to fill in concave of nose use a dental pack or rolled up 2x2 gauze Ear: dental pack or roll 2x2 to fill in posterior auricular sulcus, use tape to secure dressing, use Kling wrapped around the head for additional pressure Scalp: hair can be a problem! Bolsters can be stapled on following skin grafts, gooey gauze, plus dry gauze and a kling wrap will hold dressings in place, stockinet can be used to make a hat Ear Dressing
40 Head Dressing Dressing Application Fingers: apply gooey gauze, tent 2x2 over the gooey gauze and then hold in place with a 1 inch (surgigrip) netting (like a net stocking). Can be taped in place for more support. Allows full range of movement, easy to remove for the patient Remember: Fingers left splinted for an extended period get stiff quickly! Get your patient moving early, if the dressing is too tight they cannot move their fingers! Application of Finger Dressing
41 Dressings Dressing trick for removal of dressings from fragile wounds: Remove outer dressings. Leave gooey gauze e.g. jelonet, bactigras in place. Use ONLY 1 layer of sticky dressing on wound. Apply greasy ointment or plain Vaseline to sticky gauze before removing. The stickiness is returned to gauze. Makes for an easier removal, less pain for the patient, less disruption of wound bed, a happy patient! Sutured Wounds-Patient Instructions Keep dry for hours Keep moist with vaseline or greasy ointment Rarely are dressings applied on the face-exception: patient on blood thinners Wash with mild soap and water (no antiseptic soaps) May shower over steri-strips if applied Avoid Hydrogen Peroxide, primarily used to remove dried blood Sutures Face: remove in 5-7 days Sutures Trunk or Body: remove in days Post Operative Wound Care Instructions 1. Written in a clear concise easy to understand format 2. Outline step by step 3. Include a list of dressings needed 4. Activities to avoid 5. Suture removal date 6. Brief information of what to expect postoperatively 7. Signs and symptoms to report-signs of infection 8. Phone numbers of nurse and MD 9. Follow up date to see physician