Promoting wound healing is the focus during the PROPERTY OF ELSEVIER SAMPLE CONTENT - NOT FINAL. Surgical Wound Care CHAPTER BASIC NURSING SKILLS

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1 CHAPTER 13 UNIT TWO BASIC NURSING SKILLS Surgical Wound Care ELAINE KOCKROW Objectives After reading this chapter the student should be able to do the following: 1. Define key terms as listed. 2. Discuss the body s response during each stage of wounds healing. 3. Identify common complications of wound healing 4. Differentiate between healing by primary and secondary intention. 5. Discuss common complications of wound healing 6. Explain procedure for applying dry dressings: wet-todry dressings. 7. Identify the procedure for removing sutures and staples. 8. Discuss care of the patient with a wound drainage system: Hemovac/Davol suction, T-tube drainage. 9. Identify procedure for performing sterile wound irrigation. 10. Describe the purposes of and precautions taken when applying bandages and binders. 11. List nursing diagnoses associated with impaired skin integrity. Key Terms Be sure to check out the bonus material on the free CD-ROM, including selected audio pronunciations. bandage (p. XXX) binder (p. XXX) dehiscence (de -HĬS-ĕns, p. XXX) drainage (p. XXX) evisceration (e -vĭs-ĕr-a -shŭn, p. XXX) exudate (ĔKS-u -da t, p. XXX) granulation (grăn-u -LA -shŭn, p. XXX) incision (ĭn-sĭzh-ŭn, p. XXX) infectious process (p. XXX) inflammatory response (p. XXX) irrigation (p. XXX) primary intention (p. XXX) purulent (PU -roo-lĕnt, p. XXX) sanguineous (săng-gwĭn-e -ŭs, p. XXX) secondary intention (p. XXX) serosanguineous (SĔR-o -săng-gwĭn-e -ŭs, p. XXX) serous (SĔR-ŭs, p. XXX) tertiary intention (TĔR-she -ăr-e, p. XXX) Promoting wound healing is the focus during the postsurgical recovery phase. Various stresses affect a wound s ability to repair itself. Stress and strain (nausea, vomiting, abdominal distention, coughing, respiratory efforts) place tension against a surgical incision, especially an abdominal incision. During this phase, the abdominal muscles contract and cause intraabdominal pressure; if the incisional area is weak, dehiscence may occur. As the postoperative period lengthens, patient-related factors influence wound healing: age, nutritional status, physical condition, preexisting health problems (e.g., diabetes), and medication habits. Other factors that may affect wound healing include preoperative skin preparation, type of surgical procedure, environment within the surgical suite, and postoperative wound care. WOUND CLASSIFICATION Wound classifications result from their cause, severity of injury, amount of contamination, or the skin s integrity. For planned surgery, a wound is made by an incision (a cut produced surgically by a sharp instrument creating an opening into an organ or space in the body) or puncture (stab wound for a drainage system). In unplanned or emergency surgeries (traumatic injury from a knife stabbing), wound edges are brought together to aid healing. Unless a dirty surgery is performed (e.g., a perforated bowel, ruptured appendix), a surgical incision is cleaner than a traumatic wound. The Centers for Disease Control and Prevention (CDC) classifiy wounds according to the amount of contamination involved: clean, clean-contaminated, contaminated, and dirty or infected. A clean wound is an uninfected surgical wound; the chance of an infection occurring postoperatively is less than 5%. A surgical incision made into the respiratory, gastrointestinal (GI), or genitourinary tract after special presurgical preparation is called a clean-contaminated wound. The likelihood that an infection will occur postoperatively in a clean-contaminated wound is between 3% and 11%. A contaminated wound results from the presence of GI products (e.g., feces with Escherichia coli in the colon); from an acute, nonpurulent inflammation (inflamed appendix); or when aseptic technique is broken during surgery (scalpel is reused after incising a contaminated area). A wound infection occurs 10% to 17% of the time from a contaminated wound. Dirty 1

2 2 UNIT TWO BASIC NURSING SKILLS or infected wounds have a 27% chance of causing a wound infection. Wounds in this category (e.g., gangrenous toe) are infected before surgery. WOUND HEALING The healing process begins immediately after an injury and may continue for a year or longer. Although the healing process follows the same pattern, the type of wound and tissue, severity, and overall condition of the patient influence the overall process. Wound healing follows four phases: hemostasis, inflammatory, reconstruction, and maturation. PHASES OF WOUND HEALING Hemostasis (termination of bleeding) begins as soon as the injury occurs. As blood platelets adhere to the walls of the injured vessel, a clot begins to form. Fibrin in the clot begins to hold the wound together, and bleeding subsides. During the inflammatory phase an initial increase in blood elements (antibodies, electrolytes, plasma proteins) and water flow out of the blood vessel into the vascular space. This process causes the cardinal signs and symptoms of inflammation: erythema (redness), heat, edema (swelling), pain, and tissue dysfunction. Leukocytes appear and begin to engulf bacteria, fungi, viruses, and toxic proteins. If an infection is not present, the number of leukocytes decreases. During the inflammatory phase, cells migrate, divide, and form new cells. Slowly, blood clots dissolve and the wound fills; the sides of the wound usually meet in 24 to 48 hours. As the inflammatory phase ends, new cells and capillaries fill the wound from the underlying tissue to the surface. This process seals the wound to protect it from contamination. Collagen formation occurs during the reconstruction phase. This phase begins on the third or fourth day after injury and lasts for 2 to 3 weeks. Fibroblasts produce collagen, a gluelike protein substance that adds tensile strength to the wound and tissue. Collagen formation increases rapidly between postoperative days 5 and 25. During this phase the wound s appearance changes to an irregular, raised, purplish, immature scar. Foods rich in protein and vitamins A and C, which assist in wound repair, are encouraged during this time. If a patient is not well nourished, nutrient supplements may be ordered. Wound dehiscence most frequently occurs during the reconstruction phase. Approximately 3 weeks after surgery, fibroblasts begin to exit the wound. The wound continues to gain strength, although healed wounds rarely return to the strength the tissue had before surgery. Although tissue heals at varying speeds, internal wounds (stomach, colon) regain strength faster than skin wounds. Occasionally a keloid, which is an overgrowth of collagenous scar tissue at the site of a wound, may form during this maturation phase. The keloid s color ranges from red to pink to white. This new tissue is elevated, rounded, and firm. African-Americans, dark-complexioned whites, and young women have the highest incidence of keloid formation. Therapy can worsen the condition and should be performed only by skilled professionals. PROCESS OF WOUND HEALING The process of wound healing occurs by primary intention (primary union), secondary intention (granulation), and tertiary (third) intention. Wounds that are made surgically and that have little tissue loss heal by primary intention; skin edges are close together, and minimal scarring results. Primary intention healing begins during the inflammatory phase of healing (Figure 13-1). Secondary intention healing occurs when skin edges are not close together (approximated) or when pus has formed. If the wound has a purulent (producing or containing pus) exudate (fluid, cells, or other substances that have been slowly exuded, or discharged, from cells or blood through small pores or breaks in cell membranes) that forms when injured or diseased tissue dies, the surgeon provides a means for its release. This is accomplished through a drainage system or by packing the wound with gauze. Slowly the necrotized tissue decomposes and escapes; the cavity begins to fill with soft, pink, fleshy projections consisting of capillaries surrounded by fibrous collagen, or granulation tissue. The amount of granulation tissue required depends on the size of the wound; scarring is greater in a large wound. Tertiary intention (delayed primary intention) occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together. This occurs when a contaminated wound is left open and sutured closed after the infection is controlled. It also occurs when a primary wound becomes infected, is opened, is allowed to granulate, and is then sutured. Tertiary intention results in a larger and deeper scar than primary or secondary intention. An important concept in wound healing is that the stages of wound healing, although progressive, do not occur in a linear (strictly sequential) fashion. A normally healing wound could simultaneously be in all three stages of wound healing. The stages described previously provide a model for acute wound healing. FACTORS THAT AFFECT HEALING To promote healing the nurse should closely monitor fluid and nutritional needs of the patient. If the patient cannot tolerate food or fluids, total parenteral nutrition or nasogastric feedings can be provided. Because patients may not be able to tolerate large meals or solid foods, dietary services can provide small frequent feedings. Fluids, when tolerated, should be offered

3 Surgical Wound Care CHAPTER 13 3 A Incision with blood clot Edges approximated with suture Fine scar Irregular, large wound with blood clot hourly. Unless contraindicated, the nurse should encourage an intake of 2000 to 2400 ml in 24 hours. As the patient progresses from clear to full liquids, fluids the patient enjoys should be provided. Until the patient s hydration level is stable (usually 24 to 72 hours), the patient s intake and output (I&O) are monitored. The nurse assists the patient to achieve a balance between time to rest as a means to facilitate healing and activity to decrease venous stasis. When the patient is confined to bed, moving one body section at a time head, chest, hip, legs should be encouraged. To sit up, the patient should roll to the side and, using the elbow as a lever, push to a sitting position; this reduces the stress placed on the incision. If coughing occurs, the nurse can apply a pillow, rolled bath blanket, or the palms of the hands to the incisional area to lessen intraabdominal pressure. Visitors may be restricted if the patient tires too easily. Preexisting conditions, such as heart murmurs, and chronic diseases (arthritis, diabetes mellitus, hypertension) add stress to the recovering body and require ongoing monitoring (Table 13-1). Granulation tissue fills in wound Large scar Contaminated wound Granulation tissue Delayed closure with suture FIGURE 13-1 Types of wound healing. A, Primary intention. B, Secondary intention. C, Tertiary intention. SURGICAL WOUND The selection of the site for the surgical wound is based on the tissue and organ involved, nature of the injury or disease process, presence of inflammation or infection, and strength of the site. If surgical procedures require a drainage system, the position of the drain also influences the placement of the incision. The surgeon s goal is to enter the cavity involved, repair the injured or diseased area, and minimize trauma as quickly as possible. Patients may be placed in positions that add stress to the tissue to facilitate the surgery. Therefore pain after surgery may be caused from strained muscles and ligaments, as well as from the surgical process. Many options are available to the surgeon for closing the surgical incision. Common closures are sutures, staples, Steri-Strips, butterfly strips, and transparent sprays and films. A binder or bandage may be used to support the incision or secure dressings without using adhesive materials. The nurse inspects dressings every 2 to 4 hours for the first B C

4 Table 13-1 Factors That Impair Wound Healing PHYSIOLOGIC EFFECTS INTERVENTIONS AGE Aging alters all phases of wound healing. Vascular changes impair circulation to wound site. Reduced liver function alters synthesis of clotting factors. Inflammatory response is slowed. Formation of antibodies and lymphocytes is reduced. Collagen tissue is less pliable. Scar tissue is less elastic. MALNUTRITION All phases of wound healing are impaired. Stress from burns or severe trauma increases nutritional requirements. OBESITY Fatty tissue lacks adequate blood supply to resist bacterial infection and deliver nutrients and cellular elements. IMPAIRED OXYGENATION Low arterial oxygen tension alters synthesis of collagen and formation of epithelial cells. If local circulating blood flow is poor, tissues fail to receive needed oxygen. Decreased hemoglobin (anemia) reduces arterial oxygen levels in capillaries and interferes with tissue repair. SMOKING Smoking reduces amount of functional hemoglobin in blood, thus decreasing tissue oxygenation. Smoking may increase platelet aggregation and cause hypercoagulability. Smoking interferes with normal cellular mechanisms that promote release of oxygen to tissues. DRUGS Steroids reduce inflammatory response. Antiinflammatory drugs suppress protein synthesis, wound contraction, epithelialization, and inflammation. Prolonged antibiotic use may increase risk of superinfection. Chemotherapeutic drugs can depress bone marrow function, number of leukocytes, and inflammatory response. DIABETES MELLITUS Chronic disease causes small blood vessel disease that impairs tissue perfusion. Diabetes causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues. Hyperglycemia alters ability of leukocytes to perform phagocytosis and also supports overgrowth of fungal and yeast infection. RADIATION Fibrosis and vascular scarring eventually develop in irradiated skin layers. Tissues become fragile and poorly oxygenated. WOUND STRESS Vomiting, abdominal distention, and respiratory effort may stress suture line and disrupt wound layer. Sudden, unexpected tension on incision inhibits formation of endothelial cell and collagen networks. Instruct patient on safety precautions to avoid injuries. Be prepared to provide wound care for longer period. Teach home caregivers wound care techniques (Patient Teaching: Wound Care box). Provide balanced diet rich in protein, carbohydrates, lipids, vitamins A and C, and minerals (e.g., zinc, copper). Provide adequate amounts of calories and fluids. Observe obese patient for signs of wound infection, dehiscence, and evisceration. Provide diet adequate in iron, vitamin B, and folic acid. Monitor hematocrit and hemoglobin levels of patients with wounds. Discourage patient from smoking by explaining its effects on wound healing. Carefully observe patient; signs of inflammation may not be obvious. Vitamin A can counteract effects of steroids. Instruct patient to take preventive measures to avoid cuts or breaks in skin. Provide preventive foot care. Control blood sugar to reduce the physiologic changes associated with diabetes. Closely observe patients who have had surgery for wound complications. Control nausea with ordered antiemetics. Keep NG tubes patent and draining to avoid accumulation of secretions. Instruct patient to splint abdominal wound during coughing.

5 Surgical Wound Care CHAPTER 13 5 Table 13-2 TYPE Types of Wound Drainage APPEARANCE A. Serous Clear, watery plasma B. Purulent Thick, yellow, green, tan, or brown C. Serosanguineous Pale, red, watery: mixture of serous and sanguineous D. Sanguineous Bright red: indicates active bleeding From Elkin, M.K., Perry, A.G. & Potter, P.A. (2004). Nursing interventions and clinical skills (3rd ed.). St. Louis: Mosby. 24 hours. The day of surgery, most wounds produce either sanguineous (pertaining to blood) or serosanguineous (thin and red, composed of serum and blood) exudate. Later, as the exudate subsides, it becomes serous (thin and watery, composed of the serum portion of blood) (Table 13-2). Because pressure to the surgical wound retards bleeding, wounds are usually covered by a gauze dressing. It is imperative that the nurse inspect both the dressing or incisional area and the area under the patient. Exudate follows the flow of gravity; therefore, depending on the contour of the body, the dressing may remain dry while blood/exudate flows under the body, and hemorrhaging might go undetected. Gradually fluid from the cells clusters with leukocytes along the vessel walls so that fibrin walls off the injury and begins to build a new cell. The extent of the inflammatory response (a tissue reaction to injury) depends on the level of injury inflicted, size of the area involved, and physical condition of the patient. With repair, leukocytes attempt to rid the tissue of exudate from the injured cells. This process, phagocytosis, is an important function of leukocytes. Phagocytosis (a process by which certain cells engulf and dispose of microorganisms and cell debris) occurs when exudate from the injured cell is surrounded, engulfed, and digested by leukocytes. The leukocyte becomes the body s vacuum cleaner by removing its debris. Evidence of leukocyte action can be observed through changes in the white blood cell (WBC) count. An infectious process (a condition caused by the invasion of the body by pathogenic microorganisms) would be evidenced by an elevated WBC count. STANDARD STEPS IN WOUND CARE SKILLS All nursing skills must include certain basic steps for the safety and well-being of the patient and the nurse. To save space and minimize repetition, these steps are not included in each skill unless it is necessary to clarify them as applied for that skill. Remember that these skills are essential and must be followed with exactness to deliver appropriate and responsible nursing interventions. Before the skill: 1. Refer to medical record, care plan, or Kardex for special interventions. (Provides basis for care. Many nursing interventions require a physician s order. Verification is ensured when nurse reviews medical record.) 2. Introduce yourself; include your name and title or role. (Decreases patient anxiety.) 3. Identify patient by checking armband and requesting patient to state his or her name. (Identifies correct patient for procedure.) 4. Explain the procedure and the reason it is to be done in terms the patient can understand, and give patient time to ask questions. Advise patient of any unpleasantness that might be experienced. (Seeks cooperation, decreases patient s anxiety, and prepares patient. Also helps determine if procedure is still appropriate.) 5. Assess need for and provide patient teaching during procedure. (Promotes patient s independence.) 6. Assess patient. Each skill has an assessment section that includes specific data. (Provides baseline information for later comparisons.) 7. Wash hands and don clean gloves according to agency policy and guidelines from the CDC and Occupational Safety and Health Administration (OSHA) (see Chapter 12). (Reduces the spread of microorganisms.)

6 6 UNIT TWO BASIC NURSING SKILLS 8. Assemble equipment and complete necessary charges. (Organizes procedure. Some equipment is reusable and is kept at the bedside. Some of the equipment is disposable and charged to the patient as used. Know agency policy. Specific equipment is listed for each skill.) 9. Prepare patient for intervention: a. Close door/pull privacy curtain. (Provides privacy and promotes patient s comfort.) b. Raise bed to comfortable working height; lower side rail on side nearest the nurse. (Promotes proper body mechanics by minimizing muscle strain on caregivers and preventing injury and fatigue.) c. Position and drape patient as necessary. (Respect for privacy is basic for preserving human dignity. Patients have the right to privacy. Specific positions are included in each skill.) During the skill: 10. Promote patient involvement as possible. (Participation encourages patient motivation and cooperation.) 11. Assess patient s tolerance, being alert for signs and symptoms of discomfort and fatigue. Inability to tolerate a procedure is described in the nurse s notes. (Patient s ability to tolerate interventions varies depending on severity of illness and disability. Nurses need to use judgment in providing the opportunity for rest and comfort measures.) Completion of procedure: 12. Assist patient to a position of comfort and place needed items within easy reach. Be certain patient has a means to call for assistance and knows how to use it. (Promotes safety patients may attempt to reach items and risk falling or injury.) 13. Raise the side rails and lower the bed to the lowest position. (This minimizes the risk of patients getting out of bed unattended. Nursing judgment may allow alert, cooperative patients to have their side rails down during daytime hours without the risk of injury.) 14. Remove gloves (see Skill 13-3, step 6) and all protective barriers, such as gown, goggles, and masks if worn. Store or remove and dispose of soiled supplies and equipment according to agency policy and guidelines from CDC and OSHA (see Chapter 12). (Reduces spread of microorganisms, cleans environment, enhances patient comfort.) 15. Wash hands after patient contact and after removing gloves. (Wearing gloves does not eliminate the need to wash hands. Hand hygiene is the single most important technique in prevention and control of the spread of microorganisms.) 16. Document patient s response, expected or unexpected outcomes, and patient teaching. (Timely and quality documentation records patient progress and promotes continuity of care. Recording also fulfills legal responsibility of nurse.) Specific notes for documentation are included in each skill. 17. Report any unexpected outcomes. (Additional therapies may be necessary.) Specific notes for reporting are included in each skill. CARE OF THE INCISION Surgical wounds, because they are aseptically created, generally heal well and quickly. For psychologic reasons and to prevent trauma until epithelialization occurs, the wound is usually covered initially by a dressing. Incision coverings may be gauze, semiocclusive, or occlusive dressings (Figure 13-2). Gauze dressings permit air to reach the wound; semiocclusive dressings permit oxygen but not air impurities to pass; occlusive dressings permit neither air nor oxygen to pass. Occlusive and semiocclusive dressings are thought to promote healing by keeping wounds moist (yet sterile) so epithelial cells can slide more easily over the surface of the wound during epithelialization. Dressings over closed wounds are usually removed by the third day. Some surgeons remove dressings the first postoperative day if no drains are present. If an occlusive dressing is used, the tape strips are placed on all sides of the dressing. Otherwise the tape strips are placed several inches apart to allow air or just oxygen to pass over the wound. The nurse may use tape, ties, or bandages and cloth binders to secure a dressing over a wound site. The choice of anchoring depends on the wound size, location, presence of drainage, frequency of dressing changes, and the patient s level of activity. When the nurse removes dressings, care is taken to avoid accidental removal or displacement of un- FIGURE 13-2 Types of dressings. Left to right: Rolled gauze, Telfa, ABD, 4 4, and drain dressing.

7 Surgical Wound Care CHAPTER 13 7 derlying drains. Because removal of dressings can be painful, it may help to give an analgesic at least 30 minutes before exposing a wound. There is a trend either to leave sutured, clean wounds not dressed after surgery or to use loose dressings. These methods allow atmospheric oxygen to circulate above the wound, aiding in the healing process. In many cases if a dressing has been used for closed wounds, it is removed within 24 hours postoperatively to allow air circulation. Within 24 hours enough fibrin has usually been produced at the wound site to stop the entry of microorganisms. The nurse will refer to agency policy and the physician or surgeon. Often the initial dressing change is done by the physician or surgeon. Sterile technique is followed whenever the wound or dressing is handled (see Chapter 12 for principles of sterile technique). Asepsis not only protects the nurse against wound drainage, but also decreases the introduction of pathogenic (any microorganism capable of producing disease) organisms into the wound (Figure 13-3). Using sterile asepsis (absence of germs) lessens the chance of the patient acquiring a nosocomial (hospital-acquired) infection. Standard precautions (see Chapter 12) should be employed when handling body secretions. Good hand hygiene technique and the use of sterile aseptic procedures are essential when providing surgical wound care. A gown, mask, and protective goggles are worn if soiling or splashing of wound exudate is expected. A dry dressing may be chosen for management of a wound with little exudate/drainage. The dressing protects the wound from injury, prevents introduction of bacteria, reduces discomfort, and speeds healing. A dry dressing also prevents deeper tissues from drying out by keeping the wound surface moist. Box 13-1 How to Make Montgomery Straps If ready-made Montgomery straps are not available, follow these steps to make your own: Cut four to six strips of 2- to 3-inch-wide (5 to 7.6 cm) hypoallergenic tape of sufficient length to allow the tape to extend about 6 inches beyond the wound on each side. (The length of the tape varies depending on the patient s size and the type and amount of dressing.) Fold each strip 2 to 3 inches back on itself (sticky sides together) to form a nonadhesive tab. Then cut a small hole in the folded tab s center, close to its top edge. Make as many pairs of straps as you will need to snugly secure the dressing. Clean the patient s skin to prevent irritation. After the skin dries, apply skin protectant. Then apply the sticky side of each tape to a skin Adapted from Nursing procedures. (3rd ed.). (2000). Springhouse, PA: Lippincott Williams & Wilkins. FIGURE 13-3 Applying a drain dressing. Dry dressings are most commonly used for abrasions and nondraining postoperative incisions. The dry dressing does not debride the wound and should not be selected for wounds requiring debridement. If a dry dressing adheres to a wound, the nurse should moisten the dressing with sterile normal saline or water before removing the gauze. Moistening the dressing in this manner decreases the adherence of the dressing to the wound and reduces the risk of further trauma to the wound (Skill 13-1). WET-TO-DRY DRESSING The primary purpose of wet-to-dry dressing (Skill 13-2) is to mechanically debride a wound. The moistened contact layer of the dressing increases the absorptive ability of the dressing to collect exudate and wound debris. As the dressing dries, it adheres to the wound and debrides it when the dressing is removed. These dressings are most appropriate for barrier sheet composed of opaque hydrocolloidal or nonhydrocolloidal materials, and apply the sheet directly to the skin near the dressing. Thread a separate piece of gauze tie, umbilical tape, or twill tape (about 12 inches [30.5 cm]) through each pair of holes in the straps, and fasten each tie as you would a shoelace. Do not stress the surrounding skin by securing the ties too tightly. Repeat this procedure according to the number of Montgomery straps needed. Replace Montgomery straps whenever they become soiled (every 2 to 3 days). If skin maceration occurs, place new tape about 1 inch (2.5 cm) away from any irritation. See Skill 13-1, step 14.

8 8 UNIT TWO BASIC NURSING SKILLS Skill 13-1 Changing a Sterile Dry Dressing Nursing Action (Rationale) 1. See standard nursing interventions 1 to 9, p.. 2. Assemble equipment: Clean gloves Sterile gloves Refuse container Dressing set Sterile normal saline (if indicated) Antiseptic swabs Ointment, if ordered Sterile 4 4 gauze squares Nonadherent dressing Fluff or loose gauze Sterile abdominal pads Barrier drape (optional) Tape (e.g., paper or micropore), Montgomery straps, or binder Adhesive remover (optional) Protective apparel (gown, goggles, mask [optional]) Disposable measuring device to accurately assess wound size and amount of drainage 3. Place refuse container in convenient location away from sterile field. (Avoids reaching across sterile field to prevent contamination.) 4. Set up sterile field. (Maintains asepsis during procedure and organizes approach to procedure.) a. Open sterile dressings. b. Use barrier drape as needed. c. Open sterile gloves. d. Open dressing set, if needed. e. Prepare antiseptic swabs. 5. Loosen tape by gently removing toward incision and gently using thumb to retract skin away from tape. (Minimizes tissue trauma and decreases patient discomfort.) 6. Don clean gloves and remove dressing and discard. If drains are present, remove dressings one layer at a time. (Avoids accidental removal of drain.) 7. Assess status of wound and wound drainage. (Evaluates healing process and collects data for accurate documentation.) 8. Remove gloves; discard. Wash hands and don sterile gloves. (Prevents spread of microorganisms and maintains surgical asepsis.) 9. Cleanse wound and surrounding area with antiseptic swab, starting from incision outward, one stroke per swab (see illustration). (Aids in removing bacteria from wound areas. Prevents contaminating previously cleaned area.) Step 9 Step Use sterile gauze to dry in same manner or allow antiseptic to air dry. (Drying reduces excess moisture that could eventually harbor microorganisms.) 11. Cleanse drain site if applicable (see illustration). (Cleansing of drain site helps to remove bacteria or prevent bacteria from entering wound area.) 12. Apply antibiotic ointment, if ordered, using same techniques as for cleansing. (Helps reduce growth of microorganisms.) 13. Cover wound with appropriately sized dry sterile dressing and use drain dressing, if applicable (see Figure 13-3). (Protects wound and skin around drain site from skin impairment.) 14. Secure dressing with tape, Montgomery straps (see illustration), or binder. Some facilities use a Skin Prep at tape sites to protect skin from irrita- 5

9 Surgical Wound Care CHAPTER 13 9 A B Step 14 Montgomery straps. A, Each tie is placed at side of dressing. B, Securing ties encloses dressing. wounds that do not have significant amounts of ischemic or necrotic tissue or large amounts of drainage/exudate. Take care not to apply a dressing so wet that it remains wet continuously. A too-wet dressing may cause tissue maceration and bacterial growth. Commonly used wetting agents include normal saline and lactated Ringer s solution, which are isotonic solutions that aid in mechanical debridement. Acetic acid is effective against Pseudomonas aeruginosa but is toxic to fibroblasts in standard dilutions. Sodium hypochlorite solution (Dakin s) may be used to facilitate debridement in a wound with necrotic debris and is an effective deodorizing solution. Povidone-iodine, usually one-quarter to one-half strength, is a rapid-acting antimicrobial agent for cleansing intact skin. In wounds, the solution is toxic to fibroblasts and has questionable efficacy in infected wounds. Other antibiotic solutions may be ordered, although their use is controversial. Wetting solutions should be discarded 24 hours after opening and replaced with fresh solution because they can harbor microorganism growth. tion. Consider use of Montgomery straps when dressings require frequent changing to prevent tape irritation of skin (see Box 13-1 on p. 7). (Supports wound and ensures placement and stability of dressings.) 15. See standard nursing interventions 10 to 17, pp Document: (Records patient s progress and therapy provided.) Status of wound Description of exudate/drainage (see Table 13-2) Dressings applied Patient s response to procedure Patient teaching (see Patient Teaching: Wound Care) 17. Report any unexpected appearance of wound or drainage or accidental removal of drain within an hour to physician. (Unless patient shows evidence of wound dehiscence, notification of physician of unexpected findings within an hour is adequate.) TRANSPARENT DRESSINGS Another type of dressing is a self-adhesive transparent film, a synthetic permeable (capable of allowing the passage of fluids or substances in solution) membrane that acts as a temporary second skin. It has several advantages. It adheres to undamaged skin to contain exudate and minimize wound contamination. It also serves as a barrier to external fluids and bacteria yet still allows the wound to breathe. It promotes a moist environment that speeds epithelial cell growth. It also permits visualization of the wound. See Skill 13-3 for applying a transparent dressing. IRRIGATIONS Wound cleansing and irrigation is accomplished using sterile technique or clean technique. The cleansing solution is introduced directly into the wound with a syringe, syringe and catheter, shower, or whirlpool. When a syringe is used, the tip should remain 1 inch (2.5 cm) above the wound. If the patient has a deep wound with a narrow opening, a soft catheter is attached to the syringe to permit the fluid to enter the wound using sterile technique. Irrigation should then

10 10 UNIT TWO BASIC NURSING SKILLS Skill 13-2 Applying a Wet-to-Dry Dressing Nursing Action (Rationale) 1. See standard nursing interventions 1 to 9, p.. 2. Assemble equipment: Barrier drape Sterile dressing Gauze Sterile basin Sterile solution Antiseptic swabs Instrument set, if needed Clean gloves Sterile gloves Refuse container Tape or Montgomery straps Waterproof pad 3. Place waterproof pad appropriately. (Prevents soiling of bed or linens.) 4. Place refuse container appropriately. (Avoids reaching across sterile field and thus prevents contamination.) 5. Set up sterile field. (Maintains sterile technique during procedure and organizes approach to procedure.) a. Open barrier drape. b. Add sterile dressing and gauze. c. Add sterile basin. d. Pour sterile solution into basin. e. Add instrument set, if needed. f. Add antiseptic swabs. 6. Loosen tape by gently removing toward incision and, using thumb, gently retracting the skin away from tape (countertraction). (Minimizes tissue trauma. Decreases patient discomfort.) 7. Don clean gloves. Remove dressing and discard. Do not moisten dressings to remove, because this will interfere with the debriding process. A kind nurse will medicate the patient before the procedure. (Protects nurse from microorganisms. Prevents contamination from soiled dressing and promotes patient comfort.) 8. Assess status of wound and wound exudate/ drainage on dressing (see Table 13-2). (Evaluates healing process. Collects data for accurate documentation.) 9. Remove gloves; discard. Wash hands and don sterile gloves. (Reduces spread of microorganisms and maintains surgical asepsis.) 10. Cleanse wound from incision outward, one stroke per swab, and discard. (Removes old drainage and bacteria from skin area.) 11. Place gauze into basin. (Wets gauze with solution.) 12. Wring excess solution from dressing, leaving it slightly moist. (Prevents growth of bacteria from dressing that is too wet.) 13. Apply moist gauze dressing as a single layer directly onto wound surface. If wound is deep, gently pack gauze into wound with forceps until all wound surfaces are in contact with moist gauze (see illustration). (Allows solution to come into contact with wound, which makes it effective. Moist gauze absorbs drainage and adheres to debris.) Step 13

11 Surgical Wound Care CHAPTER Apply dry dressing over wet gauze. (Allows for absorption of excess moisture pulling moisture from the wound.) 15. Cover with additional dressing as needed. (Protects wound from bacteria.) 16. Secure with tape or Montgomery straps. (Secures dressings in place.) 17. See standard nursing interventions 10 to 17, pp Document: (Documents patient s progress and therapy provided.) Wound status Description of exudate/drainage (see Table 13-2) Dressings applied Patient s response to procedure Patient teaching (see Patient Teaching: Wound Care) 19. Discuss change in dressing procedure with physician as wound surface becomes clean and granulation tissue is evident. (Promotes anticipated wound healing.) Skill 13-3 Applying a Transparent Dressing Transparent dressings are thin, self-adhesive elastic films (e.g., Op-site or Tegaderm). This synthetic permeable membrane acts as a temporary second skin, adheres to undamaged skin to contain exudates and minimize wound contamination, and allows the wound surface to breathe. The nurse is able to assess the wound without removing the film. This dressing conforms well to body contours with less restriction of movement. It promotes a moist environment, which speeds epithelial cell growth, and can be removed without damaging underlying tissues. The film is ideal for small, superficial wounds and as a dressing over an intravenous catheter site. Transparent dressings may be with or without adhesives and may stay in place up to 7 days, if complete occlusion is maintained. For best results, these dressings are used on clean, debrided wounds that are not actively bleeding. The film is applied wrinkle free but not stretched over the skin and may be used over another, smaller dressing (e.g., Telfa) cut to fit the area of the wound. Topical medications may be applied over nonadhesive transparent dressings without disturbing the dressing. Nonadhesive transparent dressings will fall off as the wound heals. If removal is needed, moisten with normal saline. If approved by physician, the patient may shower or bathe with the dressing in place. Nursing Action (Rationale) 1. See standard nursing interventions 1-9, p.. 2. Assemble equipment: Clean disposable gloves Sterile gloves (optional) Sterile dressing set (scissors and forceps; optional) Sterile saline or wound cleanser (as ordered) Transparent dressings (size as needed and sterile 2 2 gauze pad) Refuse container (waterproof bag) 3. Position refuse container within easy reach of work area. (Helps prevent spread of microorganisms.) 4. Don clean gloves. (Protects the nurse from patient s body fluids.) 5. Remove old dressings by pulling back slowly across dressing in direction of hair growth and toward the center. (Reduces excoriation, pain, and irritation of skin after dressing removal.) 6. Remove disposable gloves by pulling them inside out over soiled dressings, and dispose of them in refuse container (see illustration). (Provides containment of soiled dressings and prevents contact of nurse s hands with drainage.) Step 6

12 12 UNIT TWO BASIC NURSING SKILLS Skill 13-3 Applying a Transparent Dressing cont d 7. Inspect wound for color, odor, and drainage/exudates. Measure if indicated. (Appearance indicates status of wound healing.) 8. Clean area gently, swabbing toward area of most exudate, or spray with cleanser know agency policy and physician s order. (Reduces transmission of microorganisms from contaminated area to cleaner site.) 9. Reapply sterile or clean gloves as indicated. (Prevents risk of exposure to body fluids if present.) 10. Dry skin around wound thoroughly with sterile gauze. Make sure skin surface is dry. (Transparent dressings with adhesive backing will not adhere to damp surface. Nonadhesive transparent dressing will cling to wet surface.) 11. Apply transparent dressing according to manufacturer s direction. a. Remove paper backing, taking care not to allow adhesive areas to touch each other (see illustration). (May result in wrinkles and be impossible to use.) b. Place film smoothly over wound without stretching (see illustration). c. Label with date, initials, and time, if required by agency policy (see illustration). 12. Remove gloves, discard them in refuse container, and wash hands. (Prevents transmission of microorganisms.) 13. See standard nursing interventions 10 to 17, pp Document: (Records care given and progress of wound.) Wound status Description of exudates Dressing applied Patient s response to procedure Patient teaching 15. Report any unexpected appearance of the wound or exudates. (Further treatment may be necessary.) Step 11b Step 11a Step 11c

13 Surgical Wound Care CHAPTER be done gently to prevent tissue injury and avoid discomfort. Fluid retention is avoided by positioning the patient on his or her side to encourage the flow of the irrigant away from the wound. With small wounds, it is often helpful to use a 35 ml syringe with a 19-gauge needle attached to facilitate optimal pressure for cleansing with minimal risk of tissue injury. Ambulatory or home patients may benefit from the use of a handheld shower for wound cleansing, holding the shower spray approximately 12 inches from the wound. If the force applies too much pressure for the patient s comfort, a clean washcloth may be tied around the shower head to disperse the force. An alternative is the shower table, frequently used in burn and trauma wound care units, which allows cleansing in acute care areas. For patients who require cleansing but cannot tolerate the aforementioned methods, the whirlpool is useful. The whirlpool procedure is frequently performed by or with the assistance of physical therapists, who then help apply dressings. Wound irrigations promote wound healing through removing debris from a wound surface, decreasing bacterial counts, and loosening and removing eschar (a black, leathery crust). Solutions used for irrigations include warm water, saline, or mild detergents. Nonsurgical indications include management of pressure Skill 13-4 Performing Sterile Irrigation Nursing Action (Rationale) 1. See standard nursing interventions 1 to 9, p.. 2. Assemble equipment: Refuse container Clean gloves Sterile gloves Dressing set Antiseptic swabs Sterile basin Warmed sterile irrigation solution (200 to 1000 ml) Irrigation syringe or soft catheter for deep wounds Clean basin Waterproof pad Sterile dressings Gown and goggles (optional) Tape, gauze, and elastic bandage, if appropriate Mask (optional) 3. Position waterproof pad appropriately. (Protects patient and bed linens from contaminated fluids.) 4. Place refuse container in convenient location away from sterile field. (Prevents reaching across sterile field, preventing contamination.) ulcers (see Chapter 18). Meticulous hand hygiene and proper infection control procedure before and after removing soiled dressings, coupled with proper irrigation procedures, limit the risk of nosocomial infection. Basic wound cleansing is accomplished by applying antiseptic solutions with sterile gauze or by irrigation. Skin cleansing in the area of the suture line or drain site is indicated when an excessive amount of drainage occurs. The presence of wound exudate is an expected stage of epithelial cell growth. An irrigation is gentle washing of an area with a stream of solution delivered through an irrigating syringe. This nursing intervention is used for wounds on any part of the torso or extremities. In addition to cleansing an area, prescribed medications may be introduced in solution form. Principles of basic wound irrigation include the following: 1. Cleanse in a direction from the least contaminated area to the most contaminated. 2. When irrigating, all the solution flows from the least contaminated to the most contaminated area. When administrating an irrigation (Skill 13-4) be sure that the flow of irrigation moves from the area being cleansed to an area that is both distal to and lower than the wound area. In wound care, the area being cleansed is considered clean and the surrounding skin surfaces 5. Set up sterile field. (Maintains asepsis during procedure and organizes approach to procedure.) a. Set up sterile basin. b. Add sterile warmed irrigation solution to basin. c. Add antiseptic swabs. d. Open sterile gloves. e. Add dressing set (optional). f. Add sterile syringe and catheter if necessary. g. Add disposable measuring device. 6. Don gown and goggles if appropriate. (Protects nurse if splashing is anticipated.) 7. Don clean gloves and remove dressing. Discard dressing in refuse container. (Protects nurse from pathogens and prevents contamination from soiled dressing.) 8. Remove gloves, dispose of in proper receptacle, and wash hands. (Reduces transmission of microorganisms.) 9. Assess status of wound and exudate/drainage on dressing (see Table 13-2). (Evaluates healing process and collects data for accurate documentation.)

14 14 UNIT TWO BASIC NURSING SKILLS Skill 13-4 Performing Sterile Irrigation cont d 10. Place collection basin appropriately (see illustration). (Collects contaminated solution.) 11. Wash hands and don sterile gloves. (Maintains asepsis.) 12. Cleanse area around wound with antiseptic swabs. (Removes bacteria and drainage.) 13. Fill irrigating syringe with solution. Attach soft catheter if irrigating a deep wound with small opening. (Allows for direct flow of solution into wound.) Use a 19-gauge needle (or angiocath) with a 35 ml syringe to clean most pressure ulcers, especially deep ulcers (see illustration). 14. Instill solution gently into wound, holding syringe approximately 1 inch above wound. If using catheter, gently insert into wound opening until slight resistance is met, pull back, and gently instill solution. (Minimizes tissue trauma, irritation, and bleeding.) 15. Allow solution to flow from clean area of wound to dirty area. (Prevents contamination of clean tissue by exudate.) 16. Pinch off catheter during withdrawal from wound. (Avoids aspiration of contaminating fluid into syringe.) 17. Refill syringe and continue irrigation until solution returns clear. (Thoroughly cleanses wound.) 18. Blot wound edges with sterile gauze. (Prevents tissue impairment from excess moisture.) 19. Dress wound again, if applicable. (Protects wound from injury and microorganisms and provides for patient comfort.) 20. See standard nursing interventions 10 to 17, pp Document: Status of wound Wound irrigation Solution used Character of exudate/drainage Patient s response to procedure Patient teaching (see Patient Teaching: Wound Care) 22. Report immediately any evidence of fresh bleeding, sharp increase in pain, retention of irrigant, or signs of shock to attending physician. (These are signs of tissue damage and fistula or sinus tract development. Shock phenomena may indicate internal bleeding or tissue damage.) Step 10 Step 13 are considered contaminated without respect to whether the wound is infected. Within the wound, the flow is directed from healthy tissue toward infected tissue. The tip of the irrigating syringe is placed above the area being cleansed. This prevents contamination of the syringe. Careful attention to placement of the syringe also prevents unsafe pressure of the flowing solution. Patient comfort should be provided, because an irrigation can cause pain. Patients may need to be medicated before performing the procedure. Gentleness is important in performing any type of irrigation to avoid tissue damage and pain. COMPLICATIONS OF WOUND HEALING Impaired wound healing, regardless of the cause, requires accurate observation and ongoing interventions. Because wound complications can be life threatening, recognizing the seriousness of signs and symptoms is vital throughout the patient s recovery phase (Table 13-3). Wound bleeding may indicate a slipped suture, dislodged clot, coagulation problem, or trauma to blood vessels or tissue. Inspection of the wound and dressing aids in detecting increased drainage and color

15 Surgical Wound Care CHAPTER Table 13-3 Terms Associated with Wound Complications Box 13-2 Responding to Wound Evisceration TERM Abscess Adhesion Cellulitis Dehiscence Evisceration Extravasation Hematoma DEFINITION Cavity containing pus and surrounded by inflamed tissue, formed as a result of suppuration in a localized infection Band of scar tissue that binds together two anatomic surfaces normally separated; most commonly found in the abdomen Infection of the skin characterized by heat, pain, erythema, and edema Separation of a surgical incision or rupture of a wound closure Protrusion of an internal organ through a wound or surgical incision Passage or escape into the tissues; usually of blood, serum or lymph Collection of extravasated blood trapped in the tissues or in an organ resulting from incomplete hemostasis after surgery changes. If hemorrhage results internally, the dressing may remain dry while the abdominal cavity collects blood. The patient with increased thirst; restlessness; rapid, thready pulse; decreased blood pressure; decreased urinary output; and cool, clammy skin may be hemorrhaging. Thus monitoring vital signs, intake and output (I&O), skin condition, wound site, and overall patient response hastens the identification of hemorrhage and hypovolemic shock. Internal abdominal bleeding, if allowed to continue, causes the abdomen to become rigid and distended. If hemorrhage is not detected and stopped, hypovolemic shock can cause the circulatory system to collapse, causing death. When wound layers separate, resulting in dehiscence, the patient may say that something has given way (see Chapter 2 in Adult Health Nursing). This feeling may result after periods of sneezing, coughing, or vomiting. Evidence of serosanguineous drainage on the dressing is an important sign to assess. Dehiscence may be preceded by serosanguineous drainage. If the wound is not covered and dehiscence occurs, the patient should remain in bed and receive nothing by mouth (NPO), be told not to cough, and be reassured, and the nurse should place a warm, moist sterile dressing over the area until the physician evaluates the site (Box 13-2). When a skin suture breaks and dehiscence occurs, Steri-Strips or a butterfly strip may close the wound effectively. Dehiscence most frequently occurs between the 5th and 12th postoperative days. Be- If a patient s wound eviscerates, you will need to respond swiftly and accurately, as outlined here. 1. Stay calm. Projecting a calm and confident manner will help keep the patient and family calm as well. 2. Ask a colleague to obtain supplies and to notify a physician while you stay with the patient. 3. Help the patient into semi-fowler s position with the knees slightly flexed after gatching the foot of the bed. This position will ease pressure on the wound, prevent further tearing of the wound edges, and reduce the risk of further evisceration. 4. Cover the protruding intestine with a sterile dressing moistened with sterile normal saline solution to help prevent wound contamination and keep the abdominal contents moist. If no sterile dressing is available, use clean towels or dressings. 5. Monitor the patient closely and assess vital signs and pulse oximetry readings. Frequent monitoring will help detect impending shock. 6. Establish intravenous access to provide fluids and prepare the patient for surgery as ordered. The patient will most likely need surgery to repair the wound and will not be permitted oral intake. 7. Continue to provide emotional support to patient and family. Wound evisceration can be extremely frightening. A calm, supportive approach can help the patient through this emergency. Adapted from Harkreader, H. & Hogan, M. (2004). Fundamentals of nursing. (2nd ed.). cause most patients have been dismissed from the hospital by day 12, patient teaching should include identification of dehiscence and the care to provide. If an evisceration (abdominal organs protrude through opened incision) follows the dehiscence the patient is to remain in bed, and the wound and contents should be covered with warm, sterile saline dressings. The surgeon is notified immediately (see Box 13-2). Wound infection, or wound sepsis, results when the surgical wound becomes contaminated. CDC labels a wound infected when it contains purulent (pus) drainage. A surgical wound infection may develop by the fourth or fifth postoperative day, whereas a contaminated wound may show an infectious process in 2 or 3 days. A patient with an infected wound displays a fever, tenderness and pain at the wound, edema, and an elevated WBC count. Purulent drainage has an odor and is brown, yellow, or green, depending on the pathogen. In infections, exudate cultures confirm the presence of the pathogenic organism, so that the appropriate medical therapy can follow (see Chapter 19).