Surgical Dressing.docx

PROCEDURE ON SURGICAL DRESSING

SUBMITTED TO: Mr. EKE Lama Tamang HOD of Medical Surgical Nursing Rufaida College of Nursing SUBMITTED BY : Sneha Sehrawat M.Ṣc. Nursing Ist Year Rufaida College of Nursing

WOUND & WOUND HEALING:-

A wound is any type of injury to the skin. Wounds can be open wounds, in which the skin is broken or torn or closed wounds. Although open wounds can bleed and run the risk of infections, closed wounds can also be dangerous depending on the extent of tissue damage. Wound healing is an intricate process where the skin or other body tissue repairs itself after injury. In normal skin, the epidermis (surface layer) and dermis (deeper layer) form a protective barrier against the external environment. When the barrier is broken, an orchestrated cascade of biochemical events is quickly set into motion to repair the damage. This process is divided into predictable phases: blood clotting (haemostasis), inflammation, the growth of new tissue (proliferation), and the remodelling of tissue (maturation). Sometimes blood clotting is considered to be part of the inflammation stage instead of its own stage. 

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Haemostasis (blood clotting): Within the first few minutes of injury, platelets in the blood begin to stick to the injured site. This activates the platelets, causing a few things to happen. They change into an amorphous shape, more suitable for clotting, and they release chemical signals to promote clotting. This results in the activation of fibrin, which forms a mesh and acts as "glue" to bind platelets to each other. This makes a clot that serves to plug the break in the blood vessel, slowing/preventing further bleeding. Inflammation: During this phase, damaged and dead cells are cleared out, along with bacteria and other pathogens or debris. This happens through the process of phagocytosis, where white blood cells "eat" debris by engulfing it. Platelet-derived growth factors are released into the wound that cause the migration and division of cells during the proliferative phase. Proliferation (growth of new tissue): In this phase, angiogenesis, collagen deposition, granulation tissue formation, epithelialisation, and wound contraction occur. In angiogenesis, vascular endothelial cells form new blood vessels. In fibroplasia and granulation tissue formation, fibroblasts grow and form a new, provisional extracellular matrix (ECM) by excreting collagen and fibronectin. Concurrently, reepithelialization of the epidermis occurs, in which epithelial cells proliferate and 'crawl' atop the wound bed, providing cover for the new tissue. In wound contraction, myofibroblasts decrease the size of the wound by gripping the

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wound edges and contracting using a mechanism that resembles that in smooth muscle cells. When the cells' roles are close to complete, unneeded cells undergo apoptosis. Maturation (remodeling): During maturation and remodeling, collagen is realigned along tension lines, and cells that are no longer needed are removed by programmed cell death, or apoptosis.

The wound healing process is not only complex but also fragile, and it is susceptible to interruption or failure leading to the formation of nonhealing chronic wounds. Factors that contribute to non-healing chronic wounds are diabetes, venous or arterial disease, infection, and metabolic deficiencies of old age. Wound care encourages and speeds wound healing via cleaning and protection from reinjury or infection. TYPES OF HEALING There are three types of healing, distinguished by just how much skin and tissue has been lost: 1. Primary Intention Healing – This occurs where the tissue surfaces have been approximated (closed). This can be with stitches, or staples, or skin glue (like Derma bond), or even with tapes (like steri-strips). This kind of closure is used when there has been very little tissue loss. It is also called “primary union” or “first intention healing.” An example of wound healing by primary intention is a surgical incision. 2. Second Intention Healing – A wound that is extensive and involves considerable tissue loss, and in which the edges cannot be brought together heals in this manner. This is how pressure ulcers heal. Secondary intention healing differs from primary intention healing in three ways: o

The repair time is longer.

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The scarring is greater.

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The chances of infection are far greater.

3. Tertiary Intention Healing – This type of wound healing is also known as “delayed” or “secondary closure” and is indicated where there is a reason to delay suturing or closing a wound some other way, for example when there is poor circulation to the injured area. These wounds are closed later. Wounds that heal by tertiary intention require more connective tissue (scar tissue) than wounds that heal by secondary intention. An example of a wound

healing by tertiary intention is an abdominal wound that is initially left open to allow for drainage but is later closed. SURGICAL DRESSING It is the process of cleansing an incision and applying sterile protective covering using aseptic technique. DRESSING A dressing is a sterile pad or compress applied to a wound to promote healing and/or prevent further harm. A dressing is designed to be in direct contact with the wound, as distinguished from a bandage, which is most often used to hold a dressing in place. DRESSING MATERIALS

TOPICAL AGENTS FOR CLEANSING WOUNDS  Skin antiseptic: mercurochrome 1- 2.5%  Non-irritating antiseptics : savlon 5%, normal saline, eusol 0.5-1 %  Oxidising agent for softening and removing crusted exudates and debris : hydrogen peroxide 1.5-3 %  Agents to remove adhesive marks from the skin : acetone, ether MATERIALS FOR SECURING DRESSINGS Dressings are secured by adhesive tapes, bandages, binders etc. The choice of the material depends on the wound size, location, presence of drainage, frequency of dressing changes and the client’s level of activity. The main purpose of these materials is to keep the dressing in place. It also helps to keep the edges of the wound together and relieves strain on the sutures. TYPES OF DRESSING Dressings vary by type of material and mode of application. They should be easy to apply, comfortable and made of materials that promote wound healing. 1. GAUZE DRESSING: are the commonest. Gauze is available in different textures and shapes e.g., in squares, rectangles and rolls of various lengths.

2. NON-ANTISEPTIC DRESSINGS : are sterile un-medicated dressings applied to a fresh wound to protect it from infection. 3. ANTISEPTIC DRESSINGS : are impregnated with some medication and are applied to wounds already infected to limit the septic process. 4. WET DRESSINGS: are used in infected wounds to soften the discharge, promote drainage and also in wounds that require debridement. It is also used to supply heat to the tissues. Moist heat is more penetrating than dry heat. Therefore moist heat is more beneficial in localizing the infection in an area. 5. PRESSURE DRESSINGS: when there is danger of bleeding or when there is oozing from the wounds, a pressure dressing may be applied. This is a thick sterile pad made of gauze or gauze and cellulose, applied with a firm bandage, binder. 6. NON-ADHERANT GAUZE DRESSINGS : these are used to cover clean wounds. Telfa gauze has a shiny, non-adherant surface that does not stick to incisions or one opening but allow drainage to pass through to the softened gauze above. 7. SELF-ADHESIVE TRANSPARENT FILM : it acts as a temporary second skin. This is ideal for small superficial wounds and wounds which do not require debridement. PURPOSES OF DRESSING There are several purpose of dressing :        

To protect the wounds from contamination with microorganisms. To aid in homeostasis. To promote healing by absorbing drainage and debriding a wound. To support or splint the wound site. To prevent the client from visualising the wound. To promote thermal insulation to the wound surface. To provide maintenance of high humidity between the wound and dressing. To provide mental and physical comfort for the patient.

ARTICLES REQUIRED STERILE DRESSING TRAY CONTAINING: i. ii. iii. iv. v. vi. vii. viii.

Artery forceps-1 (2, for extensive or infected wounds) Thumb forcep-1 Cotton swabs Gauze pieces Gallipot for cleansing solution Surgical pad Kidney tray Sterile scissors

A CLEAN TRAY CONTAINING: i. ii. iii. iv. v. vi. vii. viii. ix.

Clean gloves Sterile gloves Cleaning solution (normal saline) Ordered medications Adhesive plaster Bandage scissors Plastic bag Mackintosh Culture tube (optional)

NOTE- for major wound dressing, a larger dressing pack with additional articles may be required.

PROCEDURE

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Nursing action

Rationale

Identify the patient. Inform patient of dressing change, explain procedure and have patient lie in bed. Gather equipment and arrange at the bedside.

Encourages patient cooperation.

Check physician’s order for dressing change and any specific instruction. Close door or curtains and place waterproof pad on bed beneath area of dressing. Assist patient to comfortable position that provides easy access to wound area. Place opened, cuffed plastic bag near working area. Wash hands

Clarifies type of dressing.

Loosen tape on dressing (if tape is soiled, don clean gloves before loosening the tape)

10. Don clean disposable gloves and remove soiled dressings carefully from more clean to less clean

An organized approach will save time and energy.

Provide privacy and prevent soiling of linen.

Provides for comfort.

Reduces risk of contamination from soiled dressing and used cotton balls. Reduces spread of microorganism. Removal of tape is easier before wearing gloves

Protects nurse from contamination.

area, (if dressing is adherent to the skin, moisten it by pouring small amount of normal saline)

Cautious removal of dressing is less painful for the patient. Moistened dressing is easier to remove. Reduces anxiety of patient.

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Keep soiled side of dressing away from patient’s view. Assess the amount, colour and odour of drainage. Discard dressing in disposal bag. Pull off gloves inside out and discard in appropriate receptacle Using sterile technique, open sterile dressing tray and arrange supplies on work area. Open cleaning solution and pour into the sterile gallipot/cup over the cotton balls. Don sterile gloves.

Helps for identifying the wound healing process. Prevents spread of microorganism.

Keep supplies within easy reach and maintains sterility.

Maintains asepsis.

16. Pick up soaked cotton using artery forceps. 17. i. For a surgical wound, Moving from least to most clean from top to bottom contaminated area prevents or from center to outward. spread of microorganism to less infected area. ii. Use one cotton swab /gauze sponge for each wipe, discarding each by dropping into the plastic bag after wiping. Do not touch the plastic bag with forceps.

iii. If a drain is present, clean around it, moving from center outward in a circular motion. iv. Dry the wound using sponge in same motion

18. Apply medication ordered (ointment) to the wound on a dry sterile gauze. Apply a layer of sterile dressing over wound. 19. Place a sterile gauze slit on side under and around the drain (use precut gauze or cut one using sterile scissors) 20. Apply a second layer of gauze to wound site and a surgical pad as the outer most layer. 21. Remove gloves from inside out and discard in plastic waste bag.

Moisture provides medium for growth of microorganism and drying the wound may retard the growth of organisms and improve healing process.

Additional dressing serves as a wick for drainage.

Drainage is absorbed and surrounding skin area is protected.

Provides for absorption of wound drainage and protection from microorganism. Tape is easier to apply after gloves have been removed.

22. Apply adhesive tape to Medical tapes can cause secure the dressing. injuries if used incorrectly.  Place the tape so that the dressing cannot be folded back to

expose the wound. Place strips at the ends of the dressing, and space tapes evenly in the middle.  Ensure that the tape is long and wide enough to adhere to several inches of skin on each side of the dressing, but not so long or wide that the tape loosens with activity.  Place the tape in the opposite direction from the body action, for example, across a body joint or crease, not lengthwise. 23. Wash reusable articles to be sent for sterilization 24. Wash hands, remove all Prevents spread of infection. articles and make patient comfortable. 25. Record and Report Provides accurate  Report brisk, bright documentation of procedure. red bleeding or evidence of wound dehiscence or evisceration to physician immediately.  Report wound and peri-wound tissue appearance, colour, and tissue type and presence and characterist-ics of exudates, type and

amount of dressings used, and tolerance of client to procedure.  Record client’s level of comfort.  Write date and time of dressing applied, on tape.

CLIENT TEACHING (HOME CARE CONSIDERATIONS) Appropriate client teaching is essential for promoting wound healing and maintenance of healthy skin. i. ii.

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Emphasise on hygiene and medical asepsis; hand cleansing before and after dressing changes; and using a clean area for storage of dressing supplies. Teach the client and family about proper disposal of contaminated dressings. Advice them to dispose off contaminated items in doublebagged moisture – proof bags. Teach, how the client may bathe with the wound ( that is, does the wound need to be covered with a water-proof barrier or should it be cleansed in the shower) Suggest client to use tap water instead of normal saline. Teach the client and family members about the signs of complications and to report to the physician immediately, if any, occur.

DECUBITUS ULCER / PRESSURE SORE / BED SORE Decubitus ulcers, also known as pressure sores, are ulcerated or sloughed areas of tissue subjected to pressure from lying on mattress or sitting on a chair for a prolonged period of time resulting in the slowing of circulation and finally death (necrosis) of tissues.

COMMON SITES OF BED SORE The sites depend up on the position of the client in bed. The pressure points in the supine position are back of the head, scapula, sacral region, elbow and heels. In a side lying position the pressure points are the ears, acromion process of the shoulder, ribs, greater trochanter of the hip and ankle joint. In a prone position, the pressure points are ears, cheek, acromion process, breast (females), genitalia(males), knees and toes.

PREVENTION OF PRESSURE SORE 1. Identification of clients who are particularly prone to the development of decubitus ulcer. 2. Daily examination of the decubitus prone clients for redness, discolouration or blister on the pressure points and they should be reported and treated immediately. 3. Keep the clients clean and dry. 4. Change the position of the client every 2 hours so that another body surface bears weight. 5. Use a bed cradle to take off the weight of the bed linen of the client, so as to enable him to move in bed with ease. 6. Keep the client’s skin well lubricated to prevent cracking by using powder. 7. Protect the damaged skin. Damaged skin can be further irritated and macerated by urine, faeces, sweat etc.

8. Provide the client with adequate fluids and with a nourishing diet that is high in protein and vitamins. 9. Attend to the pressure points as often as necessary to stimulate circulation. The client who are liable to bed sores must have their back treated two hourly or more often. The back is washed with soap and warm water, dried and massaged with powder. Avoid using excess alcohol for back rub because it dries the skin and cause tissue damage. Attending to the back alone is not sufficient but should include the pressure areas at the iliac crests, ankles, heels, elbows and other pressure points. 10. Call assistance and lift the client before giving and taking bedpans. If the bedpan is chipped, care should be taken to pad the bedpan to avoid friction. 11. Provide a smooth, firm and wrinkle free bed on which the client can take rest. 12. Use special mattresses and beds to decrease the pressure on body parts, e.g. air mattresses, water mattresses etc. 13. Cut short the finger nails of the client to avoid scratching on the skin. 14. Use adequate amount of cotton under splints and plaster casts to prevent friction. 15. Use the comfort devices to take off the pressure from the pressure points, e.g. air cushions, cotton rings etc. Avoid using rubber rings since they compress the area of the skin beneath them, decreasing blood supply around the pressure points. 16. Encourage the clients to move in bed as far as it is allowed. 17. Change the linen as soon as they become wet. The back and buttocks also must be washed, dried and rubbed with powder. After each urination and defecation the back must be attended. 18. Teach the clients and their relatives the hygienic care of the skin. TREATMENT OF THE DECUBITUS ULCER The following steps are taken by the nurses. 1. Report to the sister in-charge and the physician the early symptoms of a bedsore so that the steps may be taken as early as possible to prevent further damage.

2. Whenever possible, take off the pressure from the decubitus ulcers by placing the client on pillows or foam cushions or change the position of the client (prevent the development of a pressure sore in the new area). 3. Prevent the ulcerated area from becoming infected. Inflection will retard healing of an ulcer. Follow strict aseptic technique. 4. A cleaning agent is used to clean the ulcerated area e.g., normal saline. 5. Apply all the possible measures for the healing of the wound. - Heat is applied by an electric bulb (100 watt). This is placed from 45 to 60 cm away from the wound and is left in place for 10 min. - Application of a few drops of insulin dropped from a syringe has a healing effect on the wound. The wound is then exposed to air dry. 6. Application of waterproof ointment e.g., zinc oxide on the surface of the wound will prevent infection of the underlying tissues. It will be of much value in clients with incontinence of urine. 7. For Pressure Ulcers with minimal exudate, transparent films or hydrogels, which are cross-linked polymer dressings that come in sheets or gels, are used to protect the wound from infection and create a moist environment. Hydrocolloids, which combine gelatin, pectin, and carboxymethylcellulose in the form of wafers and powders, are indicated for PUs with light-tomoderate exudates. 8. If slough is present, clean the area thoroughly twice a day with hydrogen peroxide diluted with distilled water. If the slough is loose, the physician may cut off the slough. If there is delay in healing of the wound, the surgeon may debride the ulcer and a skin graft may be applied over the ulcerated site.