Surgical Asepsis, Wound PN 2017

Care, and Simple Dressings

Surgical Asepsis

Includes procedures used

to eliminate all
microorganisms, including • Sterile procedures
spores, from an object or • Protective clothing
area • Opening sterile
packages
• Sterile field
• Pouring sterile
solutions
• Surgical hand scrub
• Gowning and gloving
 Sterile Technique

• Majority of sterile technique practice are used in the OR

• Sterile technique includes:
• Applying mask
• Protective eyewear and cap
• Performing surgical hand scrub
• Applying sterile gown and gloves

• Purpose: To maintain an area free from pathogenic micro-organisms

• Minimizes patient exposure to infection-causing agents
• Reduces infection risks of patients
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 Sterile Technique

• Proper hand hygiene is required.

• Used at bedside for procedures that require intentional
puncture of skin, insertion of devices into a sterile part
of the body, and when skin integrity is compromised
• Standard precautions are the minimum standard for
infection control.

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Sterile Technique

• Must maintain sterile technique at all times

throughout procedure
• When completing sterile procedure at bedside:
• Perform hand hygiene.
• Apply sterile gloves.
• Explain steps taken to prevent infection.

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 Person-Centred Care

• Invasive procedures cause infection risk.

• You are obligated to maintain surgical asepsis
during those procedures and to intervene to stop it
when a break in sterile technique occurs.
• Cultural considerations: Educate patients to reduce
fears or misconceptions about attire worn during
sterile asepsis.
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Preparing a Sterile Field

• A sterile field provides a sterile surface for placement

of sterile equipment.
• A sterile drape establishes a sterile field around a
treatment site.
• After sterile kit is opened, inside surface can be
considered a sterile field.
https://www.kanopy.com/en/northernc/video/231942

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 Question:

A sterile field consists of:

A. The outer portion of a sterile tray.
B. A table covered with a sterile drape.
C. Contaminated dressings from the patient.
D. Clean, latex-free catheters.

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Special Considerations

Care in the Community

• Clean technique is often required.
• Teach patient and family principles that apply to the sterile
environment.
• Assess patient and family understanding and ability to
provide a sterile environment when needed to perform a
specific procedure.

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 Sterile Gloving

• Sterile gloves help prevent the transmission of pathogens

by direct and indirect contact.
• Verify if patient or health care providers have latex allergy.
• Select the proper glove size.
• Select type of glove (latex or nonlatex).

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Recording and Reporting

• It is not necessary to record application of gloves.

Record specific procedure performed and patient’s
response and status.
• In the event of a latex allergy reaction, record patient’s
response in nurses’ notes and on vital sign flow sheet.
Note type of response and patient’s reaction to
emergency treatment.

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Skin Integrity and Wound
Assessment
PN2017
Skin Integrity and Wound Care

• Skin is the body's largest organ.

• It protects against pathogens; senses pain,
temperature, and touch; and synthesizes vitamin D.
• It is important to monitor skin integrity and prevent
skin breakdown.
• The nurse must understand normal wound healing and
assessing interventions that optimize wound healing.
Skin

• Dermal–epidermal junction
• Separates dermis and epidermis

• Epidermis
• Top layer of skin

• Dermis
• Inner layer of the skin

• Constant replacement
• Protects underlying tissue
Review

• Pressure injuries occur from unrelieved

prolonged soft tissue compression.
• Terms: pressure injury vs pressure ulcer
• Most common sites for pressure injuries:
• Bony prominences, such as: coccyx, sacrum,
heels, lateral and medial malleoli

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 Pressure Injury
• Pressure ulcer
• Pressure sore, decubitus ulcer, or bedsore
• Pathogenesis
• Pressure intensity
• Blanching
• Pressure duration
• Tissue tolerance
 Risk Factors for Pressure Injury
Development

• Impaired sensory • Moisture

perception • Nutrition
• Impaired mobility • Tissue perfusion
• Alterations in level of
• Infection
consciousness
• • Pain
Shear
• Friction • Age
 Nursing Assessment
• Skin integrity is subject to change over time.
• Baseline and continual assessment data are needed to
support skin integrity and prevent pressure ulcer
development.
• Cultural considerations should be remembered.
 Braden Pressure Risk
Assessment Scale
• Sensory perception
• Moisture
• Activity
• Mobility
• Nutrition
• Friction and shear
• Low score = high risk
See Table 39.1 in Perry & Potter (2020)
Based on the depth of tissue
destroyed:
Suspected deep tissue injury
• Discoloured intact skin
Stage 1
• Intact skin with nonblanchable redness
Stage 2
• Partial thickness loss of dermis
Stage 3
• Full-thickness tissue loss with visible fat
Stage 4
• Full-thickness tissue loss with exposed
bone, muscle, or tendon
Unstageable
• Full-thickness tissue loss, in which the
base of the ulcer is covered by slough or
eschar in the wound bed
Special Considerations

Teaching ?
Pediatric ?
Gerontological ?
Care in the Community ?

23
 Wounds
• A disruption of the integrity and function of tissues in
the body
• Classification
• Wound Healing
• Wound Repair
• Complications
Wound Classification and Process of
Healing

Classifications
• Acute
• Chronic
Healing Process
• Primary intention
• Secondary intention
• Tertiary intention
Types of Wounds

• Surgical wounds
• Pressure injury
• Skin tears
• Venous and arterial ulcers
• Diabetic ulcer
• Malignant or fungating wounds
 Classification of Wounds - Colour

Black wounds
• Necrotic tissue (destruction)
• Black in colour
• Also common in stage III and IV pressure injuries

Yellow wounds
• Death of subcutaneous fat tissue and muscle degeneration
• Yellow, cream-coloured, or gray necrotic slough, usually with purulent
drainage

Red wounds
• Red or pink granulation tissue
Wound Appearance
and Drainage
Wound appearance
• Surgical incision
• Puncture

Character of wound drainage

• Serous
• Sanguineous
• Serosanguineous
• Purulent
Wound Drains

• If a large amount of drainage is

anticipated, a drain is often
inserted in or near a surgical
wound
• Some drains are sutured in place
• Examples of draining systems are
Penrose, Hemovac, and Jackson-
Pratt.
Phases of Wound Repair

• Partial-thickness wound repair

• Full-thickness wound repair
• Inflammatory phase
• Proliferative phase
• Remodelling phase

Granulation
Tissue
Proliferative
Phase
Hemostasi
s
 Principles for Practice – Wound Repair

• Physiological wound environment principles:

• Adequate moisture
• Temperature control
• pH
• Control of bacteria burden
• Use of effective dressings
• Conditions for primary wound healing
• Conditions for secondary wound healing
• Use of dressing material that promotes wound healing
Patient Factors Affecting Wound
Healing

• What are some patient-specific factors that may affect

wound healing?
Question:

A surgical incision is an example of a wound that heals

by primary intention. Primary intention is noted when
the skin edges do which of the following?
A. Are approximated
B. Appear slightly pink
C. Migrate across the incision
D. Slightly overlap each other
 Wound Closures

• Staples
• Sutures
• Wound closures
• Tissue adhesive: Dermabond
Palpation and Cultures

Palpation of the wound

• Wear sterile gloves when palpating the wound bed
• Note drainage or tenderness

Wound cultures
• Swab wound
• Gram stain
• Tissue biopsy
Complications of Wound Healing

• Hemorrhage
• Infection
• Dehiscence
• Evisceration
• Fistulas
 Wound Assessment and Care
Principles
TIME framework for assessment
• Tissue management
• Inflammation/infection
• Moisture
• Edge

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Performing a Wound Assessment

• Wound assessment provides a baseline for further

care.
• Parameters include:
• Location, type of wound, extent of tissue involvement, type
and percentage of wound base, wound size, wound exudate,
presence of odour, peri-wound area, and pain

• Should be done on a scheduled basis to determine if

the wound is moving toward healing
• Identify type of wound healing and required dressings 39
Dressing Functions

• Maintenance of a moist environment

• Protection from outside contaminants
• Protection from further injury
• Prevention of spread of microorganisms
• Increased client comfort
• Control of bleeding
• Absorption of drainage
• Debridement
 Dressings – Factors to Consider
• Ease of application
• Conformity to body contours
• Durability and flexibility
• Cost-effectiveness
• Ability to absorb or contain
• Ease of removal without damaging healing surface
• Acceptable in appearance
Dressings

Types:
• Primary and Secondary • For infected wounds: hypertonic,
cadexomer iodine, silver, honey,
• Wet-to-dry (discouraged)
gentian violet/methylene blue
• Woven gauze • Negative pressure wound therapy
• Transparent film (VAC)
• Nonadherent contact layer
• Soft silicone
• Hydrocolloid
• Hydrogel
• Foam
• Calcium alginate
• Composite
 Dressing Selection

• Select dressings to achieve individual patient outcomes.

• Select dressings that help reduce pain; provide analgesic
doses 30 minutes prior to dressing change.
• Accommodate different cultures and religious practices.
• Use skin barriers as needed.
• Assess patient or caregiver knowledge of wound care.
• Assess and try to understand the different meanings of blood
and wounds and how they affect patients.
• Provide for patient privacy. 43
Before Dressing Change

• Examine medical record

• Last wound assessment
• Specific dressing change prescriptions
• Wound assessment tool utilized
• Assess comfort level
• Assess risk factors
• Check for allergies
• Assess readiness to learn client/family
Changing Dressings
• Type of dressing is based on current assessment.
• “Reinforce dressing prn” is a common order after surgery.
• The nurse should note placement of drains and equipment
needed.
• Sterile technique (or no-touch) should be used.
• Wound cleansing and irrigation using non-cytotoxic solutions with
surfactants
Changing Dressings

• Administer required analgesic Comfort Measures:

• Explain steps of procedure to • Administer analgesics 30–
patient 45 min before dressing
• Gather all necessary supplies change
• Recognize normal signs of • Carefully remove tape
healing
• Gently cleanse the wound
• Answer patient’s questions,
• Careful manipulation of
and document care provided
dressings and drains
• Consider patient’s position
Applying a
Dry Dressing

Wound and Pressure Ulcer Care:

https://www.kanopy.com/en/northernc/video/210594
Skin and Wound Care: https://www.kanopy.com/en/northernc/video/210276
Applying a Dressing
Dry
• Do not interact with wound tissues and cause little wound irritation.
• These dressings are commonly used for abrasions and nondraining postoperative
incisions.
• Telfa gauze dressings contain a shiny, nonadherent surface on one side that does
not stick to a wound.
• Drainage passes through the nonadherent surface to the outer gauze dressing.

Damp-to-Dry
• Gauze moistened with an appropriate solution.
• A moist-to-dry dressing has a moist contact dressing layer that touches the
wound surface. The moistened gauze increases the absorptive ability of the
dressing to collect exudate and wound debris. When other forms of moisture-
retentive dressings are not available, moist gauze is effective to mechanically
debride the wound promote wound healing.
Delegation and Collaboration

• The nurse is responsible for wound assessments,

care of acute new wounds, wound care requiring
sterile technique and evaluation of wound healing.
• The nurse directs UCP about:
• Any unique modifications of the dressing change such as
special tape or taping techniques to secure the dressing
• Reporting pain, fever, bleeding, or wound drainage to the
nurse immediately

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Communication and Documentation

• Document appearance and size of wound,

characteristics of drainage, presence of necrotic tissue,
type of dressing applied, patient’s response to dressing
change, and level of comfort.
• Document patient’s understanding through teach-back
for effective dressing change.
• Report any unexpected appearance of wound
drainage, accidental removal of drain, bright red
bleeding, or evidence of wound dehiscence or
evisceration. Copyright © 2020, Elsevier Inc. All rights reserved.
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 Communication and Documentation

1015 Removed serosanguineous soaked abdominal pad and 3 (4x4) dressings from right lower
quadrant incision. Incision well approximated. Healing ridge present. Staples intact. Incision
cleansed with normal saline and re-dressed with 3 dry (4x4s) and one abdominal dressing.
Client reported minimal pain with dressing change.-----------------------------------------M. Bedard,
RN

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Cleansing Surgical and Traumatic
Wounds
• Cleansing skin and drain sites
• Noncytotoxic solution is applied.
• Wound irrigation
• Irrigation removes exudates.
• Sterile technique is used.
Wound
Cleansing
Wound
Cleansing
 Sutures & Staples

• Silk, steel, cotton, linen, wire, nylon, and

polyester are used to sew body tissues
together.
• Steel staples cause less trauma to tissues and
provide extra strength.
• Tape closures such as Steri-Strips are used
• Removal:
• Sutures and staples
• Removed within 7 to 14 days

• Retention sutures
• Removed within 14 to 21 days
Drainage Evacuation and Binders
Drainage evacuation
• Portable units exert a safe, constant, low-pressure vacuum to remove
and collect drainage.

Bandages and binders

• Bandages: rolled gauze, elasticized knit, elastic webbing, flannel,
muslin
• Binder application: breast, abdominal
 Managing Wound Drainage Evacuation

• Open drain
• Example: Penrose
• Removes drainage
from wound and
deposits it onto skin
surface

Wound and Pressure Ulcer Care:

https://www.kanopy.com/en/northernc/video/210594
 Managing Wound Drainage Evacuation

• Closed drains
• Examples: Jackson-
Pratt (JP), Hemovac
• Uses vacuum to
draw drainage from
wound to collection
device
Delegation and Collaboration

• The assessment of wound drainage and

maintenance of drains and the drainage system
cannot be delegated to UCP.
• The nurse directs UCP to:
• Discussing any increase in frequency of emptying the
drain other than once a shift.
• Instructing to report to the nurse any change in
amount, colour, or odour of drainage.
• Reviewing the intake and output (I&O) procedure. 59
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Communication and Documentation

• Document emptying or re-establishing of vacuum in suction

device; amount, colour, and odour of drainage; dressing change
to drain site; and appearance of drain insertion site.
• Document amount of drainage on intake and output (I&O) record.
• Document to the health care provider a sudden change in amount
of drainage, either output or absence of drainage flow.
• Also report to the health care provider pungent odour of drainage
or new evidence of purulence, severe pain, or dislodgment of the
drainage tube.

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Bandages and Binders
• Bandages
• Rolled gauze, elasticized knit, elastic webbing, flannel, and muslin
• Type of binder application
• Breast, abdominal, sling
Applying Bandages and Binders
• Inspect underlying skin.
• Inspect any surgical dressing.
• Cover exposed wounds.
• Use appropriate technique to apply.
• Assess patient’s comfort.
• Assess skin of areas distal to bandage.
Applying Gauze and Elastic
Bandages
• Gauze and elastic bandages secure or wrap hard-to-
cover body areas.
• Bandages are a secondary dressing.
• Select type of bandage turn and width on the basis of
size and shape of body part.
• Place outer surface next to the skin and roll it around the
surface to be covered.
• Apply even tension during application.

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Applying an Abdominal Binder

 Binders
 Elastic or cotton
 Abdominal

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 Applying a Transparent Dressing

• Clear, adherent polyurethane sheet

• Prevents tissue dehydration and allows for
rapid, effective healing by speeding epithelial
cell growth
• Preferred for intravenous (IV) catheter insertion
site

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 Special Considerations

• Teaching
• Explain the need to change dressing if edges loosen; explain that fluid under dressing is not
“pus”; it is the result of normal interaction of body fluids with the dressing.
• Pediatric
• Adhesive may tear premature infant skin
• Tell children: the longer the dressing is left on, the easier it is to remove.
• Gerontological
• Adhesive may tear older person skin
• Care in the Community
• Wound may be cleaned in the shower with provider approval
• Explore dressing types with patient, and recommend one that the patient can easily locate
and finds easy to apply

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 Additional Dressings: Hydrocolloid or
Hydrogel Dressing

• Hydrocolloid dressings • Hydrogel dressings

• Elastomeric, adhesive, and gelling
• Glycerin- or water-based
agents
• Absorptive and hydrating • Promotes moist wound
• Forms gel that promotes moist healing and autolysis
environment, facilitates autolytic • Nonadherent with
and enzymatic debridement
absorptive properties
• Diminishes pain
• Protects wound and periwound • Cooling/soothing properties
skin

67
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 Additional Dressings: Foam and
Alginate Dressings

Polyurethane foam dressings Alginate and hydrofibre dressings

• Foamed polymer sheets with • Promote autolysis, granulation,
small open cells that hold epithelization
wound exudate away from • Calcium alginate material
the wound bed (seaweed)
• Protect wound surface while • Form a gel over the wound to
maintaining a moist, contain exudate
insulated environment

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