WOUND DRESSING SURGICAL

Definition

Wound : a cut or break in continuity of any tissue, caused by injury or operation.
Dressing : material applied to cover a wound or a disease surface of the body.
Surgical : to do with surgery; e.g. surgical treatment, surgical instrument.
Wound dressing surgical: is a treatment to applied material to cover a cut or break in continuity of any tissue, that caused by injury or operation using surgical treatment and instrument.

Tissue Repair
While changing a dressing the nurse must be knowledgeable about tissue repair or tissue healing in order to differentiate normal or unexpected appearance from abnormal changing.

• Inflammation

1. Vascular change: initially there is vasoconstriction (5 to 10 minutes) ; vessel walls lined with leukocytes ( margination ); then vasodilatation with increased blood flow and increased vessel permeability ( effect of histamine from mast cells, kinins, and prostaglandin); lymphatic become plugged with fibrin to wall of damage area.
2. Polymorphonuclear and mononuclear leukocytes leave the vessels (diapedesis) and phagocytes foreign substances.
3. Chronic inflammation: longer-lived mononuclear leukocytes (macrophages) predominant, and fibroblast deposit of the wall of collagen around each group of macrophages and foreign substances; stage of granuloma formation.

• Fibroplasia

1. Epithelization: epithelial cells of the epidermis begin to cover tissue defect through migration of basal cells across wound defect with continued mitosis in intact epithelium.
2. Deep in the wound, fibroblast synthesize collagen and ground substance; process begins about fourth or fifth day and continues for 2 or 4 weeks.
3. Capillaries regenerate by endothelial budding tissues become red.
4. Fibrin plugs are lysed
   

• Scar Maturation

1. Collagen fibers rearranged into a stronger, more organized pattern.
2. Scar remodels, sometimes for month or years as a result of collagen turnover; if collagen synthesis exceeds breakdown, a hyper tropic scar or keloid form; if collagen’s breakdown exceeds synthesis, scar gradually softness and fades.
3. Wound contracture: contraction of wound margins begin about 5 days after injuries; caused by fibroblast migration into the wound; assists in closing the defect but may also result in contractures that can be debilitating.
   

Classification of Wound:

1. Abrasion : a superficial injury.
2. Laceration : a tearing of skin and under laying tissues as result of the application of blunt force, the edge of wounds are ragged, irregular and frequently bruised.
3. Incised wound : is caused by a weapon with sharp cutting edge drawn across the skin, the margins are clean cut, without any bruising.
4. Punctured wound: is the result of pointed object being driven thru the skin. E.g. nail foot injury, knife injury.
5. Perforated wound: if the sharp objects exit through the body on the other side. The wound is small in length and width but it is quite deep. Internal damage is extensive if the wound is on the abdomen.
6. Contusion : (Bruise) it is a result of blunt trauma, causes rupture of capillary and infiltration of blood into the tissue. Superficial contusion is red, swollen immediately; a deep contusion may be not evident on one or two days. Color change to blue in one day, brown in 2-4 days, green in 5-7 days, yellow in 8-10 days and disappears in 15 days.
7. Gunshot wound : is a small circular wound causing by a bullet.
   

Classification of Dressing

1. Dry dressing: a dry dressing may be chosen for management of a wound with little drainage. The dressing protects the wound from injury, prevent introduction of bacteria, reduce discomfort and speeds healings. Dry dressing are most commonly use for abrasions and non drainage post operative incision. The dry dressing does not debric the wound and should not be selected for wounds that requiring debridement.
2. Wet to dry dressing: the primary purpose if wet to dry dressing is to mechanically debride a wound. The moistened contact layer of the dressing increases, the absorptive ability of the dressing to collect exudates and wound debris. One must take care not to apply a dressing so wet that it remains wet continuously. Too wet dressing may cause tissue maceration and bacterial growth.
   

Equipment

1. Sterile dressing tray (forceps, scissors, gauze pads)
2. Sterile gauze dressing pads (2x2 inch, 4x4 inch or surgical pads, depending on drainage and size of area to be covered), or transparent dressing.
3. Sterile bowl
4. 2-inch tape or Montgomery straps (paper tape, if allergic to other).
5. Sterile gloves (for sterile dressing change)
6. Nonsterile gloves.
7. Towel or linen sever-pads.
8. Cotton balls and cotton tips swabs.
9. Sterile irrigation saline or sterile water.
10. Cleansing solution as ordered Bacteriostatic ointment as ordered.
11. Over bed table or bedside stand.
12. Trash bag.

Concentration of antiseptics / disinfectants / ointment used for wound dressing:

1. Burn wound : clean with NaCl 0,9%, clean with sterile gauze, apply paraffin gauze / bepanthine ointment.
2. Open wound : clean with 1% hibitane in sterile water, dry and apply tetracycline / fucidine ointment.
3. Infected wound : clean with hydrogen peroxide 1:1 or 50%, remove dead tissue, then clean with 1% hibitane in sterile water. If no discharge apply tetracycline / fucidine ointment.
4. Closed abscess : clean with 3,5% hibitane in 70% alcohol, then dry apply ichtiol ointment and close with gauze.
5. Deep wound : clean with 1% hibitane in sterile water, irrigate with 0,9% NaCl and insert betadiene pack daily (diluted with NaCl).
6. Making stitch : clean the wound with 1% hibitane in sterile water, prepare for stitch and call the doctor to do the stitch. Then clean with 1% hibitane in sterile water, dry and apply dry dressing.
7. Stitch removed : clean with 3,5% hibitane in 70% alcohol, remove stitch, clean and apply dry dressing.
   

Purpose

1. Remove accumulated secretions and dead tissue from wound or incision site.
2. Decrease microorganism growth on wound or incision site.
3. Promote wound healing.
   

Desire outcome
Wound healing noted with no sign of infection.

Assessment
Assessment should focus on the following:

1. Doctor’s order regarding of type of dressing change, procedures, and frequencies of change.
2. Type and location of wound or incisions.
3. Time of last pain medication.
4. Allergies of tape or solutions used for cleaning.
   

Nursing Diagnosis
The nursing diagnosis may include the following:

1. Impaired tissue integrity related to pressure ulcer.
2. Risk of infection related to impaired skin integrity.
   

Outcome Identification and Planning
Key goal and sample goal criteria:
The client will:

1. Regain skin integrity
2. Demonstrate no sign of infection
3. Special consideration
4. Dressing changes are often painful: assess pain needs and medicate client 30 minutes before beginning of dressing.

Implementation

1. Wash hands and organize equipment (Reduces microorganism transfer Promote efficiency)
2. Explain procedures and assistance needed to client (Decrease anxiety, Promotes cooperation)
3. Assess client pain level and wait for medication to take effect before beginning (Decrease discomfort while dressing)
4. Place bedside table close to area being dressed (Facilitates management of sterile field and supplies)
5. Prepare supplies:

• Place supplies on bedside table
• Tape trash bag to side of table
• Open sterile gloves and use inside of gloves package as sterile field
• Open gauze pad packages and drops several onto sterile field; leave some pads in open packages if in plastic container (if not , place some pads into sterile bowl)
• Open dressing tray and bowl.
• Open liquid and pour saline on two gauze pads and pour ordered cleaning solution on four gauze pads
• Place several sterile cotton tip swabs and cotton balls on sterile field (use gauze instead if staples are present because cotton may catch on edges of staples)

6. Don nonsterile gloves

7. Place towel or pad under wound area

8. Loosen tape by pulling toward the wound and removed soiled dressing (soak dressing with saline if it adheres to wound, then gently pull free),Permit observation of site and expose site of cleaning.

9. Place dressing in paper bag.

10. Discard gloves and wash hands.

11. Don sterile gloves and mask

12. Pick-up saline soaked dressing pad with forceps and forms a large swab.

13. Cleans away debris and drainage from wound, moving from center outward and using a new Pad for each area cleaned. Discard old pads away from sterile supplies.

• Prevent contamination of wound from organism on skin surface.
• Maintain sterility of supplies.
  

14. Wipe wound with pads soaked with ordered cleansing solution, moving from center of wound outward, discard forceps. Reduce microorganism transfer. Avoids cross contamination.
15. Assess need for frequent dressing change and effect of tape on skin, and apply Montgomery straps to hold dressing. Prevent infection due to soiled dressing Prevent skin injury.
16. Dress wound or incisions in the following manner:

• Pick up dressing pad by edge (solution soaked or saline soaked, if wet to dry dressing).
• Place pad over the wound or incision site until site is totally covered.
• Cover with surgical pads (if wet to dry)
• Secure dressing with tape along edges or use Montgomery straps.
• Prevent contamination of dressing or wound. Allows air to reach wound

17. Indicate last dressing change and need for next change.
Write the date and time of dressing change on a stripe of tape and places the tape across dressing. Decrease spread of microorganism
18. Dispose of gloves and materials and store supplies appropriately. Maintain organized environment.
19. Position of client for comfort with call bell within reach. Facilitate comfort and communication
20. Wash hands

1. Decrease spread of microorganisms.
2. Allows handling of clean dressing without sterile instrument.
   

Evaluation
Were desired outcomes archived?

Documentation
The following should be noted in the client’s chart:

1. Location and type of wound or incision
2. Status of previous dressing
3. Status of the wound / incision site
4. Solutions and medications applied to wound
5. Client teaching done
6. Client’s tolerance of procedure
   

Sample Documentation
4/05/2005 06.00
Abdominal wound dressing saturated with serous drainage. Area surroundings are red. Site cleanse with saline. Gauze pads (4x4 inches) moistened with saline applied and covered with dry dressing. Client turn site with pillow at back. Tolerated dressing with minimal discomfort.

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