OSCE 3 Notes - Wound Care PDF

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OSCE notes from Practicum Lab (Claudia Carson's class)...

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OSCE 3 NOTES WOUND CARE Purpose - To help promote wound healing - To remove debris from the surface of a wound - To reduce the number of bacteria in the wound - To loosen & remove eschar (thick, leathery, necrotic tissue) Purpose of Wound dressing - To protect the wound from injury - To reduce discomfort - to speed wound healing - To control bleeding - To maintain a moist environment - To prevent infection & the spread of bacteria in the wound -

Before assessing the wound: 1. Review the patient’s chart - to determine the wound’s location, size & whether it’s open or closed with sutures, staples or steri-stripes 2. Recall the basic types of wound healing - to determine which type is present Wound Healing: 1. Primary Intention

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Tissue losses minimal The wound edges are pulled together & closely approximated Healing occurs by connective tissue deposition as in a surgical wound

2. Secondary Intention

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Tissue losses greater Wound edges are not approximated Healing occurs by granulation tissue information and wound edge contraction as in severe laceration or pressure ulcer

3. Tertiary Intention

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Occurs when surgical wounds are not closed But left open for 3-5 days allowing the edema or infection to diminish Wound edges are then sutured or stapled closed8o

1. Wound Assessment - Perform indirect assessment if the surgical dressing is still in place -

1. 2. 3. 4. 5. 6. 7. 8.

S.A.L.T.T. Size Apperance Location Treatment Tolerance (pt response)

- R.E.E.D.A. - Redness Edema Ecchymosis Drainage Approximation Check the Physicians order Prepare equipment Hand hygiene Don clean gloves Give patient privacy by closing the door & closing the curtain Inspect the skin - For any redness, swelling, bruising or other discoloration Palpate around the dressing (while wearing gloves) - To detect skin temperature, pain or swelling Check the dressing

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For moisture drainage & bleeding If you see complication such as Frank Bleeding, notify the physician at once Ex: Blood in vomit, urine or feces

1. Remove the tape direction toward the wound - To avoid pulling on the wound edges - Support the surrounding skin as the tape is being removed

2. Perform direct assessment (assess the used dressing) - dry? Clean? Signs of bleeding and drainage? Odor? - Wound Color? (represents the balance between chronic and new scar tissue)

IF SUTURE LINE exists, assess it Normal Findings:  Clean, well-approximated edges, possibly with crusts from wound drainage  Inflamed, swollen outer edges for first 2-3 days only  Bruised around the suture line

IF DRAINAGE exists, assess it  Color  Consistency  Amount – percentage of dressing - Quantity (scant, moderate or copious)  If indicated, collect the specimen of the drainage

2. Measure the size of the wound - Widest Length & Width - Using disposable measuring tape - Draw or take a picture of it if it’s in odd in shape

3. Using a cotton swab - Rotate the cotton swab to detect if there’s any tunnel or deeper areas - If appropriate, measure the wound depth and convert that depth to centimeters (from a ruler or measuring tape)

4. STERILE TECHNIQUE AND WOUND DRESSING 1. Explain what you’re doing 2. Adjust the bed at a working height 3. Position the patient comfortably 4. Expose the wound sight only - so that he won’t feel cold or uncomfortable 5. Place the waterproof pad under the patient, near the dressing sight

6. Form a cuff on a waterproof biohazard bag and place it on the bed 7. Don gloves 8. Remove tape - Hold down uninjured skin - Pull the tape parallel to the skin and toward the dressing (or in the direction of hair growth in a hairy area) - Remove any adhesive that remains on the skin 9. Carefully remove outer dressing and then inner dressing

- One layer at a time - If a drain is present, avoid putting tension on it - Discard the used dressing 10. Throughly examine the wound - Palpate around the wound - Note the wound size, redness, swelling, type of drainage, amount, color, odour - Describe the signs of healing to the patient 11. Dispose the gloves in the bad 12. Perform hand hygiene

STERILE TECHNIQUE 13. Get All Supplies Before Starting - Wash hands first - Place your sterile drape and arrange your dressing supplies - the shine side faces down  NOTE: Keep forceps tip well within 1 inch border of the field - 1 inch border is considered contaminated NOTE: Don’t hold more than 1/3 of forceps Don’t talk over the sterile field

Don’t pass dirty articles over sterile field Microbes get around by: - Air currents - Direct contact - Capillary action – microbes travel in moisture

14. Pour the Prescribed cleansing solution - NOTE: First, Pour a minimal amount of the solution first on the sink (so the contamination at the top will be removed

15. Wear Sterile Gloves

16. Clean the wound - Cleanse the wound from the LEAST contaminated to MOST contaminated areas - Dip the swab (cotton ball) or gauze pad in a sterile solution, then squeeze the excess - Make a dumpling fold (gauze pad)

- Continuously and one way stroke - Use a separate gauze pad or swab for each cleansing stroke - Then use a DRY GAUZE - IF THE PAIENT HAS A DRAIN, use a circular stroke, cleansing outward away from the insertion site

DRESS THE WOUND - Position a loose woven gauze as a contact layer - Apply a thicker woven pad such as serger pad or abdominal dressing

- If using MONTGOMERY TIES - Place the bands or ties over the dressing - To secure, lace the bands or ties across its snuggly enough to hold it in place, but not put pressure on the skin

- Write time & date of the dressing, and your initial on a piece of tape

- Or use STOMA ADHESIVE OR HYDROCOLLOID WINDOW - Cut a stoma adhesive or hydrocolloid pad into strips - Apply skin barrier - Apply adhesive strips to 2-4 sides of the wound - Apply the dressing - Secure it with tape - Write time & date of the dressing, and your initial on a piece of tape

APPLY A MOIST TO DRY DRESSING 1. Give patient privacy by closing the door & closing the curtain 2. Perform hand hygiene & apply sterile gloves

3. Place a woven mesh gauze or a packing strip in a container of sterile solution And moisten it completely - using forceps

4. Wring out the excess fluid And apply the moist fluffed woven mesh gauze directly onto the wound surface - Don’t touch the surrounding skin - Make sure any dead space is loosely packed with gauze - Don’t pack the wound too tightly or let the gauze pass the top of the wound

5. Apply Sterile Gauze over the Moist Gauze 6. Cover with a Serger pad or other thick woven pad

7. Secure the dressing by applying tape or Montomery Ties - If using a tape, apply a skin barrier

8. Make sure the tape extends pass the end of the dressing, ceiling the dress edges

WOUND DRAINAGE SYSTEMS 1. Hand Hygiene 2. Ensure privacy

3. Determine:  What type of system the patient uses  Number of drain tube in placed  Expected drainage for each one 4. Don Gloves 5. Open specimen container or graduated measuring cylinder 1. EMPTYING A HEMOVAC, VACUDRAIN OR CONSTAVAC 1. Open the plug on the port 2. Tilt the evacuator toward the plug 3. Then slowly squeeze the two flats together, while tilting the evacuator toward the container 4. Allow the content to drain completely to the container 5. Cleanse the port with an alcohol swab 6. Place the evacuator on a flat surface and press down, until the bottom and top touch 7. Hold the bottom & top together with NON-DOMINANT HAND 8. Replace the plug with DOMINANT HAND 9. Make sure the evacuator is working properly - Check if the vacuum is re-established - and if the drainage tubing is patent & has no tension on it.

Follow-up Care - Observe for drainage:

o In the evacuator o Around the tubing (good flow? Blockage?) o At the patient’s wound 2. EMPYTING A JACKSON-PRATT DRAIN 1. Hand hygiene 2. Don gloves 3. Expose the site 4. Open the port

5. Tilt the drainage to empty into a measuring cup

6. Clean the port with an alcohol swab 7. While compressing the bulb over the drainage container, replace the cap to close the port

8. Place the drainage system below the wound site 9. Assess the drainage, knowing its characteristic and volume

Types of Wound Drainage

10. Inspect the skin and change the dressing, following sterile technique

11. Secure with gauze sponges according to the physician or your preffered taping technique 12. Remind the patient to keep the drain lower than insertion site - whether he’s lying down, walking or sitting DRAIN REMOVAL 1. Check the doctor’s order 2. Ensure Privacy 3. Hand hygiene 4. Remove the dressing around the drainage

5. Relieve the suction by opening the drainage port Empty the drainage

6. Tell the patient that she may feel discomfort, a pulling sensation as the drain is removed - If the patient has a suture, clip and remove it 7. Grasp the drain and remove it gently & quickly Hold the Gauze over the wound - To prevent spraying of drainage 8. After immediately removal, use dressing to remove any remaining drainage around the wound or insertion site 9. Don new gloves before applying new sterile dressing - Cover the wound with 4x4 dressing and tape it in place

10. Instruct the patient to notify you if the dressing is saturated with drainage 11. Document IRRIGATING WOUNDS Equipment:  Irrigant or cleansing solution

       

Angiocatheter (for deep small wound irrigation) Waterproof underpad 4x4 gauze Sterile Gloves (if needed) Clean gloves Extra towels Speciment collection kit (if needed) Dressing Tray or supplies - gauze - cotton balls - forceps - waterproof biohazard bag - tray

PREPARATION 1. Check the physician’s order - for open wound irrigation & the type of solution to use 2. Assess the recent documentation of the patient’s wound - Related to S&S: wound size, fever, amount and consistenct of wound drainage, odor, color, results of culture, sensitivity testing, stage of wound healing and condition of the dressing 3. Pain Assessment 4. Assess the history of allergies - to antiseptics, tapes or dressing material

PROCEDURE 1. Hand hygiene 2. Ensure privacy by closing the door & closing the curtain 3. Check ID Band - Name, DOB & ID number 4. Explain the procedure what you’re doing 5. Adjust the bed into working height 6. Position the patient comfortably, so that the irrigating solution can flow into the basin 7. Expose only the wound 8. Place a waterproof pad under the patient 9. Place a towel on top of the pad

10. Place the basin parallel to the wound

11. Place the waterproof biohazard bag near the wound 12. Don PPE (gown, goggles, gloves)

13. Remove the dressing - Touch the skin, so there won’t be too much pressure during removal or tape/ dressing 14. Assess the drainage on the dressing 15. Discard the dressing & gloves into 16. Skin & Wound Assessment COLOR: red, purple, ecchymosis TEMP: cool or warm to touch TEXTURE: dry, moist, thin or leathery INTEGRITY: tears, blisters, wound, pressure injury

17. A. WIDE WOUND IRRIGATION

a. b. c. d. e. f. g. h. i. j.

Prepare the equipment & Sterile supplies (kit) Don Gloves Use irrigating solution using a syringe Flush the wound with continuous pressure 1 inch of distance above end of the wound Repeat the process until the drainage become clear in the basin Dry the wound edge with gauze If ordered, obtain a specimen for culture & sensitivity testing Dress the wound Follow up care - assess the patient for signs of discomfort - Inspect the dressing regularly

17. B. DEEP WOUND IRRIGATION but a small opening wound - Attach a soft angiocatheter to irrigating syringe

a. b. c. d.

Gently insert the catheter tip ½ inch into the wound Flush the wound using continuous pressure To prevent splashing, work slowly and gently Use Gauze pad to catch the drainage - it’s more effective since the wound is higher from the basin

e. f. g. h. i.

Repeat the process until the solution in the basin is clear Dry the wound edges with gauze If ordered, obtain a specimen for culture and sensitivity testing Dress the wound Follow up care - assess the patient for signs of discomfort - Inspect the dressing regularly

17 C. WOUND CLEANSING WITH HANDHELD SHOWER

a. Make sure patient comfortably sitting in a shower chair b. Adjust the water temperature into warm - If needed, cover it with washcloth c. Hold the shower about 12 inches above the wound d. Cleanse it for 5-10 mins e. Dry the wound edges with gauze f. If ordered, obtain a specimen for culture and sensitivity testing g. Dress the wound h. Follow up care - assess the patient for signs of discomfort - Inspect the dressing regularly - Pain assessment, rate on a scale of 0 out of 10

SURGICAL STAPLE REMOVAL - Some patients get surgical staple removed when they’re discharged or - Have their first post-op visit 1. Confirm first by checking the physician’s order - NOTE: some physicians just want to remove every other staple while some physicians want to remove all of them 2. Ensure Privacy - By closing the door & curtain 3. Hand hygiene 4. Don Gloves 5. Check ID band (check for allergies) 6. Explain what procedure you’re doing

- remind that may feel pain or no pain, tugging or feeling at the surgical site - give PRN pain medication before the procedure 7. Skin & Pain assessment - There should be NO REDNESS & BLEEDING, SIGNS OF INFECTION - if yes, let the physician know

8. Remove old dressing 9. Gather supplies - Dressing Change tray - Staple removal kit - Sterile gloves - Steri-strips (if needed; depends on the physician’s order) - it is used after removing the staples

10. Hand hygiene 11. Don sterile gloves (depends on the facility protocol; some say to wear clean gloves) 12. Clean the skin surrounding the surgical site with antiseptic solution - Clean along the incision line - to decrease risk of infection - One continuous way - Use 1 swab at a time then discard it

13. Let the area dry

14. If all staples have to be removed, remove every other staple - Start with the second staple - to prevent open up prematurely 15. Put gauze beside the patient, and dispose the suture there 16. Use staple remover - The curve part, placed that underneath the staple - Gently epress the handle, but DON’T pull up on the staple - Repeat (every other staple) 17. Clean the surrounding area 18. Put steri-strips in between the staples - Gently smoothen it

19. Remove the remaining staples

20. Clean the area 21. Put steri-strips on the spaces

22. Doff gloves 23. Hand hygiene 24. Document - Number of staples removed - characteristics of wound site - Patient response 25. Evaluate

SURGICAL SUTURE REMOVAL - As known as STITCHES - Sutures used to close the wound that caused by injury or a surgical procedure - SIMPLE INTERRUPTED SUTURE - MOST COMMON SUTURE

1. Verify the physician’s order 2. Check previous wound or dressing chart 3. Gather equipment - Dressing change tray - Suture removal kit - Steri-strip Tweezers – to hold the suture while cutting the suture Scissors – to remove / cut suture Gauze – to keep the sutures in placed Steri-strips – to prevent wound open up prematurely

4. 5. 6. 7. 8. 9.

Go to patient’s room Hand Hygiene Don gloves Ensure Privacy Check ID band Explain the procedure and get patient’s consent

- there’s tugging and pulling sensation - Give PRN pain medication, then do it after 30 mins. 10. Remove old dressing 11. Skin assessment - Redness, signs of infection, looks weak, foul looking drainage - if YES, don’t remove the suture & call the physician 12. Gather supplies at the beside - Side where your dominant hand is

13. Hand hygiene 14. Don sterile gloves (depends on the facility protocol; some say to wear clean gloves) 15. Clean the surrounding area of the wound

16. Let it dry 17. Put gauze beside the patient, and dispose the suture there 18. Use tweezer with NON-DOMINANT HAND Use Scissor with DOMINANT HAND 19. Remove every other suture - To prevent the wound open up prematurely - NOTE: DON’T pull up the thread, it will cause tension to open the wound Remove every other suture 1. TWEEZER: Grab the knot 2. SCISSOR: Cut the thread (beneath the knot) 3. TWEEZER: Lift up & remove the thread by 4. TWEEZER: Discard the thread into the gauze

20. Clean it with Antiseptic solution 21. Put steri-strip 22. Repeat the procedure 23. Doff gloves 24. Hand hygiene 25. Document - Number of staples removed - characteristics of wound site - Patient response 26. Evaluate CLEANING A DRAIN...