667
CHAPTER 32 Skin Integrity & Wound Healing
■ Assess the tissue surrounding the wound edge. Surrounding tissue that is red, warm, and/or edematous may indi- cate infection. ■ Determine the type of dressing needed. The type of dressing depends on the characteristics of the wound and the goal of treatment. Dry dressings are appropriate when
there is no need to keep the wound bed moist, such as a wound healing by primary intention or a wound covered by eschar. Removing a dry dressing can also interfere with wound healing by disrupting granulation tissue and can cause pain to the patient.
➤ When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation. Applying Dry Dressing 13. Perform hand hygiene . 14.Open sterile gauze packages Removing the Dressing 1. Place the patient in a comfortable position that provides easy access to the wound.
6.Dispose of the soiled dressing and gloves in a biohazard receptacle. Soiled dressings contain body fluids and other contaminants and should be dis- posed of as biohazardous waste. 7. Remove the cover of a tray of sterile 4 in. × 4 in. gauze. Moisten the gauze with sterile saline. The sterile container tray is impermeable and allows you to moisten the gauze while maintaining sterility. Gauze will not shed fibers into the wound (as do cot- ton balls). Fibers and any other foreign bodies in a wound promote inflammation and delay healing. 8. Don clean nonsterile gloves. 9. Gather a gauze pad by pulling the four corners up toward the middle. Use the center ball of the gauze to cleanse the wound. Forming a ball with the gauze pads pre- vents contamination of gloved hands during cleansing. 10.Gently cleanse the wound with the saline-moistened gauze by lightly wiping a section of the wound from the center toward the wound edge. Discard the gauze in a biohazard receptacle and repeat in the next section using a new piece of gauze with each wiping pass. Removes surface bacteria and exudate. 11.Discard the gloves and soiled gauze in a biohazard bag. 12. Reassess wound for size, color of tissue present, amount and type of exudate, and odor.
on a clean, dry surface. Maintains sterility of gauze.
Provides for patient comfort and proper nurse body mechanics during dressing change. 2. Perform hand hygiene and don nonsterile procedure gloves. Hand washing is one of the most import- ant measures for preventing infection transmission. 3. Gently loosen the edges of the tape of the old dressing at an angle parallel to the skin. a. Hold that edge with one hand and gently raise the edge until it is taut but not pulling on the skin. b.Using your other hand, push down on the exposed skin at the point where the tape and skin meet. Push the skin from the tape. Adhesive remover pads are advised to help prevent tearing of fragile skin. The pull–push method will help pre- vent skin stripping from the adhe- sive and reduce discomfort and skin trauma as you remove the tape. 4.Beginning at the edges of the dressing, lift the dressing toward the center of the wound. If the dressing sticks, moisten it with normal saline before removing it completely. Moistening the dressing decreases the risk of bleeding and/or removal of granulating tissue. 5. Assess the type and amount of drainage on the soiled dressing. Allows for evaluation of wound healing. Purulent drainage is an indication of infection.
15.Don nonsterile procedure gloves. 16. Apply a layer of dry dressings over the wound. If drainage is expected, use an additional layer of dressings. The first layer serves as a wick for drain- age.A second layer is needed if increased absorption is required. 17. Place strips of tape at the ends of the dressing and evenly spaced over the remainder of the dress- ing. Use strips that are sufficiently long to secure the dressing in place. Tape the dressing around all edges, “window-paning,” if appropriate. Edges remain taped down and dressing stays intact. 18. Remove gloves and discard them in a biohazard receptacle. 19. Assist the patient to a comfort- able position.
(continued on next page)
79
Powered by FlippingBook