Wound Care and Sterile Technique

Wound Care and
Sterile Technique
Skin Assessment, Risk - Braden Scale
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shear
Assessment of Wounds
Appearance: size, healing – Bates-Jensen Wound assessment tool
Intentional vs unintentional
Character of drainage: serous, sanguineous, serosanguineous,
purulent
Tunneling/undermining
Drains/Tools – Jackson Pratt, Penrose drains, VAC dressings
Palpation of wound
Pain
Types of Drainage
Undermining
• Opening wound underneath the lip of the border – poor
healing
• MEDIUM_268_2009_24_Fig1_HTML
Tunnelling
• Tunnels develop which can connect the wound to other
organs – similar to fistulas
http://www.cytomedix.com/
Jackson Pratt
Penrose Drain
Vac Dressings
Wound care
1. Cleansing
2. Irrigation
3. Debridement
4. Dressings
5. Drains
6. Surgery
Wound care
cleansing, irrigation, packing
Wound Irrigation
• Used to improve wound healing

• Removes debris, cleanses the wound of exudate and
facilitates healing by secondary intention
• Useful for deep open wounds
• Assess patient needs for pain medication prior to wound
irrigation
• Position client comfortably to permit gravitational flow of
irrigating solution through the wound and into a collection
receptacle
Wound Irrigation
• Irrigant may be sterile saline solution, saline solution, tap

water
• Apply appropriate PPE
• Use a 30ml - 35ml syringe with the appropriate solution
• Attach a 19 gauze needle or angiocatheter to the syringe
(this allows for the solution to flow at a safe pressure
which will not damage healing wound tissue)
• Syringe tip is held 2cm - 2.5cm above the upper part of
the wound and the solution allowed to flow by gravity
Wound Irrigation
• Ensure the tip of the syringe does not become contaminated
by touching the wound
• Use a continuous pressure to flush the wound until the
solution in the drainage basin is clear - clear solution
indicates that all debris has been removed
• Irrigation will take longer with smaller wound openings
• Following wound irrigation pack the wound and apply a
dressing
• Document your findings
Packing a Wound
• Purpose - Used to prevent the wound from
healing over and ensure healing from the base up
• Dressing is changed frequently so that the gauze
doesn’t dry out and damage the wound base
• Pack to the level of the wound, not to tightly,
avoid maceration of the surrounding skin
• Simple gauze most commonly used for packing,
i.e. 2x2, 4x4, ribbon gauze
Packing a Wound
• Prior to wound dressing change check

order/nursing care plan for instructions on
irrigation, packing amount/type, dressing type
Packing a Wound
Dressings - Purpose
• Protect wound from micro-organisms
• Aids in hemostasis
• Promotes healing by absorbing drainage and supports autolytic
debridement
• Supports/Splints wound (protects from trauma)
• Protects client from seeing the wound
• Maintains moist environment
Dressing Changes
• Administer required analgesic
• Discuss procedure with client
• Gather all necessary supplies
• Remove old dressing, assess area
• Prepare sterile field, as indicated
• Provide necessary care using appropriate aseptic
technique
• Obtain feedback from client regarding procedure and
answer any client question
• Document care provided
Dressings-Types
• Gauze – usually for wounds with moderate discharge or for
packing wounds, most commonly used dressing type
• Telfa – usually used for burns, does not stick
• Transparent – protection for closed wounds
• Hydrocolloid & Hydrogel- Debridement, supports moist
environment – usually used for pressure ulcers, partial and full-
thickness wounds
• Foam/alginate – For wounds with excessive discharge
• Silver alginate – antimicrobial properties, used for infected
wounds
Tissue Debridement
• Sharp: instrument, scalpel

• Mechanical: whirlpool bath, wound irrigation
• Wet to dry dressings (check hospital policy or
MD orders)
• Chemical or Enzymatic: topical enzymes to
break down devitalized tissue
• Autolytic: synthetic dressing to cover wound and
allow eschar to self digest by enzymes in the
wound
• Maggots
Obtaining a Culture
• Never collect a wound culture from an old drain
• Clean wound first with normal saline
• Swab from healthiest looking tissue to obtain results consistent
with infectious condition of wound
Method for Cleansing a Drain Site
Principles of Sterile Technique
• A sterile object remains sterile only when touched by another
sterile object
• Only sterile objects may be placed in a sterile field
• A sterile object or field out of the range of vision or an object
held below a person’s waist is contaminated
• A sterile object or field becomes contaminated by prolonged
exposure to air
• When a sterile surface comes in contact with a wet,
contaminated surface, the sterile object or field becomes
contaminated by capillary action
Principles of Sterile Technique
• Fluid flows in the direction of gravity
• The edges of a sterile field or container are considered to be
contaminated (2.5 cm border)
Preparing the Sterile Field
• Open sterile packages on flat surface
• Do not use sterile packaging if packaging is damaged
• Open outer flap AWAY from body
• Sterile field (usually the drape sterile package is wrapped in) is
an area free of microorganisms that is prepared to receive
sterile items
• To pour sterile solutions into sterile field hold bottle with label
in palm, pour out a small amount to clean lip of the bottle, keep
edge of the bottle away from the receiving container, pour
solutions slowly to avoid splashing
Donning & Removing Sterile Gloves
• Perform hand hygiene
• Glove dominant hand first
• Pull second glove over nondominant hand being careful not to
allow fingers and thumb of gloved dominant hand to touch any
part of exposed nondominant hand
• After second glove is on, interlock hands
• Cuffs usually fall down after application
• To remove sterile gloves grasp outside of one cuff with other
gloved hand, avoid touching wrist, pull glove off turning inside
out, discard then remove other glove by tucking bare hand
inside remaining glove and peeling off

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Wound Care and

• Used to improve wound healing

• Irrigant may be sterile saline solution, saline solution, tap

• Prior to wound dressing change check

• Sharp: instrument, scalpel

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