Saturday, 23 October 2010


When caring for a surgical wound, you carry out procedures that help prevent infection by stopping pathogens from entering the wound. Besides promoting patient comfort, such procedures protect the skin surface from maceration and excoriation caused by contact with irritating drainage. They also allow you to measure wound drainage to monitor fluid and electrolyte balance.
The two primary methods used to manage a draining surgical wound are dressing and pouching. Dressing is preferred unless caustic or excessive drainage is compromising your patient's skin integrity. Usually, lightly seeping wounds with drains and wounds with minimal purulent drainage can be managed with packing and gauze dressings. Some wounds, such as those that become chronic, may require an occlusive dressing.
A wound with copious, excoriating drainage calls for pouching to protect the surrounding skin. If your patient has a surgical wound, you must monitor him and choose the appropriate dressing.
Dressing a wound calls for sterile technique and sterile supplies to prevent contamination. You may use the color of the wound to help determine which type of dressing to apply. (See Tailoring wound care to wound color, page 188.) Be sure to change the dressing often enough to keep the skin dry. Always follow standard precautions set by the Centers for Disease Control and Prevention (CDC).
Waterproof trash bag • clean gloves • sterile gloves • gown and face shield or goggles, if indicated • sterile 4″ × 4″ gauze pads • large absorbent dressings, if indicated • sterile cotton-tipped applicators • sterile dressing set • povidone-iodine swabs • topical medication, if ordered • adhesive or other tape • soap and water • optional: forceps; skin protectant; nonadherent pads; collodion spray or acetone-free adhesive remover; sterile normal saline solution; graduated container; and Montgomery straps, a fishnet tube elasticized dressing support, or a T-binder.
For a wound with a drain
Sterile scissors • sterile 4″ × 4″ gauze pads without cotton lining • sump drain • ostomy pouch or another collection bag • sterile precut tracheostomy pads or drain dressings • adhesive tape (paper or silk tape if the patient is hypersensitive) • surgical mask.
For pouching a wound
Collection pouch with drainage port • sterile gloves • skin protectant • sterile gauze pads.
Preparation of equipment
Ask the patient about allergies to tapes and dressings. Assemble all equipment in the patient's room. Check the expiration date on each sterile package, and inspect for tears.
Open the waterproof trash bag, and place it near the patient's bed. Position the bag to avoid reaching across the sterile field or the wound when disposing of soiled articles. Form a cuff by turning down the top of the trash bag to provide a wide opening and to prevent contamination of instruments or gloves by touching the bag's edge.
  • Explain the procedure to the patient to allay his fears and ensure his cooperation.
Removing the old dressing
  • Check the physician's order for specific wound care and medication instructions. Note the location of surgical drains to avoid dislodging them during the procedure.
  • Assess the patient's condition.
  • Identify the patient's allergies, especially to adhesive tape, povidone-iodine or other topical solutions, or medications.
  • Provide privacy, and position the patient as necessary. To avoid chilling him, expose only the wound site.
  • Wash your hands thoroughly. Put on a gown and a face shield, if necessary. Then put on clean gloves.
  • Loosen the soiled dressing by holding the patient's skin and pulling the tape or dressing toward the wound. This protects the newly formed tissue and prevents stress on the incision. Moisten the tape with acetone-free adhesive remover, if necessary, to make the tape removal less painful (particularly if the skin is hairy). Don't apply solvents to the incision because they could contaminate the wound.
  • Slowly remove the soiled dressing. If the gauze adheres to the wound, loosen the gauze by moistening it with sterile normal saline solution.
  • Observe the dressing for the amount, type, color, and odor of drainage.
  • Discard the dressing and gloves in the waterproof trash bag.
Caring for the wound
  • Wash your hands. Establish a sterile field with all the equipment and supplies you'll need for suture-line care and the dressing change, including a sterile dressing set and povidone-iodine swabs. If the physician has ordered ointment, squeeze the needed amount onto the sterile field. If you're using an antiseptic from an unsterile bottle, pour the antiseptic cleaning agent into a sterile container so you won't contaminate your gloves. Then put on sterile gloves. (See How to put on sterile gloves.)
  • Saturate the sterile gauze pads with the prescribed cleaning agent. Avoid using cotton balls because they may shed fibers in the wound, causing irritation, infection, or adhesion.
  • If ordered, obtain a wound culture; then proceed to clean the wound.
  • Irrigate the wound, if ordered, using the specified solution.
  • Pick up the moistened gauze pad or swab, and squeeze out the excess solution.
  • Working from the top of the incision, wipe once to the bottom and then discard the gauze pad. With a second moistened pad, wipe from top to bottom in a vertical path next to the incision (as shown below).
  • Continue to work outward from the incision in lines running parallel to it. Always wipe from the clean area toward the less clean area (usually from top to bottom). Use each gauze pad or swab for only one stroke to avoid tracking wound exudate and normal body flora from surrounding skin to the clean areas. Remember that the suture line is cleaner than the adjacent skin and the top of the suture line is usually cleaner than the bottom because more drainage collects at the bottom of the wound.
  • Use sterile, cotton-tipped applicators for efficient cleaning of tight-fitting wire sutures, deep and narrow wounds, and wounds with pockets. Because the cotton on the swab is tightly wrapped, it's less likely than a cotton ball to leave fibers in the wound. Remember to wipe only once with each applicator.
  • If the patient has a surgical drain, clean the drain's surface last. Because moist drainage promotes bacterial growth, the drain is considered the most contaminated area. Clean the skin around the drain by wiping in half or full circles from the drain site outward.
  • Clean all areas of the wound to wash away debris, pus, blood, and necrotic material. Try not to disturb sutures or irritate the incision. Clean to at least 1″ (2.5 cm) beyond the end of the new dressing. If you aren't applying a new dressing, clean to at least 2″ (5 cm) beyond the incision.
  • Check to make sure the edges of the incision are lined up properly, and check for signs of infection (heat, redness, swelling, induration, and odor), dehiscence, and evisceration. If you observe such signs or if the patient reports pain at the wound site, notify the physician.
  • Wash skin surrounding the wound with soap and water, and pat dry using a sterile 4″ × 4″ gauze pad. Avoid oil-based soap because it may interfere with pouch adherence. Apply any prescribed topical medication.
  • Apply a skin protectant, if needed.
  • If ordered, pack the wound with gauze pads or strips folded to fit, using a sterile forceps. Avoid using cotton-lined gauze pads because cotton fibers can adhere to the wound surface and cause complications. Pack the wound, using the wet-to-damp method. Soaking the packing material in solution and wringing it out so that it's slightly moist provides a moist wound environment that absorbs debris and drainage. However, removing the packing won't disrupt new tissue. Don't pack the wound tightly; doing so will exert pressure and may damage the wound.
Applying a fresh gauze dressing
  • Gently place sterile 4″ × 4″ gauze pads at the center of the wound, and move progressively outward to the edges of the wound site. Extend the gauze at least 1″ (2.5 cm) beyond the incision in each direction, and cover the wound evenly with enough sterile dressings (usually two or three layers) to absorb all drainage until the next dressing change. Use large absorbent dressings to form outer layers, if needed, to provide greater absorbency.
  • Secure the dressing's edges to the patient's skin with strips of tape to maintain the sterility of the wound site (as shown on page 191). Or secure the dressing with a T-binder or Montgomery straps to prevent skin excoriation, which may occur with repeated tape removal necessitated by frequent dressing changes. (See How to make Montgomery straps.)
  • Make sure the patient is comfortable.
  • Properly dispose of the solutions and trash bag, and clean or discard soiled equipment and supplies according to your facility's policy. If your patient's wound has purulent drainage, don't return unopened sterile supplies to the sterile supply cabinet because this could cause cross-contamination of other equipment.

Dressing a wound with a drain
  • Use commercially precut gauze drain dressings or prepare a drain dressing by using sterile scissors to cut a slit in a sterile 4″ × 4″ gauze pad. Fold the pad in half; then cut inward from the center of the folded edge. Don't use a cotton-lined gauze pad because cutting the gauze opens the lining and releases cotton fibers into the wound. Prepare a second pad the same way.
  • Gently press one drain dressing close to the skin around the drain so that the tubing fits into the slit. Press the second drain dressing around the drain from the opposite direction so that the two dressings encircle the tubing.
  • Layer as many uncut sterile 4″ × 4″ gauze pads or large absorbent dressings around the tubing as needed to absorb expected drainage. Tape the dressing in place, or use a T-binder or Montgomery straps.
Pouching a wound
  • If your patient's wound is draining heavily or if drainage may damage surrounding skin, you'll need to apply a pouch.
  • Measure the wound. Cut an opening 3/8″ (1 cm) larger than the wound in the facing of the collection pouch (as shown below).

  • Apply a skin protectant as needed. (Some protectants are incorporated within the collection pouch and also provide adhesion.)
  • Make sure the drainage port at the bottom of the pouch is closed firmly to prevent leaks. Then gently press the contoured pouch opening around the wound, starting at its lower edge, to catch any drainage (as shown below).
  • To empty the pouch, put on gloves and a face shield or mask and goggles to avoid any splashing. Then insert the pouch's bottom half into a graduated biohazard container, and open the drainage port (as shown below). Note the color, consistency, odor, and amount of fluid. If ordered, obtain a culture specimen and send it to the laboratory immediately. Remember to follow the CDC's standard precautions when handling infectious drainage.
  • Wipe the bottom of the pouch and the drainage port with a gauze pad to remove any drainage that could irritate the patient's skin or cause an odor. Then reseal the port. Change the pouch only if it leaks or fails to adhere. More frequent changes are unnecessary and only irritate the patient's skin.

Special considerations
  • If the patient has two wounds in the same area, cover each wound separately with layers of sterile 4″ × 4″ gauze pads. Then cover each site with a large absorbent dressing secured to the patient's skin with tape. Don't use a single large absorbent dressing to cover both sites because drainage quickly saturates a pad, promoting cross-contamination.
  • When packing a wound, don't pack it too tightly because this compresses adjacent capillaries and may prevent the wound edges from contracting. Avoid overlapping damp packing onto surrounding skin because it macerates the intact tissue.
  • To save time when dressing a wound with a drain, use precut tracheostomy pads or drain dressings instead of custom-cutting gauze pads to fit around the drain. If your patient is sensitive to adhesive tape, use paper or silk tape because it is less likely to cause a skin reaction and peels off more easily than adhesive tape. Use a surgical mask to cradle a chin or jawline dressing; this provides a secure dressing and avoids the need to shave the patient's hair.

  • If ordered, use a collodion spray or similar topical protectant instead of a gauze dressing. Moisture- and contaminant-proof, this covering dries in a clear, impermeable film that leaves the wound visible for observation and avoids the friction caused by a dressing.
  • If a sump drain isn't adequately collecting wound secretions, reinforce it with an ostomy pouch or another collection bag. Use waterproof tape to strengthen a spot on the front of the pouch near the adhesive opening; then cut a small “Xâ€� in the tape. Feed the drain catheter into the pouch through the “Xâ€� cut. Seal the cut around the tubing with more waterproof tape; then connect the tubing to the suction pump. This method frees the drainage port at the bottom of the pouch so you don't have to remove the tubing to empty the pouch. If you use more than one collection pouch for a wound or wounds, record drainage volume separately for each pouch. Avoid using waterproof material over the dressing because it reduces air circulation and promotes infection from accumulated heat and moisture.
  • Because many physicians prefer to change the first postoperative dressing themselves to check the incision, don't change the first dressing unless you have specific instructions to do so. If you have no such order and drainage comes through the dressings, reinforce the dressing with fresh sterile gauze. Request an order to change the dressing, or ask the physician to change it as soon as possible. A reinforced dressing shouldn't remain in place longer than 24 hours because it's an excellent medium for bacterial growth.
  • For the recent postoperative patient or a patient with complications, check the dressing every 15 to 30 minutes or as ordered. For the patient with a properly healing wound, check the dressing at least once every 8 hours.
  • If the dressing becomes wet from the outside (for example, from spilled drinking water), replace it as soon as possible to prevent wound contamination.
  • If your patient will need wound care after discharge, provide appropriate teaching. If he'll be caring for the wound himself, stress the importance of using aseptic technique, and teach him how to examine the wound for signs of infection and other complications. Also show him how to change dressings, and give him written instructions for all procedures to be performed at home.
A major complication of a dressing change is an allergic reaction to an antiseptic cleaning agent, a prescribed topical medication, or adhesive tape. This reaction may lead to skin redness, rash, excoriation, or infection.
  • NURSING ALERT Take care when removing adhesive tape to prevent skin tears, especially in elderly patients.
Document the date, time, and type of wound management procedure; amount of soiled dressing and packing removed; wound appearance (size, condition of margins, presence of necrotic tissue) and odor (if present); type, color, consistency, and amount of drainage (for each wound); presence and location of drains; additional procedures, such as irrigation, packing, or application of a topical medication; type and amount of new dressing or pouch applied; and the patient's tolerance of the procedure.
Document special or detailed wound care instructions and pain management steps on the care plan. Record the color and amount of drainage on the intake and output sheet.