Wound Dressing Maintenance

Guidelines:

• Postoperative SSIs are a common and serious complication
• Affects 2%-5% of the 30-40 million individuals undergoing surgery annually in the United States
• Are the second most commonly reported HAI.
• Patients with SSIs have markedly higher mortality rates, increased lengths of stay, increased hospital readmission rates, and
  increased direct patient costs
• The patient’s normal flora is the most common reservoir of microorganisms
• Dressings cover the wound, absorb drainage, apply pressure, and provide a moist environment for healing.

Considerations:

• Wound Classifications (CDC)
  • Clean wounds (Class I)
    • ◆Uninfected, no inflammation, respiratory, alimentary, and GU tracts are not entered. Closed with primary suture line. If required, can be drained using a closed wound drainage system. Example: breast biopsy, total hip replacement, open heart surgery
  • Clean Contaminated Wounds (Class II)
    • Respiratory, alimentary, or GU tract is entered under controlled conditions. No sign of infection, no break in surgical aseptic technique. Examples: non perforated appendectomy, hysterectomy, thoracotomy.
  • Contaminated Wounds (Class III)
    • Open, fresh, accidental wounds, such as penetrating trauma, open fractures, or operations with major breaks in aseptic technique. Incisions with signs of infection or gross spillage from the GI tract are included. Examples: penetrating abdominal trauma involving bowel, gunshot wound to abdomen.
  • Dirty or Infected Wounds (Class IV)
    • Old, physically induced wounds with retained devitalized tissue and wounds that involve an existing clinical infection or perforated viscera. Examples: Excision and drainage of abscess, delayed primary closure after appendectomy for ruptured appendix

Nurse’s role:

• Assessment
  • Patient’s susceptibility for infection
• Nursing Diagnosis
  • Risk for infection, risk for impaired skin  integrity, imbalanced nutrition: less than body requirements, ineffective peripheral tissue perfusion, risk for perioperative hypothermia.
• Outcome Identification
  • Prevent wound infections and promote healing
• Planning
  • Anticipate administration of prophylactic antibiotic 1 hr prior to incision
  • Review surgeon preference card, have appropriate dressings available
  • Ensure appropriate positioning devices are readily available
• Implementation
  • Educate patient/family on what to expect for wounds, dressings, drains, or lines after surgery
  • Implements and monitors sterile technique
  • Protects the patient from cross-contamination
  • Collaborates in administration of antibiotic prophylaxis
  • Control the environment of care: normothermia, decreased traffic
  • Collaborate in controlling perioperative serum glucose levels
  • Maintaining skin integrity through proper positioning
  • Apply surgical dressings when required
  • Ensure proper hand hygiene and PPE prior to applying surgical dressings
  • Document the location/type of dressing, drains, or lines
  • Include information in hand-off report

Pitfalls:

• Wound dressing disadvantages:
  • Patient discomfort
  • Patient anxiety
  • Patient dissatisfaction
  • Inability to visualize surgical wound
• Wound drain disadvantage:
  • Create a portal for entry and exit of infectious microorganisms
  • Extreme care must be taken in emptying drain reservoirs to avoid contamination

Examples:

• Questions to ask when choosing a dressing:
  • What does the wound need
  • What is the purpose of the product
  • How well does the product function? Is there evidence to support the use of the product
  • What does the patient need?
  • What is available?
  • What is practical? Is it also cost-effective?

Linchpins (Key Points):

• Principles of infection control and prevention
• Aseptic Technique
• Skin Antisepsis
• Wound Classification