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What is the purpose of simple dsg?
- Protect wound from mechanical injury
- Protect wound from microbial contamination
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What should dsg be?
- Conform to the body
- Durable yet flexible- don't restrict ROM, how much tape, how do we secure?
- Absorb or contain exudate
- Cost effective
- Easily removed without damage to healing surface
- Different dsg types depending on wound and goal of wound management
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Dry sterile dsg heals by...
primary intention
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What does sterile dsg protect?
Protects wounds from injury
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What does sterile dsg prevent?
Prevents introduction of bacteria
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Dry sterile dsg reduces...
discomfort
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What kind of dsg speeds up healing?
Dry sterile dsg
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Complex dsg heals by...
secondary and tertiary healing
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Which pts are at risk for latex allergies?
- pts with congenital or urinary defects
- repeated catherizations or surgeries
- history of condom catheters
- multiple childhood surgeries
- certain food allergies: bananas, tomatoes, potatoes, avocadoes, kiwis
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What is the first thing we do before dsg change?
Assess pt's comfort (ex. BRP, premedicate for pain)
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List the steps to dsg change.
- Assess pt's comfort
- Explain procedure to pt
- Ensure privacy
- Position pt for procedure in comfortable position
- Obtain supplies
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This is known as "clean technique", reduces number of pathogens, used for meds, enemas, tube feedings, daily hygiene, handwashing is #1...this known as?
Medical Asepsis
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This eliminates ALL pathogens, known as "sterile technique", used for dsg change, catherizations, surgical procedures. What is this known as?
Surgical Asepsis
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How long does a bottle of saline last? What should we always do with an open bottle?
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What should we do when preparing a sterile field?
Clean over bed table. Make sure it's dry, clean, flat
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For Validation what equipment do we need for dry sterile dsg?
- Clean gloves
- Sterile gloves
- 2 packages of 4x4
- Normal saline
- Tape
- Plastic bag for trash
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How do we remove the tape from the dsg of the wound? Once we remove tape what should we do?
Pulling toward dsg using counter pressure, and assess the tape sites
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What do we look for when assessing the wound?
- Appearance
- Size
- Drainage
- Swelling
- Pain
- Status of any drains or tubes
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How do we clean surgical wounds?
- Start at cleanest area to dirtiest.
- Top to bottom
- Inside to outside
- Each stroke is a new gauze
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When taping a dsg over a joint what do we do?
Place the tape over the joint at a right angle to the direction the joint moves.
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Simple dsg are for...
Surgical or approximated wounds
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What are the purposes behind complex dsg?
- Provide and maintain moist wound healing
- Provide thermal insulation
- Absorb drainage or debride a wound or both
- Prevent hemorrhage (when applied as a pressure dsg or with elastic bandage)
- To splint or immobilize the wound site and thereby facilitate healing and prevent injury
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Why can't we delegate dsg change to a CNA?
RNs assess
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What are the goals of complex dsg?
- Removal of necrotic tissue
- Absorption of exudate
- Prevention or elimination of infection
- Provide a moist environment for healing
- Protect from further injury
- Protect surrounding tissue
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What do we assess when changing a complex dsg?
- Wound depth
- Wound size
- Wound bed (eschar or slough vs. granulation tissue)
- Drainage characteristics
- Signs of infection
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Assessment acronym
- A Anatomic location
- S size, shape
- S stage
- E exudate
- S surrounding skin
- S sinus tract, tunneling
- M margins
- E edges
- N nose (odor- indicates infection)
- T tissue
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What are the risk factors for infection?
- wounds with dead tissue
- wounds with decreased blood supply (comorbidity, pressure ulcer, peripheral artery disease)
- foreign bodies in or near wound
- anatomically at risk for contamination (bowel surgery)
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How do we choose our supplies for a complex dsg?
- Expected amt and type of drainage
- Goal of wound management (debridement, protection, pressure)
- Dry sterile dsg vs. Moisture retention
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Moisture Retention used for...
open clean wounds to promote granulation tissue
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What is the job of the wound care team?
- Improve pt outcomes for chronic wounds
- decrease cost of supplies
- decrease number of nursing visits
- early identification of pt needs
- facilitates continuity of pt care
- resource for EBN related to wound care
- EXPERTS!
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What kind of dsg is used for debridement?
Wet to dry dsg
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This dsg is moistened with normal saline, antiseptic, or antibacterial solution
Wet to Dry dsg
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This dsg absorbs exudate and debris as it dries
Wet to dry
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Do not moisten this dsg to remove.
Wet to Dry dsg
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This dsg requires frequent dsg changes, usually every 6 hrs
Wet to Dry
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This dsg is used when wound bed is clean and ready for healing
Wet to Damp
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This dsg protects fragile granulation.
Wet to Damp
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Moisten this dsg before removing if gauze adheres to wound bed
Wet to Damp
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This dsg is used when the wound bed is clean and ready for healing
Wet to Damp
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When packing a wound what do we do first?
Moisten packing material with noncytotoxic solution (normal saline)
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What do we use to pack a wound?
Fluffed gauze or ribbon gauze
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How do we pack the wound?
- Hold packing material in non-dominate hand and feed into wound with dominate hand or instrument
- Loosely pack in contact with all surfaces, no dead spaces
- No moist gauze in contact with intact skin
- Use Q-tip or instrument to pack small areas
- Never pack the wound higher than the wound surface
- Cover moist packing with dry gauze and ABD pad
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What should we remember to not do while packing the wound?
Do not touch surrounding skin with sterile packing as it is fed into the wound
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Where do we use Montgomery straps? When?
- Large abdominal area, thighs, back
- For frequent dsg changes
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"Pen rose drain" uses...
pre-cut gauze pads
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This specializes dsg is used for non-infected partial and full thickness wounds
Hydrogels (ex. Vigilon, Aquasorb)
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This specialized dsg is for dry to minimal exudate.
Hydrogels like Vigilon, Aquasorb
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This specialized dsg absorbs exudate
Alginates like Sorbsan, Algiderm
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This specialized dsg is used for partial thickness wounds
Transparent like Op-site, Tegaderm
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This specialized dsg is for autolytic debridement of eschar, used for partial and full thickness wounds
Hydrocolloids like Duoderm
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This specialized dsg is for absorption of minimal to moderate exudate
Hydrocolloids like Duoderm
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Wound irrigation is effective for...
- wound cleansing
- treatment for prevention of wound infection
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What kind of syringe and gauge do we use for wound irrigation? why?
- 35mL/19 gauge needle or angiocath
- Delivers between 4 and 15 PSI
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What do we do prior to obtaining a wound culture? Do we need sterile technique?
- Cleansing the wound
- No sterile technique
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What do we document for complex dsg?
- Specific date assessed
- Drainage
- Size
- Depth
- Undermining or tunneling
- Wound bed: red, yellow, black?
- Surrounding tissue appearance
- Treatment
- pt response to dsg change
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Surgical Asepsis is also known as...
- Sterile technique
- Aseptic technique
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Where is sterile technique commonly practiced?
OR, L&D, major diagnostic or procedural areas, also by bedside (Foley, dsg change)
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Sterile technique is also used during intentional perforation of skin like...
Injections or IV catheters
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Sterile technique is used when skin integrity is broken through...
- trauma
- surgical incison
- burns
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Sterile technique is used during procedures that involve insertion of...
catheters or instruments into sterile body cavities like urinary catheter (bladder is sterile) or laparoscopy
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What are some principles of surgical asepsis?
- Sterile object ONLY touches another sterile object
- If sterile object or sterile field is out of range of vision or held below waist then it is contaminated
- Never cough, sneeze, or laugh over sterile field
- Never reach over a sterile field, go around
- Never leave or turn your back on sterile field
- Do not open packages over sterile field
- If field becomes wet= contaminated
- 1" border of sterile field is considered contaminated
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"Strike through"
when sterile field becomes contaminated, liquid will "wick" up to sterile field (wicking)
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