WOUND CARE

OBJECTIVES y At the end of the clinical exposure, the student will be able to identify specific procedures related to wound care y At the end of the clinical exposure, the student will be able to demonstrate how the two specific procedures are accomplished PROCEDURE FOR REMOVING SKIN STAPLES OR SUTURES:  Staples and sutures may be removed just prior to discharge  With short stays after surgery, they may be removed at a subsequent ambulatory care visit  Removal of sutures or staples may produce a pinching or pulling sensation but does not usually cause pain. If pain is present or anticipated based on the condition of the wound, give the patient the ordered pain relief medication about 30 minutes before the procedure is to be performed. ASSESSMENT 1. Check the doctors order 2. Examine the current dressing 3. Check the patients unit for dressing supplies DIAGNOSIS Critically think through your data. Carefully evaluate each aspect and its relation to other data. Identify specific problems and modifications of the procedure needed for this individual. PLANNING      

Patient understand the purpose of the procedure and can cooperate The wound shows evidence of healing Skin staples were removed without adverse outcomes There is no evidence of infection in the wound Dressing is securely in place Patient states he or she is comfortable after the procedure

IMPLEMENTATION 1. Gather supplies for changing the dressing and cleaning around the wound and also obtain a dressing set that include a sterile pair of suture scissors or the package with a sterile remover 2. Loosen tape 3. Put on clean gloves 4. Remove and discard the dressing 5. Wash or disinfect your hands, and observe the wound 6. Change the dressing as appropriate based on the procedure for OPEN WOUND: Put on sterile gloves, and clean around the wound and the drain as appropriate. 7. After cleaning, remove the staples or sutures as follows: SUTURE a. If the patients wound has been closed with sutures, gently lift each suture away from the skin with the pick-up forceps b. Then snip the suture close to the skin c. Pull out by pulling in line with the suture that is still inside the tissue, so as not to traumatize the tissue at the suture exit site d. Remove every other suture first to determine whether the wound will remain closed (RATIONALE: Clipping close to the skin ensures that the

suture material that was outside the tissue is not pulled inside, which could contaminate the wound) e. Then remove the remaining sutures STAPLES a. Slide the lower jaw of the staple remover under the staple. b. Lift the staple up and squeeze the handles closed to exert pressure on the center of the staple (RATIONALE: This motion raises the ends of the staple up and out of the tissue, allowing you to remove the staple easily) c. Remove every other staple first to determine whether the wound will remain closed. d. Remove the remaining staplers e. Apply commercially available sterile strips (Steri-strips) as ordered or if included in the procedure at your facility (RATIONALE: Steri-Strips are usually used to provide extra support for holding the wound edges together after suture or staple removal) f. Place a simple dry dressing over the wound if indicated (RATIONALE: To protect the wound) 8. Remove gloves and place with the soiled dressings 9. Secure the dressing 10. Assist the patient into a comfortable position 11. Lower the bed 12. Put on clean gloves 13. Care of equipment 14. Dispose of gloves 15. Wash or disinfect your hands EVALUATION      

Patient understand the purpose of the procedure and is able to cooperate The wound shows evidence of healing Skin staples or sutures were removed without adverse reactions There is no evidence of infection in the wound Dressing is securely in place Patient states he or she is comfortable after the procedure

DOCUMENTATION  The procedures are recorded in the clients record, including the time the procedure was performed, the observations of the wound, dressing materials, cleaning solution used, and patients knowledge and comfort *