Nurse Base

Neurologic Assessment and Deterioration in Pediatric Head Trauma

2011-07-18T05:48:00.000-07:00

Inspection for external trauma, such as scalp or facial swelling, abrasions, laceration, or ecchymosis, can indicate TBI. Palpable step-off or depression indicates skull fracture, which may be associated with contusion of the brain, laceration of the dura or brain, and cerebrospinal
fluid (CSF) leak. Significant scalp swelling in the infant may be indicative of hemorrhage, which can cause anemia with pallor and tachycardia. A basilar skull fracture at the base of the anterior fossa causes “raccoon’s eyes,” or periorbital ecchymoses and can be associated with rhinorrhea (CSF leak from the nares). Fracture in the base of the middle fossa causes “battle sign,” or postauricular ecchymoses, and can be associated with otorrhea (leak of CSF from the ear). Hemotympanum can indicate temporal or basilar skull fracture. Otorrhea indicates disruption of the tympanic membrane related to temporal skull fracture. The cervical spine must be immobilized and protected from spinal cord injury until radiographic clearance is accomplished. The entire spine is immobilized, inspected, and palpated for deformity, swelling, tenderness, and crepitance.

Every patient assessment must begin with evaluation of adequate airway, breathing, and circulation, which are vital to sustain life. A decreased level of consciousness (LOC) after TBI can interfere with protection of the pediatric airway. Inadequate ventilation results in hypercarbia and hypoxia, which cause vasodilation and secondary ischemic brain injury. Vasodilation and resultant ischemia contribute to further increases in ICP. Vital control centers located within the brainstem regulate respiratory and cardiac functions. Brainstem pathophysiology can be identified by changes in the vital signs. The following abnormal respiratory rate and patterns indicate neurologic dysfunction secondary to progressive brainstem compression as a result of increasing ICP:

1. Cheyne-Stokes: repeated cycles of breaths that gradually increase and decrease in rate and depth, followed by a respiratory pause – indicates bilateral hemispheric or diencephalic injury.
2. Central Neurogenic Hyperventilation: increased rate and depth of respirations – indicates midbrain/ upper pons injury.
3. Apneustic: a pause at full or prolonged (slow and deep) inspiration – indicates injury to the upper pons.
4. Ataxic: no pattern in rate or depth – indicates medulla or lower brainstem dysfunction with impending herniation; injury to the respiratory centers in the medulla (also known as agonal respirations).
5. Apnea: respirations cease.

The child’s LOC, and whether it is worsening or improving, is the most important indicator of neurologic status. The neurologically intact child is awake, alert, and responsive to his/her surroundings. Level of responsiveness varies with the developmental age of the child. Infants should respond to feeding and measures to console them. Toddlers and older children should recognize and respond to their parents. Older children and adolescents should be able to follow commands. Children of all ages should respond to and withdraw from painful stimulus. After neurologic injury, pediatric head-injured victims may have alteration in LOC, first subtly, becoming restless, disoriented, and confused. Further decreases in the LOC leads to somnolence (arouses to full consciousness and resumes sleep if not stimulated), lethargy (requires vigorous stimulation to arouse to full consciousness), stupor (nearly unconscious, may moan or withdraw from pain), and finally comatose (unresponsive). A worsening LOC suggests neurologic deterioration. Any subtle change from documented baseline, including parent’s concern that child is “not acting right,” must be taken seriously and reported to the physician.

Pediatric Anatomy and Physiology in Head Trauma

2011-07-08T05:41:00.000-07:00

The adage that “children are not just small adults” holds true when discussing pediatric head trauma. The pediatric craniocerebral anatomy increases the child’s vulnerability to head trauma as well as protects them against worsened severity or outcome. In general, children under the age of 2 years or who are nonverbal require a higher level of suspicion for injury, as the assessment is less revealing secondary to the child’s developmental age.

The physically larger and proportionately heavier pediatric cranium, together with the increased laxity of the cervical spine, create a fulcrum leading to an increased propensity for traumatic injury of the head and cervical spine. The skull consists of eight cranial bones, which are separated by sutures until around 18–24 months. Open cranial sutures are protective against gradual increases in intracranial pressure (ICP), for example as a result of tumors or hydrocephalus increased. Rapidly expanding mass lesions, however, are not tolerated and result increased ICP. The head circumference of infants should be measured and recorded on admission and daily, as a rapidly increasing head circumference is indicative of increased ICP. Presence of bulging or firm fontanels, with infant calm and in an upright posture, can also be an indicator of increased ICP. The infant’s skull is thinner, softer, and more deformable when fractured, but heals quickly after fracture due to accelerated bone growth.

The pediatric brain is softer due to a higher water content and less myelination. The subarachnoid space is wider. The thin pediatric skull, soft brain, and large subarachnoid space allow increased movement of the brain within the skull, which makes the child more susceptible to brain injury, including extraparenchymal hemorrhage, shearing or tearing of neuronal processes, and diffuse axonal injury.

Children have a smaller intracranial space in which smaller increases in volume produce exponentially larger increases in ICP. The pediatric skull can absorb a significant impact with little external evidence of significant intracranial injury. When evaluating the head-injured child, the nurse must consider all external indications such as bruising, swelling and lacerations, as well as the mechanism of injury and the degree of neurologic deficit.

impaired Walking

2011-06-16T04:18:00.000-07:00

Taxonomy II: Activity/Rest—Class 2 Activity/Exercise (00088)
[Diagnostic Division: Activity/Rest]
Submitted 1998
Definition: Limitation of independent movement within the environment on foot

Related Factors
To be developed
[Condition affecting muscles/joints impairing ability to walk]

Defining Characteristics
SUBJECTIVE OR OBJECTIVE
Impaired ability to walk required distances, walk on an incline/ decline, or on uneven surfaces, to navigate curbs, climb stairs
[Specify level of independence—refer to ND impaired physical Mobility, for suggested functional level classification]

Desired Outcomes/Evaluation
Criteria—Client Will:
• Be able to move about within environment as needed/desired within limits of ability or with appropriate adjuncts.
• Verbalize understanding of situation/risk factors and safety measures.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess causative/contributing factors:
• Identify condition/diagnoses that contribute to difficulty walking (e.g., advanced age, acute illness, weakness/chronic illness, recent surgery, trauma, arthritis, brain injury, vision impairments, pain, fatigue, cognitive dysfunction).
• Determine ability to follow directions, and note emotional/ behavioral responses that may be affecting the situation.
NURSING PRIORITY NO. 2. To assess functional ability:
• Determine degree of impairment in relation to suggested functional scale (0 to 4), noting that impairment can be either temporary/permanent or progressive.
• Note emotional/behavioral responses of client/SO to problems of mobility.
NURSING PRIORITY NO. 3. To promote safe, optimal level of independence in walking:
• Assist with treatment of underlying condition causing dysfunction as needed/indicated by individual situation.

• Consult with PT/OT to develop individual mobility/walking program and identify appropriate adjunctive devices.
• Demonstrate use of adjunctive devices (e.g., walker, cane, crutches, prosthesis).
• Schedule walking/exercise activities interspersed with adequate rest periods to reduce fatigue.
• Provide ample time to perform mobility-related tasks.
• Advance levels of exercise as able.
• Provide safety measures as indicated, including environmental management/fall prevention.
NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Involve client/SO in care, assisting them to learn ways of managing deficits to enhance safety for client and SO(s)/caregivers.
• Identify appropriate resources for obtaining and maintaining appliances, equipment, and environmental modifications to promote mobility.
• Instruct client/SO in safety measures as individually indicated (e.g., maintaining safe travel pathway, proper lighting/ handrails on stairs, etc.) to reduce risk of falls.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Individual findings, including level of function/ability to participate in specific/desired activities.
PLANNING
• Plan of care and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Discharge/long-range needs, noting who is responsible for each action to be taken.
• Specific referrals made.
• Sources of/maintenance for assistive devices.

[actual/] risk for other-directed Violence

2011-06-13T22:08:00.000-07:00

Taxonomy II: Safety/Protection—Class 3 Violence (00138) [Diagnostic Division: Safety] Submitted 1980;
Revised 1996
Definition: At risk for behaviors in which an individual demonstrates that he or she can be physically, emotionally,
and/or sexually harmful to others

Risk Factors/[Indicators]*
HISTORY OF VIOLENCE:
Against others (e.g., hitting, kicking, scratching, biting or spitting, or throwing objects at someone; attempted rape, rape, sexual molestation; urinating/defecating on a person)
Threats (e.g., verbal threats against property/person, social threats, cursing, threatening notes/letters or gestures, sexual threats)
Antisocial behavior (e.g., stealing, insistent borrowing, insistent demands for privileges, insistent interruption of meetings; refusal to eat or to take medication, ignoring instructions)

*NOTE: Although a risk diagnosis does not have defining characteristics (signs and symptoms), the factors identified here can be used to denote an actual diagnosis or as indicators of risk for/escalation of violence.

Wandering [specify sporadic or continuous]

2011-06-11T18:35:00.000-07:00

Taxonomy II: Activity/Rest—Class 2 Activity/Exercise (00154)
[Diagnostic Division: Safety]
Submitted 2000
Definition: Meandering, aimless, or repetitive locomotion that exposes the individual to harm; frequently incongruent with boundaries, limits, or obstacles

Related Factors
Cognitive impairment, specifically memory and recall deficits, disorientation, poor visuoconstructive (or visuospatial) ability, language (primarily expressive) defects
Cortical atrophy
Premorbid behavior (e.g., outgoing, sociable personality; premorbid dementia)
Separation from familiar people and places
Emotional state, especially frustration, anxiety, boredom, or depression (agitation)
Physiological state or need (e.g., hunger/thirst, pain, urination, constipation)
Over/understimulating social or physical environment; sedation
Time of day

Defining Characteristics
OBJECTIVE
Frequent or continuous movement from place to place, often revisiting the same destinations
Persistent locomotion in search of “missing” or unattainable people or places; scanning, seeking, or searching behaviors
Haphazard locomotion; fretful locomotion or pacing; long periods of locomotion without an apparent destination
Locomotion into unauthorized or private spaces; trespassing
Locomotion resulting in unintended leaving of a premise
Inability to locate significant landmarks in a familiar setting; getting lost
Locomotion that cannot be easily dissuaded or redirected; following behind or shadowing a caregiver’s locomotion
Hyperactivity
Periods of locomotion interspersed with periods of nonlocomotion (e.g., sitting, standing, sleeping)

Desired Outcomes/Evaluation
Criteria—Client Will:
• Be free of injury, or unplanned exits.
Caregiver(s) Will:
• Modify environment as indicated to enhance safety.
• Provide for maximal independence of client.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess degree of impairment/stage of disease process:
• Ascertain history of client’s memory loss and cognitive changes.
• Note results of diagnostic testing, confirming diagnosis and type of dementia.
• Evaluate client’s mental status during daytime and nighttime, noting when client’s confusion is most pronounced, and when client sleeps.
• Monitor client’s use/need for assistive devices such as glasses, hearing aids, cane, and so forth.
• Assess frequency and pattern of wandering behavior to determine individual risks/safety needs.
• Identify client’s reason for wandering if possible (e.g., looking for lost item, desire to go home, boredom, need for activity, hunger, thirst, or discomfort).
• Ascertain if client has delusions due to shadows, lights, and noises.

NURSING PRIORITY NO. 2. To assist client/caregiver to deal with situations:
• Provide a structured daily routine. Decreases wandering behavior and minimizes caregiver stress.
• Encourage participation in family activities and familiar routines such as folding laundry, listening to music, walking outdoors. Activities and exercises may reduce anxiety and restlessness.
• Bring client to bathroom on a regular schedule.
• Provide safe place for client to wander, away from safety hazards (e.g., hot water/kitchen stove, open stairway) and other noisy clients. Arrange furniture and other items to accommodate wandering.
• Make sure that doors have alarms and that alarms are turned on. Provide door and window locks that are not easily opened to prevent unsafe exits.
• Provide 24-hour reality orientation. (Client can be awake at any time and fail to recognize day/night routines.)

• Sit with client and talk. Provide TV/radio/music.
• Avoid overstimulation from activities or new partners/roommate during rest periods when client is in a facility.
• Use pressure-sensitive bed/chair alarms to alert caregivers of movement.
• Avoid using physical or chemical restraints (sedatives) to control wandering behavior. May increase agitation, sensory deprivation, and falls, and may contribute to wandering behavior.
• Provide consistent staff as much as possible.
• Provide room near monitoring station; check client location on frequent basis.

NURSING PRIORITY NO. 3. To Promote Wellness (Teaching/ Discharge Considerations):
• Identify problems that are remediable and assist client/SO to seek appropriate assistance and access resources. (Encourages problem solving to improve condition rather than accept the status quo.)
• Notify neighbors about client’s condition and request that they contact client’s family or local police if they see client outside alone. Community awareness can prevent/reduce risk of client being lost or hurt.
• Use community resources, such as Alzheimer’s Association Safe Return Program, to assist in identification, location, and safe return of individual with wandering behaviors.
• Help client/SO develop plan of care when problem is progressive.
• Refer to community resources such as day care programs, support groups, and so forth.
• Refer to NDs: acute Confusion; disturbed Sensory Perception, (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory); risk for Injury, risk for Falls.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings, including individual concerns, family involvement, and support factors/availability of resources.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses of client/SO(s) to plan interventions and actions performed.

• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-range needs and who is responsible for actions to be taken.
• Specific referrals made.

Standardized Nursing Languages

2011-06-07T22:30:00.000-07:00

The nursing process is complex and consists of three principle components: assessment, problem identification, and problem management. Since the early 1990s, there has been an ongoing effort to develop and promote a standardized nursing language.

Until recently, good information from nursing documentation has been difficult to utilize in decision-making processes in areas such as the cost and quality of nursing care, resource allocation, effective research, and level of staffing. The documentation was inconsistent and nonstandardized, and it provided a poor assessment of the knowledge and skill that nursing brings to healthcare.

One basic component of any data collection process is a standardized language. Standardized language involves defining a series of terms or phrases that can be applied where there are many ways of saying the same thing. In the case of nursing, there was a need for a common language that addressed and linked the three components of nursing care data elements—diagnoses, interventions, and outcomes. In the case of the SNLs, three different sets of nomenclatures are needed.

Chronic Obstructive Pulmonary Disease (COPD) and Asthma

2011-06-07T02:18:00.000-07:00

All respiratory diseases characterized by chronic obstruction to airflow fall under the broad classification of COPD, also known as chronic airflow limitations (CAL). COPD is a condition of chronic dyspnea with expiratory airflow limitation that does not significantly fluctuate. Within that broad category, the primary cause of the obstruction may vary; examples include airway inflammation, mucous plugging, narrowed airway lumina, or airway destruction. The term COPD includes chronic bronchitis and emphysema. Although asthma also involves airway inflammation and periodic narrowing of the airway lumina (hyperreactivity), the condition is the result of individual response to a wide variety of stimuli/triggers and is therefore episodic in nature with fluctuations/exacerbations of symptoms. Because client response and therapy needs can be similar, asthma has been included in this plan of care.

Asthma: Sometimes called chronic reactive airway disease, asthma is a chronic inflammatory disorder characterized by episodic exacerbations of reversible inflammation and constriction of bronchial smooth muscle, hypersecretion of mucus, and edema. Precipitating factors include allergens (e.g., foods, animals, latex, plants, molds), emotional upheaval, air pollution, cold weather, exercise, chemicals, medications, and viral infections. The prevalence of asthma is rising, accounting for the sixth most common chronic disease in the United States.

Chronic bronchitis: Widespread inflammation of airways with narrowing or blocking of airways, increased production of mucous/sputum (productive cough), and marked cyanosis.

Emphysema: Most severe form of COPD characterized by recurrent inflammation that damages and eventually destroys alveolar walls to create large blebs or bullae (air spaces) and collapsed bronchioles on expiration (air-trapping). Clinically, emphysema typically presents with nonproductive or minimally productive cough and progressive dyspnea.

Note: Chronic bronchitis and emphysema coexist in many clients and are most commonly seen in hospitalized COPD clients when acute exacerbations occur. Chronic bronchitis and emphysema are usually irreversible, although some effects can be mediated.

CARE SETTING
Primarily community level; however, severe exacerbations may necessitate emergency and/or inpatient hospital stay.

RELATED CONCERNS
Heart failure: chronic, Pneumonia, Psychosocial aspects of care, Ventilatory assistance (mechanical), Surgical intervention

CARE SETTING FOR HYPERTENSION: SEVERE

2011-06-06T07:14:00.000-07:00

Hypertension was previously defined as blood pressure greater than 140/90 mm Hg by the 1992 Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure and was classified in stages, according the the degree of severity. In 2003, new guidelines were issued by the National Heart, Lung, and Blood Institute (NHLBI) that include a lower “normal blood pressure,” a “prehypertension” level, and a merging of staging categories.

Normal blood pressure is now defined as measurements less than 120/80 mm Hg and prehypertension as 120–139/80–89 mm Hg. Hypertension is defined as pressure greater than 140/90 mm Hg; and is classified according to the degree of severity. Stage I (mild) is 140/90–159/99. Stage II (moderate) is 160/100 or greater. Stage III (severe) is present when systolic pressure is greater than 180 and diastolic pressure is greater than 110. Stage IV (very severe) occurs when systolic pressure is 210 or greater with diastolic pressure greater than 120. Stages II and III hypertension have essentially been combined in the new guidelines, as their treatment is the same.

Hypertension is also categorized according to etiology: as primary/essential (approximately 95% of all cases), when it has no identifiable cause; or secondary, which occurs as a result of an identifiable, sometimes correctable, pathologic condition (e.g., kidney disorders, use of medications, drugs or other chemicals, adrenal gland tumors, or primary aldosteronism).

Hypertension increases with age and is one of the major risk factors in the development of cardiovascular disease. Current research has demonstrated that the systolic blood pressure is a more important determinant of cardiovascular risk in people over 50 years of age; however, in clients under 50 years old, the diastolic blood pressure is the major predictor.

Blood pressure in the “prehypertension” range responds well to lifestyle changes (e.g., weight management and exercise), and is not usually treated with medications unless other risk factors are present, such as diabetes or heart disease. However, recent studies indicate that persons with prehypertension are at high risk for developing hypertension and death from heart diease and stroke.

The goal of treatment is to prevent the long-term sequelae of the disease (i.e., target organ disease [TOD]). Although the elderly are most prone to this disorder and its sequelae, it is a growing health problem across many cultures, and is demonstrated in youger people in multiple populations.

CARE SETTING
Although hypertension is usually treated in a community setting, management of stages III and IV with symptoms of complications/ compromise may require inpatient care, especially when TOD is present. The majority of interventions included here can be used in either setting.

RELATED CONCERNS
Cerebrovascular accident/stroke, Myocardial infarction, Psychosocial aspects of care, Renal failure: acute, Renal failure: chronic

List of Nursing Diagnosis NANDA 2011

2011-05-28T21:41:00.001-07:00

Label: List of Nursing Diagnosis NANDA 2011, NANDA, Nursing Diagnosis

Nanda Nursing Diagnosis List 2011

List of NANDA Nursing diagnosis Accepted for Use and Research Divided into 13 domains and 47 classes, below the full list of 13 Domains and 47 classes NANDA Nursing diagnosis. And complete list of NANDA Nursing diagnosis based on alphabetical order.

Domains Health Promotions
1. Health awareness
2. Health management
Domains nutrition’s
1. ingestion
2. digestion
3. Absorption
4. Metabolism
5. Hydration
Domains Elimination/exchange
1. Urinary System
2. Gastrointestinal System
3. Integumentary system
4. Pulmonary System
Domains Activity/Rest
1. Sleep/Rest
2. Activity/Exercise
3. Energy Balance
4. Cardiovascular-pulmonary Responses
5. Self-Care
Domains Perception/Cognition
1. Attention
2. Orientation
3. Sensation/Perception Cognition
4. Communication
Domains Self Perception
1. Self-Concept
2. Self-Esteem
3. Body Image
Domains Role Relationship
1. Caregiving Roles
2. Family Relationship
3. Role Performance
Domains Sexuality
1. Sexual Identity
2. Sexual Function
3. Reproduction
Domains Coping/Stress Tolerance
1. Post-Trauma Responses
2. Coping Responses
3. Neuro-behavioral Stress
Domains Life Principles
1. Values
2. Beliefs
3. Values/Belief/action Congruence
Domains Safety/protection
1. infection
2. Physical Injury
3. Violence
4. Environmental Hazards
5. Defensive Processes
6. Thermo regulation
Domains Comfort
1. Physical Comfort
2. Environmental Comfort
3. social Comfort
Domains Growth/Development
1. Growth
2. Development
source : http://nurse-nanda.blogspot.com/2011/05/list-of-nursing-diagnosis-nanda-2011.html

UNDERSTANDING VACUUM-ASSISTED CLOSURE THERAPY

2011-02-24T20:35:00.000-08:00

Vacuum-assisted closure (VAC) therapy, also called negative pressure wound therapy, is an option to consider when a wound fails to heal in a timely manner. VAC therapy encourages healing by applying localized subatmospheric pressure at the site of the wound. This reduces edema and bacterial colonization and stimulates the formation of granulation tissue.

VACUUM-ASSISTED CLOSURE THERAPY

2011-02-22T20:33:00.000-08:00

Vacuum-assisted closure (VAC) therapy, also known as negative pressure wound therapy, is used to enhance delayed or impaired wound healing. The VAC device applies localized subatmospheric pressure to draw the edges of the wound toward the center. It's applied after a special dressing is placed in the wound or over a graft or flap; this wound packing removes fluids from the wound and stimulates growth of healthy granulation tissue. (See Understanding vacuum-assisted closure therapy.)

VAC therapy is indicated for acute and traumatic wounds, pressure ulcers, and chronic open wounds, such as diabetic ulcers, meshed grafts, and skin flaps. It's contraindicated for fistulas that involve organs or body cavities, necrotic tissue with eschar, untreated osteomyelitis, and malignant wounds. This therapy should be used cautiously in patients with active bleeding, in those taking anticoagulants, and when achieving wound hemostasis has been difficult.

Equipment

Waterproof trash bag â€¢ goggles â€¢ gown, if indicated â€¢ emesis basin â€¢ normal saline solution â€¢ clean gloves â€¢ sterile gloves â€¢ sterile scissors â€¢ linen-saver pad â€¢ 35-ml piston syringe with 19G catheter â€¢ reticulated foam â€¢ fenestrated tubing â€¢ evacuation tubing â€¢ skin protectant wipe â€¢ transparent occlusive air-permeable drape â€¢ evacuation canister â€¢ vacuum unit.

Preparation of equipment

Assemble the VAC device at the bedside per manufacturer's instructions. Set negative pressure according to the physician's order (25 to 200 mm Hg).

Implementation

Check the physician's order, and assess the patient's condition.
Explain the procedure to the patient, provide privacy, and wash your hands. Put on gogglesâ€”and a gown, if necessaryâ€”to protect yourself from wound drainage and contamination.
Place a linen-saver pad under the patient to catch any spills and avoid linen changes. Position the patient to allow maximum wound exposure. Place the emesis basin under the wound to collect any drainage.
Put on clean gloves. Remove the soiled dressing and discard it in the waterproof trash bag. Attach the 19G catheter to the 35-ml piston syringe and irrigate the wound thoroughly using the normal saline solution.
Clean the area around the wound with normal saline solution; wipe intact skin with a skin protectant wipe and allow it to dry well. Remove and discard your gloves.
Put on sterile gloves. Using sterile scissors, cut the foam to the shape and measurement of the wound. More than one piece of foam may be necessary if the first piece is cut too small.
Carefully place the foam in the wound. Next, place the fenestrated tubing into the center of the foam. The fenestrated tubing, embedded into the foam, delivers negative pressure to the wound.
Place the transparent occlusive air permeable drape over the foam, enclosing both the foam and the tubing. Remove and discard your gloves.
Connect the free end of the fenestrated tubing to the evacuation tubing connected to the evacuation canister.
Turn on the vacuum unit.
Make sure the patient is comfortable.
Properly dispose of drainage, solution, linen-saver pad, and trash bag, and clean or dispose of soiled equipment and supplies according to facility policy and Centers for Disease Control and Prevention guidelines.

Special considerations

Change the dressing every 48 hours. Try to coordinate dressing change with the physician's visit so he can inspect the wound.
Measure the amount of drainage every shift.
Adjust the negative pressure setting according to the physician's orders.
Audible and visual alarms alert you if the unit is tipped greater than 45 degrees, the canister is full, the dressing has an air leak, or the canister becomes dislodged.

Complications

Care and cleaning of wounds may temporarily increase the patient's pain. They also increase the risk for infection.

Documentation

Document the frequency and duration of therapy, the amount of negative pressure applied, the size and condition of the wound, and the patient's response to treatment.

USING A CLOSED-WOUND DRAINAGE SYSTEM

2011-02-14T20:30:00.000-08:00

The portable closed-wound drainage system draws drainage from a wound site, such as the chest wall postmastectomy (shown at left), by means of a Y tube. To empty the drainage, remove the plug and empty it into a graduated cylinder. To reestablish suction, compress the drainage unit against a firm surface to expel air and, while holding it down, replace the plug with your other hand (as shown in the center). The same principle is used for the Jackson-Pratt bulb drain (shown at right).

CLOSED-WOUND DRAIN MANAGEMENT

2011-01-17T00:11:00.000-08:00

Typically inserted during surgery in anticipation of substantial postoperative drainage, a closed-wound drain promotes healing and prevents swelling by suctioning the serosanguinous fluid that accumulates at the wound site. By removing this fluid, the closed-wound drain helps reduce the risk of infection and skin breakdown as well as the number of dressing changes. Hemovac and Jackson-Pratt closed drainage systems are used most commonly.

A closed-wound drain consists of perforated tubing connected to a portable vacuum unit. The distal end of the tubing lies within the wound and usually leaves the body from a site other than the primary suture line to preserve the integrity of the surgical wound. The tubing exit site is treated as an additional surgical wound; the drain is usually sutured to the skin.

If the wound produces heavy drainage, the closed-wound drain may be left in place for longer than 1 week. Drainage must be emptied and measured frequently to maintain maximum suction and prevent strain on the suture line.

Equipment

Graduated biohazard cylinder â€¢ sterile laboratory container, if needed â€¢ alcohol pads â€¢ gloves â€¢ gown â€¢ face shield â€¢ trash bag â€¢ sterile gauze pads â€¢ antiseptic cleaning agent â€¢ prepackaged povidone-iodine swabs.

Implementation

Check the physician's order, and assess the patient's condition.
Explain the procedure to the patient, provide privacy, and wash your hands.
Unclip the vacuum unit from the patient's bed or gown.
Using aseptic technique, release the vacuum by removing the spout plug on the collection chamber. The container expands completely as it draws in air.
Empty the unit's contents into a graduated biohazard cylinder, and note the amount and appearance of the drainage. If diagnostic tests will be performed on the fluid specimen, pour the drainage directly into a sterile laboratory container, note the amount and appearance, and send it to the laboratory.
Maintaining aseptic technique, use an alcohol pad to clean the unit's spout and plug.
To reestablish the vacuum that creates the drain's suction power, fully compress the vacuum unit. With one hand holding the unit compressed to maintain the vacuum, replace the spout plug with your other hand. (See Using a closed-wound drainage system.)
Check the patency of the equipment. Make sure the tubing is free of twists, kinks, and leaks because the drainage system must be airtight to work properly. The vacuum unit should remain compressed when you release manual pressure; rapid reinflation indicates an air leak. If this occurs, recompress the unit and make sure the spout plug is secure.
Secure the vacuum unit to the patient's gown. Fasten it below wound level to promote drainage. Don't apply tension on drainage tubing when fastening the unit to prevent possible dislodgment. Remove and discard your gloves, and wash your hands thoroughly.
Observe the sutures that secure the drain to the patient's skin; look for signs of pulling or tearing and for swelling or infection of surrounding skin. Gently clean the sutures with sterile gauze pads soaked in an antiseptic cleaning agent or with a povidone-iodine swab.
Properly dispose of drainage, solutions, and trash bag, and clean or dispose of soiled equipment and supplies according to facility policy.

Special considerations

Empty the drain and measure its contents once during each shift if drainage has accumulated, more often if drainage is excessive. Removing excess drainage maintains maximum suction and avoids straining the drain's suture line.
If the patient has more than one closed drain, number the drains so you can record drainage from each site.
NURSING ALERT Be careful not to mistake chest tubes with water seal drainage devices for closed-wound drains because the care of these devices differs from closed-wound drainage systems, and the vacuum of a chest tube should never be released.

Complications

Occlusion of the tubing by fibrin, clots, or other particles can reduce or obstruct drainage.

Documentation

Record the date and time you empty the drain, appearance of the drain site and presence of swelling or signs of infection, equipment malfunction and consequent nursing action, and the patient's tolerance of the treatment. On the intake and output sheet, record drainage color, consistency, type, and amount. If the patient has more than one closed-wound drain, number the drains and record the information above separately for each drainage site.

IRRIGATING A DEEP WOUND

2011-01-07T00:06:00.000-08:00

When preparing to irrigate a wound, attach a 19G needle or catheter to a 35-ml piston syringe. This setup delivers an irrigation pressure of 8 psi, which is effective in cleaning the wound and reducing the risk of trauma and wound infection. To prevent tissue damage or, in an abdominal wound, intestinal perforation, avoid forcing the needle or catheter into the wound.

Irrigate the wound with gentle pressure until the solution returns clean. Then position the emesis basin under the wound to collect any remaining drainage.

WOUND IRRIGATION

2010-12-25T20:20:00.000-08:00

Irrigation cleans tissues and flushes cell debris and drainage from an open wound. Irrigation with a commercial wound cleaner helps the wound heal properly from the inside tissue layers outward to the skin surface; it also helps prevent premature surface healing over an abscess pocket or infected tract. Performed properly, wound irrigation requires strict sterile technique. After irrigation, open wounds usually are packed to absorb additional drainage. Always follow the standard precaution guidelines of the Centers for Disease Control and Prevention (CDC).

Equipment

Waterproof trash bag â€¢ linen-saver pad â€¢ emesis basin â€¢ clean gloves â€¢ sterile gloves â€¢ goggles â€¢ gown, if indicated â€¢ prescribed irrigant such as sterile normal saline solution â€¢ sterile water or normal saline solution â€¢ soft rubber or plastic catheter â€¢ sterile container â€¢ materials as needed for wound care â€¢ sterile irrigation and dressing set â€¢ commercial wound cleaner â€¢ 35-ml piston syringe with 19G needle or catheter â€¢ skin protectant wipe.

Preparation of equipment

Assemble all equipment in the patient's room. Check the expiration date on each sterile package and inspect for tears. Check the sterilization date and the date that each bottle of irrigating solution was opened; don't use any solution that's been open longer than 24 hours.

Using aseptic technique, dilute the prescribed irrigant to the correct proportions with sterile water or normal saline solution, if necessary. Let the solution stand until it reaches room temperature, or warm it to 90Â° to 95Â° F (32.2Â° to 35Â° C).

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, which will keep instruments or gloves from touching the bag's edge, thus preventing contamination.

Implementation

Check the physician's order, and assess the patient's condition. Identify the patient's allergies, especially to povidone-iodine or other topical solutions or medications.
Explain the procedure to the patient, provide privacy, and position the patient correctly for the procedure. Place the linen-saver pad under the patient to catch any spills and avoid linen changes. Place the emesis basin below the wound so that the irrigating solution flows from the wound into the basin.
Wash your hands thoroughly. If necessary, put on a gown to protect your clothing from wound drainage and contamination. Put on clean gloves.
Remove the soiled dressing; then discard the dressing and gloves in the trash bag.
Establish a sterile field with all the equipment and supplies you'll need for irrigation and wound care. Pour the prescribed amount of irrigating solution into a sterile container so you won't contaminate your sterile gloves later by picking up unsterile containers. Put on sterile gloves, gown, and goggles, if indicated.
Fill the syringe with the irrigating solution; then connect the catheter to the syringe. Gently instill a slow, steady stream of irrigating solution into the wound until the syringe empties. (See Irrigating a deep wound, page 202.) Make sure the solution flows from the clean to the dirty area of the wound to prevent contamination of clean tissue by exudate. Also make sure the solution reaches all areas of the wound.
Refill the syringe, reconnect it to the catheter, and repeat the irrigation.
Continue to irrigate the wound until you've administered the prescribed amount of solution or until the solution returns clear. Note the amount of solution administered. Then remove and discard the catheter and syringe in the waterproof trash bag.
Keep the patient positioned to allow further wound drainage into the basin.
Clean the area around the wound with normal saline solution; wipe intact skin with a skin protectant wipe and allow it to dry well to help prevent skin breakdown and infection.
Pack the wound, if ordered, and apply a sterile dressing. Remove and discard your gloves and gown.
Make sure the patient is comfortable.
Properly dispose of drainage, solutions, and trash bag, and clean or dispose of soiled equipment and supplies according to facility policy and CDC guidelines. To prevent contamination of other equipment, don't return unopened sterile supplies to the sterile supply cabinet.

Special considerations

Try to coordinate wound irrigation with the physician's visit so that he can inspect the wound.
Use only the irrigant specified by the physician because others may be erosive or otherwise harmful.
Remember to follow your facility's policy and CDC guidelines concerning wound and skin precautions.
Irrigate with a bulb syringe if the wound is small or not particularly deep or if a piston syringe is unavailable. However, use a bulb syringe cautiously because this type of syringe doesn't deliver enough pressure to adequately clean the wound.

Home care

If the wound must be irrigated at home, teach the patient or a family member how to perform this procedure using strict aseptic technique. Ask for a return demonstration of the proper technique. Provide written instructions. Arrange for home health supplies and nursing visits, as appropriate. Urge the patient to call the physician if he detects signs of infection.

Complications

Wound irrigation increases the risk of infection and may cause excoriation and increased pain. Pressure over 15 psi causes trauma to the wound and directs bacteria back into the tissue.

Documentation

Record the date and time of irrigation, amount and type of irrigant, appearance of the wound, sloughing tissue or exudate, amount of solution returned, skin care performed around the wound, dressings applied, and the patient's tolerance of the treatment.

TRAUMATIC WOUND MANAGEMENT

2010-12-20T20:09:00.000-08:00

Traumatic wounds include abrasions, lacerations, puncture wounds, and amputations. In an abrasion, the skin is scraped, with partial loss of the skin surface. In a laceration, the skin is torn, causing jagged, irregular edges; the severity of a laceration depends on its size, depth, and location. A puncture wound occurs when a pointed object, such as a knife or glass fragment, penetrates the skin. Traumatic amputation refers to the removal of part of the body, a limb, or part of a limb.

When caring for a patient with a traumatic wound, first assess his ABCsâ€”airway, breathing, and circulation. It may seem natural to focus on a gruesome injury, but a patent airway and pumping heart take first priority. Once the patient's ABCs are stabilized, you can turn your attention to the traumatic wound. Initial management concentrates on controlling bleeding, usually by applying firm, direct pressure and elevating the extremity. If bleeding continues, you may need to compress a pressure point. Assess the condition of the wound. Management and cleaning technique usually depend on the specific type of wound and degree of contamination.

Equipment

Sterile basin â€¢ normal saline solution â€¢ sterile 4â€³ Ã— 4â€³ gauze pads â€¢ sterile gloves â€¢ clean gloves â€¢ sterile cotton-tipped applicators â€¢ dry sterile dressing, nonadherent pad, or petroleum gauze â€¢ linen-saver pad â€¢ optional: scissors, towel, goggles, mask, gown, 50-ml catheter-tip syringe, surgical scrub brush, antibacterial ointment, porous tape, sterile forceps, sutures and suture set, hydrogen peroxide.

Preparation of equipment

Place a linen-saver pad under the area to be cleaned. Remove any clothing covering the wound. If necessary, cut hair around the wound with scissors to promote cleaning and treatment.

Assemble needed equipment at the patient's bedside. Fill a sterile basin with normal saline solution. Make sure the treatment area has enough light to allow close observation of the wound. Depending on the nature and location of the wound, wear sterile or clean gloves to avoid spreading infection.

Implementation

Check the patient's medical history for previous tetanus immunization and, if needed and ordered, arrange for immunization.
Administer pain medication, if ordered.
Wash your hands.
Use appropriate protective equipment, such as a gown, a mask, and goggles, if spraying or splashing of body fluids is possible.

For an abrasion

Flush the scraped skin with normal saline solution.
Remove dirt or gravel with a sterile 4â€³ Ã— 4â€³ gauze pad moistened with normal saline solution. Rub in the opposite direction from which the dirt or gravel became embedded.
If the wound is extremely dirty, you may use a surgical brush to scrub it.
With a small wound, allow it to dry and form a scab. With a larger wound, you may need to cover it with a nonadherent pad or petroleum gauze and a light dressing. Apply antibacterial ointment if ordered.

For a laceration

Moisten a sterile 4â€³ Ã— 4â€³ gauze pad with normal saline solution. Clean the wound gently, working outward from its center to about 2â€³ (5 cm) beyond its edges. Discard the soiled gauze pad and use a fresh one as necessary. Continue until the wound appears clean.
If the wound is dirty, you may irrigate it with a 50-ml catheter-tip syringe and normal saline solution.
Assist the physician in suturing the wound edges using the suture kit, or apply sterile strips of porous tape.
Apply the prescribed antibacterial ointment to help prevent infection.
Apply a dry sterile dressing over the wound to absorb drainage and help prevent bacterial contamination.

For a puncture wound

If the wound is minor, allow it to bleed for a few minutes before cleaning it.
For a larger puncture wound, you may need to irrigate it before applying a dry dressing.
Stabilize any embedded foreign object until the physician can remove it. After he removes the object and bleeding is stabilized, clean the wound as you'd clean a laceration or deep puncture wound.

For an amputation

Apply a gauze pad moistened with normal saline solution to the amputation site. Elevate the affected part, and immobilize it for surgery.
Recover the amputated part, and prepare it for transport to a facility where microvascular surgery is performed.

Special considerations

When irrigating a traumatic wound, avoid using more than 8 psi of pressure. High-pressure irrigation can seriously interfere with healing, kill cells, and allow bacteria to infiltrate the tissue.
To clean the wound, you may use normal saline or hydrogen peroxide (its foaming action facilitates debris removal). However, peroxide should never be instilled into a deep wound because of the risk of embolism from the evolving gases. Be sure to rinse your hands well after using hydrogen peroxide.
Avoid cleaning a traumatic wound with alcohol because alcohol causes pain and tissue dehydration. Also, avoid using antiseptics for wound cleaning because they can impede healing. In addition, never use a cotton ball or cotton-filled gauze pad to clean a wound because cotton fibers left in the wound can cause contamination.
After a wound has been cleaned, the physician may want to debride it to remove dead tissue and reduce the risk of infection and scarring. If this is necessary, pack the wound with gauze pads soaked in normal saline solution until debridement.
Observe for signs and symptoms of infection, such as warm red skin at the site or purulent discharge. Be aware that infection of a traumatic wound can delay healing, increase scar formation, and trigger systemic infection, such as septicemia.
Observe all dressings. If edema is present, adjust the dressing to avoid impairing circulation to the area.

Complications

Cleaning and care of traumatic wounds may temporarily increase the patient's pain. Excessive, vigorous cleaning may further disrupt tissue integrity.

Documentation

Document the date and time of the procedure, wound size and condition, medication administration, specific wound care measures, and patient teaching.

RECOGNIZING DEHISCENCE AND EVISCERATION

2010-11-27T20:05:00.000-08:00

In wound dehiscence (top), the layers of the surgical wound separate. In evisceration (bottom), the viscera (in this case, a bowel loop) protrude through the surgical incision.

Wound dehiscence

Evisceration of bowel loop

TYPES OF ADHESIVE SKIN CLOSURES

2010-11-14T21:18:00.000-08:00

Steri-Strips are used as a primary means of keeping a wound closed after suture removal. They're made of thin strips of sterile, nonwoven, porous fabric tape.

Butterfly closures consist of sterile, waterproof adhesive strips. A narrow, nonadhesive â€œbridgeâ€ connects the two expanded adhesive portions. These strips are used to close small wounds and assist healing after suture removal

WOUND DEHISCENCE AND EVISCERATION MANAGEMENT

2010-11-06T04:52:00.000-07:00

Although surgical wounds typically heal without incident, occasionally the edges of a wound may fail to join or may separate even after they seem to be healing normally. This development, called wound dehiscence, may lead to an even more serious complication: evisceration, in which a portion of the viscera (usually a bowel loop) protrudes through the incision. Evisceration, in turn, can lead to peritonitis and septic shock. (See Recognizing dehiscence and evisceration.) Dehiscence and evisceration are most likely to occur 6 to 7 days after surgery. By then, sutures may have been removed and the patient can cough easily and breathe deeplyâ€”both of which strain the incision. Some wound dehiscence may be managed conservatively using a medical approach, such as sterile dressing application and wound monitoring.

NURSING ALERT Wound evisceration requires quick intervention to prevent potentially fatal shock; the wound is usually closed in the operating room.

Several factors can contribute to these complications. Poor nutritionâ€”either from inadequate intake or a condition such as diabetes mellitusâ€”may hinder wound healing. Chronic pulmonary or cardiac disease can also slow healing because the injured tissue doesn't get needed nutrients and oxygen. Localized wound infection may limit closure, delay healing, and weaken the incision. Also, stress on the incision from coughing or vomiting may cause abdominal distention or severe stretching. A midline abdominal incision, for instance, poses a high risk of wound dehiscence.

Equipment

Two sterile towels â€¢ 1 L of sterile normal saline solution â€¢ sterile irrigation set, including a basin, solution container, and 50-ml catheter-tip syringe â€¢ several large abdominal dressings â€¢ sterile, waterproof drape â€¢ linen-saver pads â€¢ sterile gloves.

If the patient will return to the operating room, also gather the following equipment: I.V. administration set and I.V. fluids â€¢ equipment for nasogastric (NG) intubation â€¢ sedative, as ordered â€¢ suction apparatus.

Implementation

Provide reassurance and support to ease the patient's anxiety. Tell him to stay in bed. If possible, stay with him while someone else notifies the physician and collects the necessary equipment.
Place a linen-saver pad under the patient to keep the sheets dry when you moisten the exposed viscera.
Using sterile technique, unfold a sterile towel to create a sterile field. Open the package containing the irrigation set, and place the basin, solution container, and 50-ml syringe on the sterile field.
Open the bottle of normal saline solution and pour about 400 ml into the solution container. Also pour about 200 ml into the sterile basin.
Open several large abdominal dressings, and place them on the sterile field.
Put on the sterile gloves, and place one or two of the large abdominal dressings into the basin to saturate them with saline solution.
Place the moistened dressings over the exposed viscera. Then place a sterile, waterproof drape over the dressings to prevent the sheets from getting wet.
Moisten the dressings every hour by withdrawing saline solution from the container through the syringe and then gently squirting the solution on the dressings.
When you moisten the dressings, inspect the color of the viscera. If it appears dusky or black, notify the physician immediately. With its blood supply interrupted, a protruding organ may become ischemic and necrotic.
Keep the patient on absolute bed rest in low Fowler's position (no more than 20 degrees' elevation) with his knees flexed. This prevents injury and reduces stress on an abdominal incision.
Don't allow the patient to have anything by mouth to decrease the risk of aspiration during surgery.
Monitor the patient's pulse, respirations, blood pressure, and temperature every 15 minutes to detect shock.
If necessary, prepare the patient to return to the operating room. After gathering the appropriate equipment, start an I.V. infusion, as ordered.
Insert an NG tube and connect it to continuous or intermittent low suction, as ordered.
Depending on the circumstances, some of these procedures may not be done at the bedside. For instance, NG intubation may make the patient gag or vomit, causing further evisceration. For this reason, the physician may choose to have the NG tube inserted in the operating room with the patient under anesthesia.
Continue to reassure the patient while you prepare him for surgery. Make sure he has signed a consent form and that the operating room staff has been informed about the procedure.
Administer preoperative medications to the patient, as ordered.

Special considerations

The best treatment is prevention. If you're caring for a postoperative patient who's at risk for poor healing, make sure he receives an adequate supply of protein, vitamins, and calories. Monitor his dietary deficiencies, and discuss any problems with the physician and the dietitian.
When changing wound dressings, always use sterile technique. Inspect the incision with each dressing change, and if you recognize the early signs of infection, start treatment before dehiscence or evisceration can occur. If local infection develops, clean the wound as necessary to eliminate a buildup of purulent drainage. Make sure bandages aren't so tight that they limit blood supply to the wound.

Complications

Infection, which can lead to peritonitis and, possibly, septic shock, is the most severe and most common complication of wound dehiscence and evisceration. Caused by bacterial contamination or by drying of normally moist abdominal contents, infection can impair circulation and lead to necrosis of the affected organ.

Documentation

Note when the problem occurred, the patient's activity preceding the problem, his condition, and the time the physician was notified. Describe the appearance of the wound or eviscerated organ; amount, color, consistency, and odor of any drainage; and nursing actions taken. Record the patient's vital signs, his response to the incident, and the physician's actions.

Finally, make sure you change the patient care plan to reflect nursing actions needed to promote proper healing.

SKIN STAPLE AND CLIP REMOVAL

2010-11-01T05:16:00.000-07:00

Skin staples or clips may be used instead of standard sutures to close lacerations or surgical wounds. Because they can secure a wound more quickly than sutures, they may substitute for surface sutures when cosmetic results aren't a prime consideration, such as in abdominal closure. When properly placed, staples and clips distribute tension evenly along the suture line with minimal tissue trauma and compression, facilitating healing and minimizing scarring. Because staples and clips are made from surgical stainless steel, tissue reaction to them is minimal. Usually, physicians remove skin staples and clips, but some facilities permit qualified nurses to perform this procedure.

Skin staples and clips are contraindicated when wound location requires cosmetically superior results or when the incision site makes it impossible to maintain at least a 5-mm distance between the staple and underlying bone, vessels, or internal organs.

Equipment

Waterproof trash bag â€¢ adjustable light â€¢ clean gloves, if needed â€¢ sterile gloves â€¢ sterile gauze pads â€¢ sterile staple or clip extractor â€¢ povidone-iodine solution or other antiseptic cleaning agent â€¢ sterile cotton-tipped applicators â€¢ optional: butterfly adhesive strips or Steri-Strips, compound benzoin tincture or other skin protectant.

Prepackaged, sterile, disposable staple or clip extractors are available.

Preparation of equipment

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 bag to provide a wide opening, then preventing contamination of instruments or gloves by touching the bag's edge.

Implementation

If your facility allows you to remove skin staples and clips, check the physician's order to confirm the exact timing and details for this procedure.
Check for patient allergies, especially to adhesive tape and povidone-iodine or other topical solutions or medications.
Explain the procedure to the patient. Tell him that he may feel a slight pulling or tickling sensation but little discomfort during staple removal. Reassure him that because his incision is healing properly, removing the supporting staples or clips won't weaken the incision line.
Provide privacy, and place the patient in a comfortable position that doesn't place undue tension on the incision. Because some patients experience nausea or dizziness during the procedure, have the patient recline if possible. Adjust the light to shine directly on the incision.
Wash your hands thoroughly.
If the patient's wound has a dressing, put on clean gloves and carefully remove it. Discard the dressing and the gloves in the waterproof trash bag.
Assess the patient's incision. Notify the physician of gaping, drainage, inflammation, and other signs of infection.
Establish a sterile work area with all the equipment and supplies you'll need for removing staples or clips and for cleaning and dressing the incision. Open the package containing the sterile staple or clip extractor, maintaining asepsis. Put on sterile gloves.
Wipe the incision gently with sterile gauze pads soaked in an antiseptic cleaning agent or with sterile cotton-tipped applicators to remove surface encrustations.
Pick up the sterile staple or clip extractor. Then, starting at one end of the incision, remove the staple or clip. (See Removing a staple.) Hold the extractor over the trash bag, and release the handle to discard the staple or clip.
Repeat the procedure for each staple or clip until all are removed.
Apply a sterile gauze dressing, if needed, to prevent infection and irritation from clothing. Then discard your gloves.
Make sure the patient is comfortable. According to the physician's preference, inform the patient that he may shower in 1 or 2 days if the incision is dry and healing well.
Properly dispose of solutions and the trash bag, and clean or dispose of soiled equipment and supplies according to facility policy.

Special considerations

Carefully check the physician's order for the time and extent of staple or clip removal. The physician may want you to remove only alternate staples or clips initially and to leave the others in place for an additional day or two to support the incision.
When removing a staple or clip, place the extractor's jaws carefully between the patient's skin and the staple or clip to avoid patient discomfort. If extraction is difficult, notify the physician; staples or clips placed too deeply within the skin or left in place too long may resist removal.
If the wound dehisces after staples or clips are removed, apply butterfly adhesive strips or Steri-Strips to approximate and support the edges, and call the physician immediately to repair the wound. (See Types of adhesive skin closures.)
You may also apply butterfly adhesive strips or Steri-Strips after removing staples or clips even if the wound is healing normally to give added support to the incision and prevent lateral tension from forming a wide scar. Use a small amount of compound benzoin tincture or other skin protectant to ensure adherence. Leave the strips in place for 3 to 5 days.

Home care

If the patient is being discharged, teach him how to remove the dressing and care for the wound. Instruct him to call the physician immediately if he observes wound discharge or any other abnormal change. Tell him that the redness surrounding the incision should gradually disappear and that after a few weeks, only a thin line will be visible.

Documentation

Record the date and time of staple or clip removal, number of staples or clips removed, appearance of the incision, dressings or butterfly strips applied, signs of wound complications, and the patient's tolerance of the procedure.

REMOVING A STAPLE

2010-11-01T05:13:00.000-07:00

Position the extractor's lower jaws beneath the span of the first staple (as shown below).

Squeeze the handles until they're completely closed; then lift the staple away from the skin (as shown below). The extractor changes the shape of the staple and pulls the prongs out of the intradermal tissue.

METHODS FOR REMOVING SUTURES

2010-11-01T01:01:00.000-07:00

Removal techniques depend on the type of sutures to be removed. The illustrations below show removal steps for four common suture types. Keep in mind that for all suture types, it's important to grasp and cut sutures in the correct place to avoid pulling the exposed (thus contaminated) suture material through subcutaneous tissue.

Plain interrupted sutures

Using sterile forceps, grasp the knot of the first suture and raise it off the skin. This will expose a small portion of the suture that was below skin level. Place the rounded tip of sterile curved-tip suture scissors against the skin, and cut through the exposed portion of the suture. Then, still holding the knot with the forceps, pull the cut suture up and out of the skin in a smooth continuous motion to avoid causing the patient pain. Discard the suture. Repeat the process for every other suture, initially; if the wound doesn't gape, you can then remove the remaining sutures as ordered.

Plain continuous sutures

Cut the first suture on the side opposite the knot. Next, cut the same side of the next suture in line. Then lift the first suture out in the direction of the knot. Proceed along the suture line, grasping each suture where you grasped the knot on the first one.

Mattress interrupted sutures

If possible, remove the small, visible portion of the suture opposite the knot by cutting it at each visible end and lifting the small piece away from the skin to prevent pulling it through and contaminating subcutaneous tissue. Then remove the rest of the suture by pulling it out in the direction of the knot. If the visible portion is too small to cut twice, cut it once and pull the entire suture out in the opposite direction. Repeat these steps for the remaining sutures, and monitor the incision carefully for infection.

Mattress continuous sutures

Follow the procedure for removing mattress interrupted sutures, first removing the small visible portion of the suture, if possible, to prevent pulling it through and contaminating subcutaneous tissue. Then extract the rest of the suture in the direction of the knot.

SUTURE REMOVAL

2010-10-31T22:58:00.000-07:00

The goal of this procedure is to remove skin sutures from a healed wound without damaging newly formed tissue. The timing of suture removal depends on the shape, size, and location of the sutured incision; the absence of inflammation, drainage, and infection; and the patient's general condition. Usually, for a sufficiently healed wound, sutures are removed 7 to 10 days after insertion. Techniques for removal depend on the method of suturing, but all require sterile procedure to prevent contamination. Although sutures usually are removed by a physician, in many facilities, a nurse may remove them on the physician's order.

Equipment

Waterproof trash bag â€¢ adjustable light â€¢ clean gloves, if the wound is dressed â€¢ sterile gloves â€¢ sterile forceps or sterile hemostat â€¢ normal saline solution â€¢ sterile gauze pads â€¢ antiseptic cleaning agent â€¢ sterile curve-tipped suture scissors â€¢ povidone-iodine pads â€¢ optional: adhesive butterfly strips or Steri-Strips and compound benzoin tincture or other skin protectant.

Prepackaged, sterile suture-removal trays are available.

Preparation of equipment

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 properly to avoid reaching across the sterile field or the suture line when disposing of soiled articles. Form a cuff by turning down the top of the trash bag to provide a wide opening and prevent contamination of instruments or gloves by touching the bag's edge.

Implementation

If your facility allows you to remove sutures, check the physician's order to confirm the details for this procedure.
Check for patient allergies, especially to adhesive tape and povidone-iodine or other topical solutions or medications.
Tell the patient that you're going to remove the stitches from his wound. Assure him that this procedure typically is painless, but that he may feel a tickling sensation as the stitches come out. Reassure him that because his wound is healing properly, removing the stitches won't weaken the incision.
Provide privacy, and position the patient so he's comfortable without placing undue tension on the suture line. Because some patients experience nausea or dizziness during the procedure, have the patient recline if possible. Adjust the light to have it shine directly on the suture line.
Wash your hands thoroughly. If the patient's wound has a dressing, put on clean gloves and carefully remove the dressing. Discard the dressing and the gloves in the waterproof trash bag.
Observe the patient's wound for possible gaping, drainage, inflammation, signs of infection, and embedded sutures. Notify the physician if the wound has failed to heal properly. The absence of a healing ridge under the suture line 5 to 7 days after insertion indicates that the line needs continued support and protection during the healing process.
Establish a sterile work area with all the equipment and supplies you'll need for suture removal and wound care. Open the sterile suture-removal tray, maintaining sterility of the contents, and put on sterile gloves.
Using sterile technique, clean the suture line to decrease the number of microorganisms present and reduce the risk of infection. The cleaning process should also moisten the sutures sufficiently to ease removal. Soften them further, if needed, with normal saline solution.
Proceed according to the type of suture you're removing. (See Methods for removing sutures.) Because the visible part of a suture is exposed to skin bacteria and considered contaminated, be sure to cut sutures at the skin surface on one side of the visible part of the suture. Remove the suture by lifting and pulling the visible end off the skin to avoid drawing this contaminated portion back through subcutaneous tissue.
If ordered, remove every other suture to maintain some support for the incision. Then go back and remove the remaining sutures.
After removing sutures, wipe the incision gently with gauze pads soaked in an antiseptic cleaning agent or with a povidone-iodine pad. Apply a light sterile gauze dressing, if needed, to prevent infection and irritation from clothing. Then discard your gloves.
Make sure the patient is comfortable. According to the physician's preference, inform the patient that he may shower in 1 or 2 days if the incision is dry and heals well.
Properly dispose of the solutions and trash bag, and clean or dispose of soiled equipment and supplies according to your facility's policy.

Special considerations

Be sure to check the physician's order for the time of suture removal. Usually, you'll remove sutures on the head and neck 3 to 5 days after insertion; on the chest and abdomen, 5 to 7 days after insertion; and on the lower extremities, 7 to 10 days after insertion.
If the patient has interrupted sutures or an incompletely healed suture line, remove only those sutures specified by the physician. He may want to leave some sutures in place for an additional day or two to support the suture line.
If the patient has both retention and regular sutures in place, check the physician's order for the sequence in which they are to be removed. Because retention sutures link underlying fat and muscle tissue and give added support to the obese or slow-healing patient, they usually remain in place for 14 to 21 days.
Be particularly careful to clean the suture line before attempting to remove mattress sutures. This decreases the risk of infection when the visible, contaminated part of the stitch is too small to cut twice for sterile removal and must be pulled through tissue. After you have removed mattress sutures this way, monitor the suture line carefully for subsequent infection.
If the wound dehisces during suture removal, apply butterfly adhesive strips or Steri-Strips to support and approximate the edges and call the physician immediately to repair the wound.
Apply butterfly adhesive strips or Steri-Strips after any suture removal, if desired, to give added support to the incision line and prevent lateral tension on the wound from forming a wide scar. Use a small amount of compound benzoin tincture or other skin protectant to ensure adherence. Leave the strips in place for 3 to 5 days, as ordered.

Home care

Documentation

Record the date and time of suture removal, type and number of sutures, appearance of the suture line, signs of wound complications, dressings or butterfly strips applied, and the patient's tolerance of the procedure.

HOW TO PUT ON STERILE GLOVES

2010-10-31T22:41:00.000-07:00

Using your nondominant hand, pick up the opposite glove by grasping the exposed inside of the cuff.

Slip the gloved fingers of your dominant hand under the glove of the loose glove to pick it up.

Pull the glove onto your dominant hand. Be sure to keep your thumb folded inward to avoid touching the sterile part of the glove. Allow the glove to come uncuffed as you finish inserting your hand, but don't touch the outside of the glove.

Slide your nondominant hand into the glove, holding your dominant thumb as far away as possible to avoid brushing against your arm. Allow the glove to come uncuffed as you finish putting it on, but don't touch the skin side of the cuff with your other gloved hand.

HOW TO MAKE MONTGOMERY STRAPS

2010-10-28T05:51:00.000-07:00

An abdominal dressing requiring frequent changes can be secured with Montgomery straps to promote the patient's comfort. If ready-made straps aren't available, follow these steps to make your own:

Cut four to six strips of 2â€³ or 3â€³ wide hypoallergenic tape of sufficient length to allow the tape to extend about 6â€³ (15.2 cm) beyond the wound on each side. (The length of the tape will vary according to the patient's size and the type and amount of dressing.)
Fold one of each strip 2â€³ to 3â€³ (5 to 7.5 cm) back on itself (sticky sides together) to form a nonadhesive tab. Then cut a small hole in the folded tab's center, close to its top edge. Make as many pairs of straps as you'll need to snugly secure the dressing.
Clean the patient's skin to prevent irritation. After his skin dries, apply a skin protectant. Then apply the sticky side of each tape to a skin barrier sheet composed of opaque hydrocolloidal or nonhydrocolloidal materials, and apply the sheet directly to the skin near the dressing. Next, thread a separate piece of gauze tie, umbilical tape, or twill tape (about 12â€³ [30.5 cm]) through each pair of holes in the straps, and fasten each tie as you would a shoelace. Don't stress the surrounding skin by securing the ties too tightly.
Repeat this procedure according to the number of Montgomery straps needed.
Replace Montgomery straps every 2 to 3 days or whenever they become soiled. If skin maceration occurs, place new tapes about 1â€³ (2.5 cm) away from any irritation.