HHC Health & Home Care Clinical Policy And

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HHC HEALTH & HOME CARE Section: 7-8 Skin Care: Dressing Changes __RN 2. Instruct patient/caregiver in care of the wound including: a. Reporting any changes in pain, drainage, temperature, or other signs and symptoms of infection. b. Techniques to change or reinforce dressings. It is not routine to teach lay people to pack wounds. c. Diet to promote healing. d. Medications/disease processes that may be impeding healing. e. Activities permitted. 114
HHC HEALTH & HOME CARE Section: 7-9 Skin Care: Wound Care Using A Collection Pouch __RN PURPOSE: To manage a draining wound by protecting the surrounding skin from irritating drainage, to allow measurement of drainage, and to protect the wound from trauma and external contamination. CONSIDERATIONS: 1. There are two major methods for managing a draining wound: a. Dressing. b. Pouching. (See Dressing Changes, No. 7.08.) 2. Pouching is the better choice when skin integrity is compromised by caustic or copious drainage. *Rule of thumb - IF wound drains more than 50cc output in 24 hours, a pouching procedure should be considered. 3. Wound pouching provides accurate measurement of drainage, eliminates the need for frequent dressing changes, limits the spread of contamination, and improves the patient’s comfort. 4. Irrigation of the wound and pouch usually accompanies the pouching procedure. Collection pouches are available which are especially designed for wound care management. EQUIPMENT: Impervious trash bag Instruments, e.g., forceps, scissors Protective bed pad Gloves Apron or gown (optional) Protective eye wear (optional) Collection pouch (with access port if irrigation ordered) Skin protectant Sterile gauze pads Waterproof or micropore tape Graduated, collection container -optional IF IRRIGATION ORDERED EQUIPMENT: Clean basin Prescribed irrigant such as sterile normal saline Sterile, soft-rubber catheter 50cc to 60cc piston syringe Container PROCEDURE: 1. Adhere to Universal Precautions. 2. Review the physician’s orders. 3. Explain procedure to patient. 4. Prepare materials and equipment for wound care including opening impervious trash bag and establishing the sterile field. 5. Empty the collection pouch by inserting the bottom half of the pouch into a graduated, collection container and open the drainage port. Observe the color, consistency, odor, and amount of fluid. Wipe the bottom of the pouch and the drainage port with a gauze sponge to remove any spillage that could irritate the patient's skin or cause an odor. Close the access port. 6. Observe for: a. Wound size including length, width, and depth. b. Drainage characteristics including type, amount, color, and odor. c. Evidence of wound healing or deterioration. d. Symptoms of infection including redness, swelling, pain, discharge, or increased temperature. e. Development of undermining or sinus tract that may require packing. 7. Observe the collection pouch for leakage, nonadhesion of the pouch including undermining of the seal, or malfunction of pouch. Change pouch every 5-7 days or more frequently if seal is broken. Unnecessary change may contribute to skin irritation. 8. Changing the pouch: a. Remove leaking pouch using the push-pull method to avoid trauma to skin. Hold skin taut and gently remove facing from skin by pushing skin away from facing. b. Don clean gloves and cleanse wound and/or irrigate the wound as ordered. (See Wound Irrigation, No. 7-12.) c. Remove gloves and discard in appropriate container. Measure the wound and pattern an opening 1/8" (0.3 cm) larger in the collection pouch's facing or face plate if collection pouch has a skin protectant incorporated in the faceplate. d. If pouch does not have wafer barrier/skin protectant, apply wafer barrier skin protectant as needed. e. Make sure the drainage port at the bottom of the pouch is securely closed. Gently press the contoured pouch opening around the wound beginning at the wound's lower edge to catch any drainage. Picture frame taping may be advisable to achieve more pouching security. Apply strips of tape to cover each of the four sides of the facing. 115
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