COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 705 Effective Date: August 31, 2006 SUBJECT: EMERGENCY CARE OF WOUNDS (FIRST AID) 1. PURPOSE: Proper wound care is necessary to promote an intact skin layer after healing. The integument system is the body s first line of defense against invasion by infectious microorganisms. Wound healing involves a series of physiological processes. These processes can be affected by location, severity, and extent of the injury. The purpose of this policy is to identify the different kinds of wounds and the appropriate care for each while observing proper blood and body fluid precaution and preventing infection. 2. POLICY: 1. All Individuals shall receive prompt and appropriate care of their wounds along with teaching and guidance on how they can help in their care. 2. Nursing staff will check if the Individual s tetanus vaccination is current and will obtain a physician s order to give the Tetanus-Diphtheria Adult Toxoid if the vaccination is not current. (Refer to Infection Control Manual Immunization Protocols for the schedule of primary immunization for Tetanus - Diphtheria Adult Toxoid protocol). 3. PRECAUTIONS: 1. The fluid blood & moist body substances of all Individuals shall be treated as though they were contagious. Refer to universal precautions infection control 2. In all reasonably anticipated exposures to blood or other potentially infectious material, Personal Protective Equipment (PPE) and engineering controls shall be used. 4. DEFINITIONS: A wound is an injury to the tissues of the body causing disruption of the normal tissue pattern, such as an injury caused by a physical means. -1-
5. CLASSIFICATION OF WOUNDS: A) Contusion - Closed wound caused by a blow to body by blunt object; a bruise characterized by swelling, discoloration, and pain. B) Laceration - Made by an object which tears tissue, producing jagged irregular edges. C) Puncture - A wound in which a foreign object, usually pointed or sharp in nature, pierces the skin. D) Incised - A clean cut made by a sharp instrument, such as a knife. E) Abrasion - Superficial wound involving scraping or rubbing of skin s surface. 6. GENERAL INFORMATION: A) Clean Wound: Wound containing no pathogenic organisms. This wound, like a surgical incision, is aseptically made and does not enter the alimentary, respiratory, or genito-urinary tract. There is low risk of infection. B) Clean-contaminated Wound: Wound made under aseptic conditions but involving a body cavity that normally harbors microorganisms, e.g. surgical wound entering the gastrointestinal, genito-urinary, respiratory tract, or oropharyngeal cavity under controlled conditions. There is a greater risk of infection than with clean wound. C) Contaminated Wound: Wound existing under conditions in which presence of microorganisms is likely. Open, traumatic, accidental wounds; surgical wound in which break in asepsis occurred. Tissues are often not healthy and show inflammation. There is a high risk of infection. D) Infected Wound: A wound or incision invaded by a pathogenic agent like a bacteria, virus, or fungi and under favorable conditions multiplies causing injurious effects. Any wound that does not properly heal and grows organisms. Wound presents signs of infection (inflammation, purulent drainage, skin separation) -2-
7. EQUIPMENT NEEDED: -Disposable gloves -Gown (if wound is infected and purulent) -Forceps -Dressing and materials (e.g. gauze, bandages) -Tape -Scissors -Red bag for infectious waste and bio-hazardous waste container 8. EXPECTED OUTCOMES: -Stop bleeding; -Protect from contamination and infection; -Prevent shock; -Wound begins to heal; dressing is clean and dry; wound is free of drainage and inflammation; -Skin integrity is maintained. 9. ASSESSMENT: -Establish history and circumstances of how the wound occurred including physical factors involved. -Ascertain the time the incident happened. -Determine history of allergies and of past tetanus immunization. -Inspect the wound by checking for depth of the wound; nerve, vessel, or tendon involvement; bone injury; foreign bodies; general extent of wound contamination; and odor. -Assess drainage from wound (amount, color) and consistency of drainage. 10. INTERVENTIONS/IMPLEMENTATION: Controlling bleeding: NURSING ACTIONS KEY POINTS A. Put on gloves. A. Follow Standard Precautions. B. Assess the injury. B. Determine type and extent of injury. C. Have other staff notify physician and HSS. C. Prompt intervention is vital to alleviating and treating the trauma. Red Bag should be brought to the site. Dial 7119 for Non-Life Threatening Medical -3-
Emergencies. D. Apply direct pressure using thick pad, towel, or your gloved hand and elevate affected part if it does not cause pain. E. If bleeding is not controlled by direct pressure, apply pressure to a pressure point. F. When bleeding is under control, gradually release pressure point; but maintain direct pressure on wound. G. Avoid the use of a tourniquet unless a limb has been completely severed. H. Assess for shock and treat when indicated. D. Control bleeding by applying direct pressure. If a dressing becomes saturated with blood, add another layer of dressing. Continue to apply pressure. Elevation of the affected part aids in reducing the bleeding. E. Monitor Vital Signs including pain rating assessment. Be alert for signs and symptoms of shock. F. Refer to NPPM #715 Emergency Care of Hemorrhage. G. Tourniquets are restricted to lifesaving measures only. H. Refer to NPPM #707 Shock. Cleansing wounds: NURSING ACTION KEY POINTS A. Hand hygiene A. Reduces transmission of microorganisms. B. Assemble supplies and materials needed. Explain the procedure to the Individual. B. Explaining the procedure to the Individual assists with gaining the Individual s cooperation and allaying Individual anxiety. C. Put gloves on. C. Maintain Standard Precautions. D. If a specimen is needed for culture and sensitivity, swab infected area with maximum saturation of cotton-tipped culture swab and place it back into the culture tube. D. Specimen for culture is best obtained before the wound is cleaned. -4-
E. Cleanse small wound with mild soap and water. Rinse thoroughly with clean water. F. Clean large or deep wounds only when ordered by physician. G. Surgical incisions are cleaned along the edge in small circular motion. Do not scrub back and forth across the incision line. H. Apply clean and dry dressing using only the amount of tape necessary to securely attach the dressing. I. Dispose of blood soaked contaminated materials and dressings in the biohazardous container. E. Gentle cleansing of a wound removes contaminants that might serve as sources of infection. Most antiseptic agents are caustic to tissues and may impair tissue healing. F. Follow physician s order as prescribed. G. To prevent contamination and mechanical trauma to the incision. H. Too much tape may cause irritation and trauma to the skin. I. To prevent transmission of pathogenic organisms. 11. INDIVIDUAL TEACHING: Instruct Individual on wound care and explain why these steps are necessary. Instruct the Individual in the following: 1. To ask for pain medication if needed. 2. Report immediately to the nursing staff if any of the following signs occur: a. Redness or swelling; b. Increased warmth around the wound; c. Pus, unusual drainage, and/or foul odor from the wound; d. Presence of red streaks around the wound e. Fever above 100º Fahrenheit or chills. Discuss what activities the Individual is allowed to undertake while the wound ishealing. 4. Keep suture area clean. Avoid tub baths. 5. Never rub vigorously near the suture line and pat dry after shower. 6. Show the Individual how to support the incision when coughing. -5-
7. Avoid touching the incision or wound area (as well as drainage tubings if present) to prevent infection. 12. EVALUATION/DOCUMENTATION: Include the following in the documentation about the wound and the care given: 1. Describe the type of wound, e.g. surgical, accidental or inflicted injury. 2. Indicate location, size, condition of the wound and amount of drainage. 3. Identify if Individual is experiencing any pain or discomfort. 4. Describe the wound care provided. 5. Individual teaching given and his or her understanding of these. 6. Discuss and document the Individual s perceptions and feelings regarding the wound, especially if this may cause scaring or disfigurement after healing. 7. Monitor and report healing progress. -6-