How to prep around infected tissue?

[LAM2010, BSN]

Hi, I've been an OR nurse for a year and a half now, and just when I think I know how to do something, I won't get a case like it in months and then by the time I go to do it in a case, someone tells me I do it wrong.

You prep clean to dirty. An infected wound is dirty. AORN articles I've found are vague.

I don't know where to start with a nasty infected wound. And what if it's on the arm - you've got the dirty wound, then you've got the armpit... so frustrating....

And of course when I have a more experienced person showing me, I'm under pressure because her arm's getting tired holding a big fat leg, and the surgeon is standing there waiting. So I retain nothing.

What source can I go to for definitive answers and not vague ones?

p.s. I think that one reason we starting prepping the foot at the amputation site (then continuing up the leg to the knee) could be that, since I'll be holding this leg by myself with no help, I have no choice but to prep that way... ? I hate for that to be acceptable, if this is why someone just told me to do that today.

Thanks,

Lori

[canesdukegirl, BSN, RN]

I had one of these today, in fact. We had a big open infected wound. We prepped inside the wound with CHG from the middle to the outer edges. Then we used Chloraprep to finish prepping out the skin, working from just around the edges of the wound outward.

[brownbook]

Hi, I am not an OR nurse. I work pre and post op. I have occasionally done moderate sedation in the OR.

I can sympathize with your feelings, frustration. Sounds like situations I get myself into far too often. FINALLY after nursing for almost 20 + years (in a wide variety of areas), I am learning, getting comfortable with, asking a doctor or surgeon, "How do you want this done?"

Every journal you read might give vague or even conflicting information. Every surgeon you ask might give a different answer.

The surgeon was standing there. Simply say, "how do you want this preped?" Most men (hate to be a sexists, but still most surgeons are male) like specific direct questions. I remind myself of this before I ask my "dumb" question. Probably a better way to ask in that case would be. "Do you want me to scrub the wound with _________." (name the specific prep you normally use.)

You don't have to, and l NEVER will, know all the answers. If the surgeon gives you the "look" (rolling of the eyes, etc.) or an exasperated sigh, just toughen up you skin. (I know easier said than done, only took me 20 years!) Your question is completely appropriate!!!

Please excuse any spelling or typos, my spell check suddenly disappeared?

[michele742]

@brownbook - Great! Sounds like if I ever become an OR nurse, I will be well prepared with 18 years of marriage to my wonderful, eye-rolling, sarcastic husband :) He is the 'master' of it...lol! (I say that lovingly, of course).

[LAM2010, BSN]

I am back on here, almost 4 years later! LOL But this was good advice!

One of my challenges as a "newer" nurse back then, was that *I* wanted to have the knowledge and know the best practices about how to prep (or any other skill). Sometimes surgeons are not correct or don't do it the best way - Honestly. Some say "however you want". Some will tell you exactly what you're doing wrong without you having to ask (or needing their input...). One surgeon even "tested" me -- an older, really nice, really experienced surgeon -- "Aren't you going to prep around the wound first?" And I said, "...No, I'm going outside in, she's infected..." And he said, "Yes! I was just testing you." (I wasn't offended, because I knew the surgeon a little better). If it's "that" surgeon who is very picky and demands you do it his way, then I do it within reason. Almost all of them use correct technique. But since I left that job and went to a new one... and worked with staff from the most "reputable" medical center in town and their prepping techniques made me cringe.... I knew I was trained VERY well at my first job (small hospital in the country). :)

[RobtheORNurse]

Clean to dirty

[NedRN]

Clean to dirty is the "right" way, but the truth is that it seldom matters. You are working on the "dirty" part, right? Whether it is an open wound or lady parts. Do bugs dragged outside the actual surgical area matter? No. But I doubt you will find a definitive reference or study so you will have to take that as opinion, common sense though it might be.

That said, sometimes there is a secondary dirty area that could make a difference, such as an armpit or foot that needs to be prepped into the field but is not part of the incision or wound. I would do those last as you don't want to drag in those "bugs" to an area with different microbiome. That is also obviously icky, but again good luck finding a definitive source.

[Rose_Queen, BSN, MSN, RN]

We do a multi-stage prep: prep the dirty area, then get new prep supplies and prep around the dirty area. If possible, we isolate the dirty area. For example, if we were doing abdominal surgery on someone with a colostomy, we would prep around the colostomy then the colostomy itself, then cover with counted sponge and tegaderm. Get second set of prep supplies and prep rest of abdomen and over the tegaderm. Whenever possible, we exclude dirty areas from the surgical field: if we have a BKA and the patient's toes are necrotic and gangrenous, we would prep to mid foot and then cover with an impervious stockinette to about mid calf and then secure with coban. The way my specialty team preps infected incisions that are coming back for I&D is to prep the incision, change gloves, use fresh sponges, and prep around the area. It's still a contaminated (Class IV) wound, but at least we aren't bringing bacteria from the periphery of the prep back to the surgical area, and we aren't spreading the microorganisms from the infection to the rest of the surgical field.