Removing Staples....

TazziRN, RN · Oct 18, 2007

One technique I learned after my c-section that I've told my pts with staples: put bacitracin ointment on them daily, it prevents or minimizes any crusty sticking between the skin and staples. It will still hurt in the knees but at least there won't be that extra pinch with each staple pulled.

CapeCodMermaid, RN · Oct 18, 2007

Bacitracin is not a good recommendation. It causes the overgrowth of all sorts of other nasty bugs. I won't let it in my building.

caliotter3 · Nov 26, 2007

Interesting comment on bacitracin. See it everywhere.

jnette, ASN, EMT-I · Nov 26, 2007

Interesting comment on bacitracin. See it everywhere.

And this is truly the first time I have ever heard/read about it... right here! :eek:

We use a LOT of bacitracin. :uhoh21:

Any article links to back that up? Might want to send this on to our agency clinical director or WC folks for discussion. hmmmmmmm.

Is Neopsporin any better? Any recommendations?

Home Health Columnist / Guide · Nov 27, 2007

Difference between bacitracin and bactroban.

We only use peroxide and h20, no ointment.

Patients with edema I reluctant to remove staples....remove every other one especially if c/o discomfort; if really miserable, I'll stop and send to MD especially if repeat and suspect infection or too much fluid beneath knee. Bracing either side of incision with 3 fingers over knee then gently removing AFTER I soaked areas with peroxide if too crusty helps. ...slap those steri strips on ASAP too.

General

As with other antibiotic preparations, prolonged use of POLYSPORIN Ophthalmic Ointment may result in overgrowth of nonsusceptible organisms including fungi. If superinfection occurs, appropriate measures should be initiated.

Bacterial resistance to POLYSPORIN Ointment may also develop. If purulent discharge, inflammation

http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=2276

CapeCodMermaid, RN · Nov 27, 2007

Peroxide??? It's against CMS guidelines to use peroxide full strength or even 1/2 strength. It is cytotoxic. It's another product I won't allow in the building. Sorry I can't cite an article about bacitracin but I do remember reading about it and hearing it from one of the infectious disease docs at the hospital. If we keep slapping antibiotic ointment on wounds without cause, we are doomed to more resistant bacteria.

Home Health Columnist / Guide · Nov 27, 2007

trying to get doctors to change practice standards is a challenge!

there is a difference between wd care to fresh surgical incision and chronic wound care too.

most of our surgical wd care is clean soap and water or nss, air dry or if scant drainage, dry sterile dressing. most stappled wounds are open to air 2-3 days post op for our otho patients.

caution: common topicals may be hazardous to your patient’s health

pg 2

topical antibiotic creams have been
implicated as a common cause of
allergic contact dermatitis per a recent
mayo clinic study reported at the 2006
american academy of dermatology
convention. the top ten allergens
found in contact dermatitis are:
• nickel
• gold
• balsam of peru (found in
granulex and xenaderm)
• thimerosol (found in vaccine)
• neomycin sulfate (found in first
aid creams including triple
antibiotic ointment [tao])
• formaldehyde
• cobalt chloride
• bacitracin
• quanternium 15
• fragrance mix

http://www.nesao.com/15032_nes.pdf

good resource produced by pa's quality improvment org

quality insights of pennsylvania

surgical wound care: patient self care booklet

ceu article:

surgical wound infections in the intensive care unit the nurse's role

journal of wound, ostomy and continence nursing, september/october 2007

topical therapy

principles of surgical wound healing are similar to those of any wound, including moisture balance in the wound and attention to systemic factors necessary for wound healing and tissue repair. the first postoperative dressing change may be performed by the surgeon, but additional changes are often performed by nurses. the specifics of wound care vary, depending on whether the wound is expected to heal by primary or secondary intention; wounds healing by primary intention are closed at the surface, whereas wounds healing by delayed primary or secondary intention are left open to drain. careful selection of a dressing that matches the goals of topical therapy, compliance with principles of asepsis or appropriate clean technique, and adherence to universal precautions are essential to optimal healing. primary intention healing requires approximating the edges of the wound with a mechanical device such as sutures, staples, or adhesive strips for minimal scar formation. occasionally when dead tissue has been removed, the surgical incision is left open to heal by delayed primary intention. in this case, the wound edges are initially left open and brought together within 4 to 6 days before granulation tissue can be seen. healing by delayed primary intention is frequently used after traumatic injuries and in dirty wounds.
1,35,36

the dressing for wounds healing by primary intention is usually left in place for 24 to 48 hours unless significant drainage or bleeding from the wound site occurs. the goal of the dressing is to provide a bacterial barrier until re-epithelialization has taken place and the wound closes. the decision to remove the dressing using clean or aseptic technique varies according to the condition of the wound and the patient's overall health. regardless of the technique employed, care is taken to prevent infected materials from contacting the wound.
6,7,20,33 the wound is gently packed with moist sterile gauze and dressing changes are performed every 4 to 6 hours during wound healing. closed wounds can be sufficiently cleaned with normal saline. however, if it is established that there is some kind of infection in the wound, it can be cleansed with hydrogen peroxide, iodine, or acetic acid, according to the type of microorganisms present. 37

systemic measures to promote wound healing by primary intention should maximize incisional blood flow and oxygenation. specific strategies include maintenance of adequate hydration, aggressive pain management to prevent excessive sympathetic stimulation and vasoconstriction, measures to keep the patient (and wound bed) warm, and emotional support to minimize anxiety.
6,7,20,33

secondary intention healing occurs when the wound is infected or there has been excessive trauma or skin loss. in this case, the wound edges are left open and closure requires formation of granulation tissue, contraction of the wound edges, and epithelial resurfacing.
1,35,36 in many situations, the process of wound healing is further complicated by patient characteristics or comorbidities that interfere with healing such as advanced age, immunosuppression, radiotherapy or chemotherapy, administration of corticosteroids, malnutrition, diabetes mellitus, or vasopressor therapy. 35

during the dressing change in wounds healing by secondary intention, the nurse should assess the wound for color, odor, and amount of drainage.
38,39 wounds characterized by red healthy tissue should be kept lightly moist and protected from excessive trauma until healing occurs. the optimal dressing is selected based on the wound's depth, presence of tunneling or undermined areas, and the volume of exudate. wounds with significant depth or tunneling and moderate to large amounts of exudate are ideally managed with an absorptive dressing such as an alginate, while wounds with depth but minimal amounts of exudate are usually best managed with amorphous gels, damp fluffed gauze, and a transparent film cover dressing. wounds that are infected or critically colonized may be dressed with a dressing that contains an anti-infective agent such as a sustained release iodine or topical antibiotic. 38-40 in recent years there has been an increase in the availability of silver impregnated dressings. silver and silver compounds are used successfully in the treatment of acute and chronic wounds for their property of inhibiting multiple types of bacteria. 6,7,26,36

in wounds with necrotic tissue, a topical therapy is selected that removes necrotic tissue and establishes a clean wound bed.
38-40 debridement options would include enzymatic agents containing collagenase, papain-urea, or papain-urea with a chlorophyllin-copper complex or with dressings that maintain a moist wound bed that supports autolysis. wounds with more extensive necrosis may undergo sharp or mechanical wound debridement as well.

wounds left to heal by tertiary intention are left open until the infection has been controlled and a clean wound bed is achieved. in this case, the edges are brought as closely together as possible and sutured in place only after infection has been eradicated, and necrotic tissue excised. in general the scar that is left after healing by secondary or tertiary intention is wider and deeper than scars left after healing by primary intention.
39

topical therapy for wounds left to heal by tertiary intention may include autolytic or enzymatic debridement to eliminate necrotic tissue, agents to reduce the bacterial load on the wound surface, and vacuum-assisted closure devices to create a well-vascularized wound bed prior to surgical closure.
6,7,26,36