Decubitus Wounds Procedure

DECUBITUS WOUNDS PROCEDURE UNDERSTANDING Decubitus assessment is anbetween examination of local tissueand necrosis which tendsover to occur when soft tissue is compressed bony prominences external surfaces a long period of time. OBJECTIVE a. To thedetermine skin indicators of tissue pressure includes visual and tactile inspection of b. To determine the client's normal skin characteristics and any potential or actual areas of damage c. To obtain further data regarding induration and damage to the skin and underlying tissue. POLICY Carrying out physical examinations and special actions as a result of collaboration PROCEDURE Preparation a. Sterile set b. Alcohol swab c. Sterile gauze d. com for 0.9% NaCl solution e. Anatomical tweezers f. Chirurgi tweezers g. Sterile cotton swab h. Derian tule or cutimed sorbad/topical medicinal ointment i. Plaster scissors j. Plaster/adhesive or hypafix k. Alcohol 70% l. 0.9% NaCl solution m. Clean handscoon n. Sterile handscoon o. Disposable millimeter ruler p. Adequate lighting Procedure: PRE-INTERACTION STAGE a. Assess patient needs according to related actions b. Tools are fully prepared c. The device is brought closer to the patient d. Wash your hands properly ORIENTATION STAGE a. Therapeutic greetings are delivered in a friendly manner b. Correctly identify the patient* c. The purpose of the action is conveyed correctly d. Action procedures are conveyed correctly e. Action steps are presented briefly f. The required time is provided g. Give clients the opportunity to ask questions h. The patient's privacy environment is prepared WORK STAGE Use clean handscoon a. Open the bandage using alcohol cotton and throw it away in the trash can or plastic bag provided b. Observe themillimeter wound, measure the length, depth and width of the woundtheusing a disposable ruler. Then look at the condition of the wound, color around edgeis fluid of theorwound, the color of the wound, the degree of the wound and whetherthe there not. Record all observations Open sterile set a. The gauze istweezers rolled onto the tip of the chirugi tweezers, then one hand holds the anatomical b. Clean sterile gauze has beenthetreated 0.9% NaCl, from the inside the outwound (circularusing movements) whilethat squeezing woundwith to remove the exudate c. The gauze is only used once and replaced again d. Repeat cleaning until all wounds are clean and exudate comes out e. Discard clean handscoon Use sterile handscoon a. Use cuted sorbad for wounds that contain a lot of exudate b. Bandage the wound using sterile gauze. If7 the wound is stillAnd wetiforthestillwound oozingis a lot ofstarting fluid, then wrap the wound with up to layers of gauze. to dry out, just bandage it in 3 layers. Fixation using plaster or hypafix a. Dispose of handscoon and gauze in the appropriate place provided b. Assist the patient in a comfortable position c. Remove and plastic bagsproperly containing dirty bandages and handscoon. Clean theequipment tools and dispose of trash d. Washing hands e. Report anycondition changes inofthe in charge. Note dressing changes, assess the thewound woundtoandthethenurse patient's response TERMINATION STAGE a. Evaluate responses and actions carried out correctly b. The patient is well groomed c. Provide education related to follow-up after the action is taken d. Tools are neatly arranged e. The subsequent time contract was submitted correctly f. Therapeutic greetings are delivered in a friendly manner g. Wash your hands properly