University:
West Coast University
Course:
NURS 100 | Fundamentals of Nursing
Academic year:

2021
Views:

290

Pages:

1
Author:

5prinzg1s

ACTIVE LEARNING TEMPLATE: Nursing Skill STUDENT NAME _____________________________________ Wound Care SKILL NAME____________________________________________________________________________ REVIEW MODULE CHAPTER ___________ Description of Skill Preforming wound cleaning or irriagtion Indications - Wound care per orders - Replacment of soilded dressing - Wound harbors a biofilm - Wound contains excessive exudate - Wound contains necrotic tissue or debris in wound bed Outcomes/Evaluation - Patient wound will be free from worsening infection for durration of care - Wound will show improvment withing 5 days - Patients wound will remain free of necrotic tissue and debris for durration of care. - Patient will demonstrate wound care using aseptic procedure before discharge. Potential Complications - Worsened Infection - Introduction of microbes into wound - Damage to the wound bed increasing wound healing time. - Reactions to cleansers or medications ACTIVE LEARNING TEMPLATES CONSIDERATIONS Nursing Interventions (pre, intra, post) Pre - Assess appearance of dressing. - Assess wound for size, color, condition, drainage amount, color of drainage, smells. Intra - Maintain sterile field - Maintain sterility of wound and dressings - Note presence of tunneling - Collect required samples before cleaning - Rinse from clean to dirty - Apply clean dressing with date and time Post - Document findings Client Education - Monitor for increased pain at the wound or near the wound. - Monitor for increased drainage of foul odors - Monitor for sudden bleeding - Keep dressing clean and dry - Patient should maintain dietary recomendations of the provider including protein needs. Nursing Interventions - Cleanse wound from clean to dirty - Use gentle friction when cleaning or apply solution to skin. - Isotonic solutions are prefered. - Never use same gauze across wound more than once. - Do not use materials that shed fibers - Use piston syringe or sterile straight catheter for deeper wound irrigation. - Use NS 0.9%, lactated ringers or antibiotic/antimicrobial solutions. THERAPEUTIC PROCEDURE A9