PRACTICAL WOUND DRESSING procedure practical
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This document provides comprehensive guidelines on wound care, including cleaning and dressing techniques, types of wounds, and indications for treatment. It outlines specific types of wounds such as surgical, chronic, and pressure injuries, along with the necessary equipment and procedures for effective management. Key steps include thorough cleansing of the wound, proper dressing application, and regular assessment of the wound condition.
PRACTICAL WOUND DRESSING procedure practical
- 1. Cleaning a Wound and Applying a Dressing (General Guidelines)
- 2. WOUND CARE - A wound is a break in the skin or body tissue caused by injury or surgical incision WOUND CLEANING- A wound must be cleansed thoroughly if they contain contaminants, debris or residual dressing parts. APPLYING & REMOVNG A WOUND DRESSING- Dressings are applied to wounds to prevent from further contamination and to promote wound healing. They should be removed only to perform assessment of the wound or to undertake a specific treatment. General Guidelines
- 3. A wound is an injury that breaks the skin or other body tissue. Wounds can be open, with broken skin and exposed body tissue, or closed when there is damage to tissue under intact skin. TYPES OF WOUND : Penetrating wounds o Puncture wounds o Surgical wounds and incisions o Thermal, chemical or electric burns o Bites and stings o Gunshot wounds, or other high velocity projectiles that can penetrate the body Blunt force trauma- o Abrasions o Lacerations o Skin tears General Guidelines
- 4. Closed wounds are often caused by blunt trauma, and though the injured tissue is not exposed, there can be bleeding and damage to underlying muscle, internal organs and bones. Major types of closed wounds include: Contusions – blunt trauma causing pressure damage to the skin and/or underlying tissues Blisters Seroma – a fluid-filled area that develops under the skin or tissue Hematoma – a blood-filled area that develops under the skin or tissue (occurring when there is internal blood vessel damage to an artery or vein) Crush injuries General Guidelines
- 5. Ulcers Ulcers are a third type of wound of which there are four main types – pressure, venous, arterial and neuropathic. Venous and arterial ulcers are vascular wounds caused by problems with the circulatory system. As their names suggest, they result from insufficient blood flow in the veins and arteries, respectively. Both types are painful, most commonly found on the legs or feet, and can lead to infections such as cellulitis. General Guidelines
- 6. Types of Chronic Wounds 1. Pressure Injuries - Also known as bedsores, pressure sores, or decubitus ulcers, these wounds cause when there is a pressure and/or shearing force on the skin. The people who are more prone to these chronic wounds are with limited mobility due to any medical illness or unable to walk, move all or part of their body to a different position. 2. Diabetic Ulcers - These ulcers generally occur on the feet and are a result of changes to nerves and circulation in the body caused by diabetes. It includes Neuropathic, Ischaemic, and Neuro- ischaemic. General Guidelines Different Types Of Wounds - Wound Care Surgeons. (n.d.). Https://Www.Woundcaresurgeons.Org. https://www.woundcaresurgeons.org/blogs/know-about-different-types-of-wounds
- 7. Surgical wounds are cuts or incisions in the skin by a scalpel or drain placed during surgery. They are usually closed with sutures but are sometimes left open to heal. Signs of infection after surgery include increased pain and redness around the wound, delayed healing, a weeping wound or the presence of pus or a foul smell. General Guidelines
- 8. 01 03 Diagnosis Here you could describe the topic of the section 02 Types of Wound
- 9. 1. provide a temporary protective physical barrier, absorb wound drainage, and provide the moisture necessary to optimize re- epithelialization. Cleaning a Wound and Applying a Dressing • Reduce pain. • Apply compression for hemorrhage or venous stasis. • Immobilize an injured body part. • Protect the wound and surrounding tissue. • Promote moist wound healing. Purpose : Indications:
- 10. 1.Equipment : 1. PPE 2. dressing Kit 3. nonsterile gloves 4. sterile gloves 5. wound cleansing solution or sterile saline 6. sterile 2′′x 2′′ gauze for wound cleansing 7. 4′′ x 4′′ sterile gauze for wound dressing, 8. scissors, and tape (if needed). Antiseptic solution (Iodine) waste receptacle or bag a waterproof pad 9. dressing adhesive or tape Cleaning a Wound and Applying a Dressing
- 11. 1. Review the patient’s health record for prescribed wound care or the nursing care plan related to wound care. Gather necessary supplies. 2. Perform hand hygiene and put on PPE, if indicated. https://opentextbc.ca/clinicalskills/chapter/1-6-hand-hygiene/ 3. Identify the patient. Cleaning a Wound and Applying a Dressing
- 12. 4. Assemble equipment on the overbed table or other surface within reach. 5. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why you are going to do it. 6. Assess the patient for the possible need for nonpharmacologic pain-reducing interventions or analgesic medication before wound care dressing change. Administer appropriate prescribed analgesic. Allow enough time for the analgesic to achieve its effectiveness. Cleaning a Wound and Applying a Dressing
- 13. 7. Place a waste receptacle or bag at a convenient location for use during the procedure. 8. Adjust the bed to a comfortable working height, usually elbow height of the caregiver (VHACEOSH, 2016). 9. Assist the patient to a comfortable position that provides easy access to the wound area. Use the bath blanket to cover any exposed area other than the wound. Place a waterproof pad under the wound site. 10. Check the position of drains, tubes, or other adjuncts before removing the dressing. Put on clean, disposable gloves and loosen the tape or adhesive edge on the old dressings by removing in the direction of hair growth and the use of a push–pull method. Push–pull method: lift a corner of the dressing away from the skin, and then gently push the skin away from the dressing/adhesive. Continue moving fingers of the opposite hand to support the skin as the product is removed (McNichol et al., 2013). Cleaning a Wound and Applying a Dressing
- 14. Carefully lift the adhesive barrier from the surrounding skin to prevent medical adhesive– related skin injury (MARSI). Remove the sides/edges first, then the center. If there is resistance, use an adhesive remover (McNichol et al., 2013). 11. Carefully remove the soiled dressings. If any part of the dressing sticks to the underlying skin, use small amounts of sterile saline to help loosen and remove it. Cleaning a Wound and Applying a Dressing
- 15. 12. After removing the dressing, note the presence, amount, type, color, and odor of any drainage on the dressings. Place soiled dressings in the appropriate waste receptacle. Remove your gloves and dispose of them in an appropriate waste receptacle. 13. Perform hand hygiene. 14. Inspect the wound site for size, appearance, and drainage. Assess if any pain is present. Check the status of sutures, adhesive closure strips, staples, and drains or tubes, if present. Note any problems to include in your documentation. Cleaning a Wound and Applying a Dressing
- 16. Cleaning a Wound and Applying a Dressing 15 Using sterile technique, prepare a sterile work area and open the needed supplies. 16 Open the sterile cleaning solution. Depending on the amount of cleaning needed, the solution might be poured directly over gauze sponges over a container for small cleaning jobs, or into a basin for more complex or larger cleaning. 17 Put on sterile gloves. Alternatively, clean gloves (clean technique) may be used when cleaning a chronic wound or pressure injury.
- 17. Cleaning a Wound and Applying a Dressing 18 19 Once the wound is cleaned, dry the area using a gauze sponge in the same manner. Clean the wound. Clean from top to bottom and/or from the center to the outside. Use new gauze for each wipe, placing the used gauze in the waste receptacle. Alternatively, spray the wound from top to bottom with a commercially prepared wound cleanser; wound irrigation is often used to clean open wounds and may also be used for other types of wounds. Refer to Skill .
- 18. Cleaning a Wound and Applying a Dressing 19 If a drain is in use at the wound location, clean around the drain. Refer to Skills 8-6, 8-7, 8-8, and 8-9.. 20 Remove gloves and place them in the waste receptacle. Perform hand hygiene. 21 Once the wound is cleaned, dry the area using a gauze sponge in the same manner. 22 Apply any topical medications, foams, gels, and/or gauze to the wound as prescribed; ensure products stay confined to the wound and do not impact on intact surrounding tissue/skin. 23 Put on sterile gloves. Alternately, clean gloves (clean technique) may be used when cleaning a chronic wound or pressure injury. Apply a skin protectant or barrier to the healthy skin around the wound where the dressing adhesive or tape will be placed and where wound drainage may come in contact with the skin.
- 19. Cleaning a Wound and Applying a Dressing 25 26 As necessary, apply a surgical or abdominal pad (ABD) over the gauze at the site of the outermost layer of the dressing, with the side of the dressing with the blue line facing away from the patient. Alternately, note the side of the dressing that contains the moisture barrier and place away from the patient, based on the dressing material in Apply tape, Montgomery straps, or roller gauze to secure the dressings. Alternately, many commercial wound products are self- adhesive and do not require additional tape. Remove and discard gloves. 24 Gently place a layer of dry, sterile dressing or other prescribed cover dressing at the wound center and extend it at least 1 in beyond the wound in all directions. Alternately, follow the manufacturer’s directions for application. Forceps may be used to apply the dressing.
- 20. Cleaning a Wound and Applying a Dressing 28 29 Remove PPE, if used. Perform hand hygiene. Check all wound dressings at least every shift. More frequent checks may be needed if the wound is more complex or dressings become saturated quickly. After securing the dressing, label it with date and time. Remove all remaining equipment; place the patient in a comfortable position, with side rails up as indicated and bed in the lowest position. 27
- 21. Thank you! Prepared by: Eloisa M. Bonus, RN MAN