Wound Management
Wound Management is ofton feared by the student and it should not be. It is one of the lab Simulations and ought to be firm in our minds. There will of course be variations unique to each wound and each pt.
The mneumonic I made up for this is "ACT DR" I think of a nurse finding a wound and inciting the physician to write orders for wound care.
As with all AOC the critical elements start with complying with established guidelines which include pt safety, asepsis, emotional well being,privacy,standard precautions, and promotion . It is a good idea to gather all supplies BEFORE commencing any wound care.The usual supplies include but are not limited to: a water proof bag for disposal of old contaminated dressings,clean gloves, sterile gloves,any topical preparations needed, adhesive tape, the dressing actually needed,sterile scissors,and chux to protect the bed. You may need a gown to protect clothes from a weeping wound. Check the expiration date on any supplies. This assures sterility of the product. Be sure the old dressing is not dragged accross the wound or surrounding skin. This AOC will be treated as a medication administration so IDENTIFY your pt before you begin!!!!!!
A- Assess wound. this is done, of course after the removal and disposal of the old dressing. you will need to observe the qualities of the wound. Location, size, type(puncture, surgical incision,abrasion,decubiti ect) observe the wound bed for color , drainage and any odor. Drainage needs to be accurately described as a change could signal progress or deterioration in a wound.Common drainage types include:seous, sero-sanguinous, purulant or sanguinous. Especially with purulant drainage ,specify color ,viscosity, amount and odor.
C- Cleanse and irrigate. I am putting the two of these together. The dressing order should designate the type of solution for cleansing or irrigation.The usual is room temp solution, but be aware that this may be designated also. If Betadine is ordered, ask the pt if they have an allergy to iodine.This is also a good time to find out if they have an adhesive allergy.Protect the bed and pt from the irrigation return.Observe the characteristics of the irrigation return.Dry off the surrounding skin tissue.
T-topical preps. These are ordered and will be specified on the Kardex. Treat these as you would a medication.
D-Dressing. apply the ordered dressing over the wound.If this is a sterile wound remember to open up all the supplies maintaining sterility and donning sterile gloves.Securely tape your dressing in place. Initial, date and time it as you would in the sim lab.
R- Record. All the information gathered during the wound management needs to be recorded from the wound appearance , irrigation return and pt response.SIGN the MAR!. this is an area many forget. Do not mess up a good dressing change with a flub here!
And you are done! Not so bad is it?
The mneumonic I made up for this is "ACT DR" I think of a nurse finding a wound and inciting the physician to write orders for wound care.
As with all AOC the critical elements start with complying with established guidelines which include pt safety, asepsis, emotional well being,privacy,standard precautions, and promotion . It is a good idea to gather all supplies BEFORE commencing any wound care.The usual supplies include but are not limited to: a water proof bag for disposal of old contaminated dressings,clean gloves, sterile gloves,any topical preparations needed, adhesive tape, the dressing actually needed,sterile scissors,and chux to protect the bed. You may need a gown to protect clothes from a weeping wound. Check the expiration date on any supplies. This assures sterility of the product. Be sure the old dressing is not dragged accross the wound or surrounding skin. This AOC will be treated as a medication administration so IDENTIFY your pt before you begin!!!!!!
A- Assess wound. this is done, of course after the removal and disposal of the old dressing. you will need to observe the qualities of the wound. Location, size, type(puncture, surgical incision,abrasion,decubiti ect) observe the wound bed for color , drainage and any odor. Drainage needs to be accurately described as a change could signal progress or deterioration in a wound.Common drainage types include:seous, sero-sanguinous, purulant or sanguinous. Especially with purulant drainage ,specify color ,viscosity, amount and odor.
C- Cleanse and irrigate. I am putting the two of these together. The dressing order should designate the type of solution for cleansing or irrigation.The usual is room temp solution, but be aware that this may be designated also. If Betadine is ordered, ask the pt if they have an allergy to iodine.This is also a good time to find out if they have an adhesive allergy.Protect the bed and pt from the irrigation return.Observe the characteristics of the irrigation return.Dry off the surrounding skin tissue.
T-topical preps. These are ordered and will be specified on the Kardex. Treat these as you would a medication.
D-Dressing. apply the ordered dressing over the wound.If this is a sterile wound remember to open up all the supplies maintaining sterility and donning sterile gloves.Securely tape your dressing in place. Initial, date and time it as you would in the sim lab.
R- Record. All the information gathered during the wound management needs to be recorded from the wound appearance , irrigation return and pt response.SIGN the MAR!. this is an area many forget. Do not mess up a good dressing change with a flub here!
And you are done! Not so bad is it?
posted by taming the beast at 10:22 AM
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