Krystal Gail Consumo LlanoraVictoria Healthcare ClinicMarch 2, 2011

INTRODUCTIONWound care is very important part of Nursing procedure in any health care setting. Wound come in all sizes and forms, and each one offers unique challenges to infection prevention.Wound is a type of injury in which a skin is torn, cut or punctured (open wound) or where blunt force trauma causes contusion (closed wound).

INTRODUCTIONDressing is an adjunct used by a person for application to a wound to promote healing and/or prevent further harm. A dressing is designed to be in direct contact with wound, which makes it different from a bandage, which is primarily used to hold a dressing in place.

CORE PURPOSES OF A DRESSING:A dressing can have a number of purposes, depending on the type, severity and position of the wound, although all purposes are focused towards promoting recovery and preventing further harm from the wound.

KEY PURPOSES OF DRESSING ARE:Stem Bleeding helps seal the wound to expedite the clotting process.Absorb exudates soak up blood, plasma and other fluids exuded from the wound, containing it in one place.Ease pain some dressing may have a pain relieving effect, and others may have placebo effect.

KEY PURPOSES OF DRESSING ARE:4. Debride the wound removal of slough and foreign objects from the wound5. Protection from infection and mechanical damage6. Promote healing through granulation and epithelialization.

CLASSIFICATION OF A WOUND:Size of the Wound Large wounds are more serious than small ones, they usually involve more severe bleeding, more damage to the underlying organs or tissues, and greater degree of shock.Small wounds are sometimes more dangerous than large ones; they may become infected more readily due to neglect

CLASSIFICATION OF A WOUND:Location of the Wound since the wound may involve serious damage to the deeper structures, as well as to the skin and the tissue immediately below it, the location of the wound is important

CLASSIFICATION OF A WOUND:Types of wounds: Abrasions made when skin is rubbed or scraped off. Rope burns, floor burns and skinned knees or elbows are common examples of abrasions. It can be infected easily because dirt and germs may be embedded in the tissues.Incisions commonly called CUTS, are wounds made by sharp cutting instruments such as knives, razors and broken glass. It tends to bleed freely because the blood vessels are cut cleanly and without ragged edges.

CLASSIFICATION OF A WOUND:Types of wounds:Lacerations wounds are torn rather than cut. They have ragged, irregular edges and masses of torn tissue underneath. Usually made by blunt, rather than sharp objects. Punctures caused by objects that penetrates into the tissues while leaving a small surface opening. Wounds made by nails, needles, wire and bullets are usually punctures.

CLASSIFICATION OF A WOUND:Types of wounds:Avulsions is the tearing away of tissue from a body part. Bleeding usually heavy. In certain situations, the torn tissue may be surgically reattached.Amputations is a nonsurgical removal of the limb from the body. Bleeding is heavy and requires a tourniquet to stop the flow. Shock is certain to develop in these cases.

THINGS USUALLY USED WHEN DOING WOUND DRESSING:

Sterile tray (small cup, forceps, Kelly, scissors and etc)Sterile gauze (melolin, urgosterile)Vaseline gauze (urgotul)Adhesive tape (urgosyval, urgoderm)NaCl and Betadine Lidocaine spray (if necessary)Clean gloves, waste bin, under padSyringe (for irrigation)

STEPS TO FOLLOW FOR A WOUND DRESSING:(if the patient comes after an accident, call the doctor first to assess the wound before doing wound dressing)Check the severity and type of wound Do the medical hand washing and put on a pair of non-sterile glovesExplain procedure and prepare equipmentsPrepare the patient and position carefullyClean the wound with hydrogen peroxide (you can pour the hydrogen peroxide directly but make sure that the tip of the container doesnt touch the wound

STEPS TO FOLLOW FOR A WOUND DRESSING:(if the patient comes after an accident, call the doctor first to assess the wound before doing wound dressing)Wipe the wound with sterile gauze (inside outside direction / circular motion) Discard the gauze in the waste bin and continue pouring hydrogen peroxide until you can see few bubbles from the wound.Soak the gauze in the cup of Sodium Chloride and wipe the wound. Remove some blood surrounding it.

STEPS TO FOLLOW FOR A WOUND DRESSING:(if the patient comes after an accident, call the doctor first to assess the wound before doing wound dressing)After it, clean the wound with Betadine solutionCover it with sterile gauze (if the wound is deep, you can use compress for the blood to be absorb well) Ex.: melolin, urgotul, urgosterile Tape and secure the wound, make sure that the tape is not too tight to create circulation in the blood.Advise patient to change dressing everyday or depends on Doctors order.

STEPS TO FOLLOW FOR A WOUND DRESSING:(if the patient comes after an accident, call the doctor first to assess the wound before doing wound dressing)Check the order of the doctor before let the patient go outside the roomSend the file to the cashier for payment and make an appointment if there is a schedule for follow upNote the procedure youve done in the Nurses Note (PMSI)If the patient wants to buy some gauze or dressing materials, inform the pharmacist

STEPS TO FOLLOW FOR A WOUND DRESSING:(if the patient comes after an accident, call the doctor first to assess the wound before doing wound dressing)Clean the area after the procedure, return all the equipments in the proper place, arrange it properly and inform the housekeeper to take the tray you used during the procedure Make sure that all instruments inside the tray are complete.Wash your hands again

STEPS TO FOLLOW FOR A WOUND DRESSING:(wet to dry dressing, if patient return for dressing change)Wash hand and put on a pair of non-sterile glovesPrepare all the equipments neededPrepare the patient and position carefullyCarefully remove the tapeRemove the old dressing. If it is sticking to the skin, wet it with sterile water or NaCl to loosen itRemove the gauze pads or packing tape from inside the woundThrow the old dressing in the waste bin and gloves and wash hands again

STEPS TO FOLLOW FOR A WOUND DRESSING:(wet to dry dressing, if patient return for dressing change)Put on a new pair of non-sterile glovesCheck the wound for signs of infection (redness, swelling, pus, warm to touch, bad odor, drainage that is darker or thicker) if you suspect infection call Doctor first to recheck the wound before cleaning itYou should not bleed much when cleaning it, but small amount of blood is okay.Pour saline into a clean bowl

STEPS TO FOLLOW FOR A WOUND DRESSING:(wet to dry dressing, if patient return for dressing change)Place gauze pads into the bowl, squeeze the saline from the gauze pads until it is no longer dripping.Gently clean the wound using aseptic technique.Put betadine after and cover the wound using gauze pack and tapePut all used supplies in the waste bin and clean the area, return all the equipments thats being used, removed gloves and wash hand

STEPS TO FOLLOW FOR A WOUND DRESSING:(wet to dry dressing, if patient return for dressing change)Order dressing change (simple/complicated) in the PMSISend patient file to the cashier for payment and record the procedure youve done in PMSI (Nurses Notes)(if the patient has surgical incision, inform the patient when to come back for removal of suture)

STEPS TO FOLLOW FOR A WOUND DRESSING:(when to call the Doctor)More rednessMore painSwellingBleedingThe wound is larger or deeperThe wound looks dried out or darkTemperature above 100F for more than 4 hoursDrainage coming from or around the incision or wound and it: is not decreasing after 3 to 5 days, increasing and becomes thick, tan or yellow or smells bad.