Tuesday, July 26, 2011

Simple Wound Dressing

Things Required: 
  • Septanol and tissue (to clean the wound trolley)
  • Gloves
  • Apron
  • IMR
  • Basic wound dressing pack
  • Normal saline solution
  • Micropore
  • Scissors and pen
  • Other wound dressing cleansing solutions or products like chlorhexidine, tegaderm, mepore
Always check the items you take for expiry date and clarity (if applicable).

1. Verify order and patient's need for this procedure. Perform hand rub.

2. Clean wound dressing trolley. Wear apron.

3. Approach and identify patient again with 2 patient identifiers: patient’s name and IC by asking patient and verifying it with his wrist tag. If patient is in pain, ask for pain score and offer interventions like ice packs or pain relief medications. If patient refuses the procedure, explain the importance of the procedure and get patient to rest and mentally prepare himself first.

4. Prepare the environment like switching on the lights, switching off the fans, screening the curtains and ensuring the correct working height. Always position your trolley and stand such that your dominant hand is nearer to the patient.

5. Perform hand rub. Open the sterile wound dressing pack without touching anything inside. Arrange the items inside and take out the plastic bag by maneuvering them from the outside of the dressing pack (the non-sterile side).

6. Pour normal saline and open other excess items, carefully touching only the packaging.

7. Expose wound with gloves. Palpate around/ along the wound site and note any Colour, Odour, Consistency and Amount of exudates (if applicable).

8. Perform surgical handwash. Dry with the tissue paper provided in the dressing pack, picking it up by taking only its corner.

9. Drape the area where you are cleaning the wound. Be careful not to touch anywhere else (especially the patient) except the drape.

10. Soak and squeeze out excess water from the cotton balls and arrange any items in the sterile field (where necessary) using the forceps provided.

11. Using one cotton ball at a time and one swipe per cotton ball, clean the wound from the least contaminated area (ie. the inner of the wound) to the most contaminated area. Lastly, clean the area surrounding the wound. The technique for cleaning the wound would be to take a clean cotton ball using your non-dominant hand and pass it over to your dominant hand outside the sterile field and use the dominant hand to clean the wound. If patient seems uncomfortable or in pain, stop and ask the patient if he needs you to stop the procedure for a while etc.

12. Tap the cleaned areas dry with gauze.

13. Cover with suitable/ prescribed wound products and label the “date changed”.

14. Explain to patient that the procedure has been completed and ask if patient has any questions for you like “how is their wound healing?”, “how long will their wound take to heal?” etc. Ensure patient’s safety and comfort levels and that the call bell is within reach before leaving the patient.

15. Discard soiled requisites, clean trolley and wash hands.

16. Record the procedure in the relevant documents like the nursing notes and wound chart. Report any abnormalities.

Note: If patient seems uncomfortable or in pain during any part of the procedure, ask if he needs a break, any pain relief medications, or try blowing or soothing (sayang) the area surrounding the wound.

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