Skill 31-1 Cleaning a wound and applying a dry sterile dressing skills testing - Nursing Interventions Assessment And Community Care PDF

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Summary

Summary of skills required for testing in lab practical setting. They are detailed and you must know them step by step to pass. The course was for Dr. Briand McGowan Nursing Interventions in Fall 2016....

Description

SKI L L3 1 1Cl e a ni n gaWo u n da n dAp p l y i n gaDr y , St e r i l eDr e s s i n g St u d e n t Na me :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Re v i e we r : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _/ 4 3=_ _ _ _ _ _ _ _ _ _ _ %

I n s t r u c t i o n st os t u d e n t s :Y o ua r et oc ha n g et h ed r ys t e r i l ed r e s s i n go f ap a t i e n t wi t hawo u ndc l o s e dwi t hs u t u r e sors t a p l e s . 1 . )_ _ _ _ _ _(1) Review the medical orders for wound care or the nursing plan of care related to wound. 2.) ______(1) Gather the necessary supplies and bring to the bedside stand or overbed table. 3.) (1) Perform hand hygiene. 4.) (1) Identify the patient. 5.)

(1) Close the curtains around the bed.

6.)

(1) Explain what you are going to do and why you are going to do it to the patient.

7.) (1) Assess the patient for possible need for nonpharmacologic pain – reducing interventions or analgesic mediation before wound care dressing change. Administer appropriate prescribed analgesic. Allow enough time for analgesic to achieve effectiveness. 8.. )

_(1) Place a waste receptacle or bag at a convenient location for use during the procedure.

9.) ______ (1) Adjust bed to comfortable working height. 10.) (1) 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 that the wound area. 11.) _____ (1) Place a water proof pad under the wound site. 12.) __ (1) Put on clean, disposable gloves and loosen tape on the old dressings. If necessary, use an adhesive remover to help get the tape off. 13,) _____(1) Carefully remove the soiled dressings. If any part of the dressing sticks to the underlying skin, use a small amount of sterile saline to help loosen and remove. 14.) (1) After removing the dressing, note the presence, amount, type, color, and odor of any drainage on the dressings. 1 5 . )_ _ _ _ _ _ _ _ _( 1 )Pl a c es o i l e dd r e s s i n g si nt h ea p p r o p r i a t ewa s t er e c e p t a c l e . 1 6 . )_ _ _ _ _ _( 1 )Re mo v ey o u r g l o v e sa n dd i s p o s eo f t h e mi na na p p r o p r i a t ewa s t er e c e p t a c l e . 1 7 . ) _ _ _ _ _ _ _( 1 ) I n s p e c t t h ewo u n ds i t ef o r s i z e , a p p e a r a n c e , a n dd r a i n a g e .A s s e s si f a n yp a i ni sp r e s e n t .Ch e c kt h es t a t u so f t h es u t u r e s , a d h e s i v ec l o s u r es t r i p s , s t a p l e s , a n dd r a i n so r t u b e s , i f p r e s e n t .No t ea n yp r o b l e mst oi n c l u d ei ny o u r d o c u me n t a t i o n . 1 8 . )_ _ _ _ _ _ _( 5 )Us i n gs t e r i l et e c h n i q u e , p r e p a r eas t e r i l ewo r ka r e aa n do p e nt h en e e d e ds u p p l i e s . 1 9 . )_ _ _ _ _ _( 1 ) Op e nt h es t e r i l ec l e a n i n gs o l u t i o n .De p e n d i n go nt h ea mo u n t o f c l e a n i n gn e e d e d , t h es o l u t i o nmi g h t b ep o u r e d d i r e c t l yo v e rg a u z es p o n g e so v e r ac o n t a i n e rf o r s ma l l c l e a n i n gj o b so r , i n t oab a s i nf o r mo r ec o mp l e xo r l a r g e r c l e a n i n g . 2 0 . )_ _ _ _ _ _( 5 ) Pu to ns t e r i l eg l o v e s . 2 1 . )_ _ _ _ _ _( 5 ) Cl e a nt h ewo u n d .Cl e a nt h ewo u n df r omt opt ob o t t omf r o mt h ec e nt e rt ot heo u t s i d e . F o l l o wi n gt h i s p a t t e r n , us en e wg a u z ef ore a c hwi p e , p l a c i n gt h eu s e dg a u z ei nawa s t er e c e p t a c l e . 2 2 . )_ _ _ _ _ _( 1 ) On c et h ewo u n di sc l e a n e d , d r yt h ea r e au s i n gag a u z eas p o n g ei nt h es a mema n n e r .Ap p l yo i n t me n t o r p e r f o r m o t h e r t r e a t me n t sa so r d e r e d .

2 3 . )_ _ _ _ _ _( 1 ) Ap p l yal a y e r o f d r y , s t e r i l e , d r e s s i n go v e r t h ewo u n d .F o r c e p sma yb eu s e dt oa p p l yd r e s s i n g . 2 4 . )_ _ _ _ _ _( 1 ) Pl a c eas e c o n dl a y e r o f g a u z eo v e r t h ewo u n ds i t e . 2 5 . )_ _ _ _ _ _( 1 ) Ap p l yas u r g i c a l o r a b d o mi n a l p a d( ABD) o v e r t h eg a u z ea t t h es i t ea st h eo u t e r mo s t l a y e ro f d r e s s i n g . 2 6 . )_ _ _ _ _ _( 1 ) Re mo v ea n dd i s c a r dg l o v e s . 2 7 . )_ _ _ _ _ _( 1 ) Ap p l yt a p e , Mo n t g o me r ys t r a p s , o r r o l l e r g a u z et os e c u r ed r e s s i n g s . 2 8 . )_ _ _ _ _ _( 1 ) Af t e r s e c u r i n gt h ed r e s s i n g , l a b e l d r e s s i n gwi t hd a t ea n dt i me . 2 9 . )_ _ _ _ _ _( 1 ) Re mo v ea l l r e ma i n i n ge q u i p me n t ; p l a c et h ep a t i e n t i nac o mf o r t a b l ep o s i t i o n , wi t hs i d er a i l su pa n db e di nt h e l o we s t p o s i t i o n . 3 0 . )_ _ _ _ _ _( 1 ) Pe r f o r mh a n dh y g i e n e . 3 1 . )_ _ _ _ _ _( 1 ) Ch e c ka l l wo u n dd r e s s i n ge v e r ys h i f t .Mo r ef r e q u e n t c h e c k sma yb en e e d e di f t h ewo u n di smo r ec o mp l e x d r e s s i n g sb e c o mes a t u r a t e dq u i c k l y ....