Title | Wound Care and Cleansing Nursing Skill ATI Template |
---|---|
Author | Derek Johanson |
Course | fundamentals of nursing |
Institution | Raritan Valley Community College |
Pages | 1 |
File Size | 81.5 KB |
File Type | |
Total Downloads | 11 |
Total Views | 122 |
ATI Nursing Skill Template about wound care and wound cleansing...
ACTIVE LEARNING TEMPLATE:
Nursing Skill
STUDENT NAME _____________________________________
Care SKILL NAMEWound ____________________________________________________________________________
REVIEW MODULE CHAPTER ___________
Description of Skill Preforming wound cleaning or irriagtion
Indications - Wound care per orders - Replacment of soilded dressing - Wound harbors a biofilm - Wound contains excessive exudate - Wound contains necrotic tissue or debris in wound bed
Outcomes/Evaluation - Patient wound will be free from worsening infection for durration of care - Wound will show improvment withing 5 days - Patients wound will remain free of necrotic tissue and debris for durration of care. - Patient will demonstrate wound care using aseptic procedure before discharge.
Potential Complications - Worsened Infection - Introduction of microbes into wound - Damage to the wound bed increasing wound healing time. - Reactions to cleansers or medications
ACTIVE LEARNING TEMPLATES
CONSIDERATIONS
Nursing Interventions (pre, intra, post) Pre - Assess appearance of dressing. - Assess wound for size, color, condition, drainage amount, color of drainage, smells. Intra - Maintain sterile field - Maintain sterility of wound and dressings - Note presence of tunneling - Collect required samples before cleaning - Rinse from clean to dirty - Apply clean dressing with date and time Post - Document findings
Client Education - Monitor for increased pain at the wound or near the wound. - Monitor for increased drainage of foul odors - Monitor for sudden bleeding - Keep dressing clean and dry - Patient should maintain dietary recomendations of the provider including protein needs.
Nursing Interventions - Cleanse wound from clean to dirty - Use gentle friction when cleaning or apply solution to skin. - Isotonic solutions are prefered. - Never use same gauze across wound more than once. - Do not use materials that shed fibers - Use piston syringe or sterile straight catheter for deeper wound irrigation. - Use NS 0.9%, lactated ringers or antibiotic/antimicrobial solutions.
THERAPEUTIC PROCEDURE
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