Wound Care Validation Notes PDF

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Validation notes for wound care...

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STEP 1: VERIFY MD ORDER AND NOTE THE TYPE AND STRENGTH OF THE ORDERED IRRIGATION SOLUTION REGULAR NPSGS + PROVIDE PRIVACY (1) PERFORM ENVIRONMENTAL SAFETY CHECK (SCAN THE ROOM) (2) ENSURE PROPER BODY MECHANICS (VERBALIZE) ------------------------------------------------------------------STEP 2: ASSESS FOR PROCEDURE NEED. EDUCATE THE PATIENT ABOUT THE RATIONALE OF PROCEDURE. “I am going to be changing your wound dressing because it is soiled” ------------------------------------------------------------------STEP 3: ASSESS & EDUCATE  Assess the patient’s condition, including the dressing and wound as well as the pain level.  Medicate (you should know this)  Explain the procedure “Today I will be changing you’re dressing on your coccyx area, and this will assist with the healing process. I am going to apply a new wound dressing.” ------------------------------------------------------------------STEP 4: EVALUATE  Evaluate PAIN LEVEL -------------------------------------------------------------------GATHER ALL SUPPLIES

-------------------------------------------------------------------PERFORM HAND HYGIENE & APPLY CLEAN GLOVES

-------------------------------------------------------------------STEP 5: POSITION  Provide privacy  Put bed rails down and adjust bed height if needed.  Set up biohazard bag (edge of the bed) -------------------------------------------------------------------STEP 6: ASSESS  Remove the old dressing, including packing.  Assess COCA (Color, Odor, Consistency and Amount of Drainage)  Dispose of old dressing in biohazard bag  Assess the wound edges and wound bed  Check for and note: 1. Healthy granulated tissue 2. Exudates 3. Slough 4. Eschar 5. Indurations 6. Swelling -------------------------------------------------------------------STEP 7: MEASURE  Using the tools, measure LENGTH, WIDTH, DEPTH and TUNNELING (Using wound measuring tools, sterile cotton swabs)  THEN DISPOSE IN BIOHAZARD -------------------------------------------------------------------STEP 8: IRRIGATE  Set up irrigation supplies.  Irrigate wound using gauze pads to catch solution and debris.  Pat wound bed with sterile gauze as needed  DISPOSE IN BIOHAZARD -------------------------------------------------------------------WASH YOUR HANDS -------> NOW STERILE -------------------------------------------------------------------STEP 9: STERILE FIELD 1. Prepare sterile dressing change tray, dressing supplies, and irrigation solution using sterile technique -------------------------------------------------------------------STEP 10: STERILE TECHNIQUE

1. Apply sterile gloves 2. Repack wound with sterile dressing 3. Apply sterile top dressing 4. Apply tape and label with time/date/PG -------------------------------------------------------------------WASH YOUR HANDS AGAIN! -------------------------------------------------------------------NPSG – Dispose of soiled supplies in biohazard 2. Ensure a safe environment ------------------------------------------------------------------WASH HANDS AGAIN...