KLE U INSTITUTE OF NURSING SCIENCES, BELGAUM

SUB: NURSING FOUNDATIONS

TOPIC: WOUND CARE

GUIDED BY, MRS.SUCHITRA RATHOD ASST. PROFESSOR DEPT. OF NURSING FOUNDATIONS

PRESENTED BY, MR.SHIVRAJ KUMAR R D M.Sc 1st yr

CONTENTS: 1) Introduction 2) Definition of wound 3) Classification of wound 4) Wound healing process 5) Factors affecting wound healing 6) Complications of wound healing 7) Definition of wound dressing 8) Purposes of Wound care

9) General Instructions for wound healing:

Maintain strict aseptic technique to prevent cross infection. All articles should be disinfected thoroughly. Wash hands thoroughly before & after procedure. Instruments used for one dressing cannot be used for another until they have been sterilized. Use mask, sterile gloves, and gowns for large dressings. Dressings should not be done immediately after sweeping & dusting room because wound gets contaminated. Avoid talking, coughing & sneezing when the wound is opened. Cleaning of wound should be done from cleanest area to less clean area. Avoid meal timings for doing dressing. It should be done after half an hour before or after meal.

 Give an analgesic prior to painful dressings.

10) Preliminary Assessment: Check the diagnosis & general condition of the patient. Check the purpose for which dressing is to be done. Check the condition of the wound. Check the physicians order for type of dressings to be applied. Check the patients name, bed number. Check the nurses record to find out the general condition of wound. Check the consciousness of patient & ability to follow instructions. Check the articles available in the unit.

11)

Preparation of the Patient:

Identify the patient & position him comfortably. Explain the procedure & provide privacy. Offer bed pan or urinal prior to dressing. Close the doors & windows to prevent draughts. Shave the area if necessary to remove hair. Protect the bed with mackintosh. Expose the part as necessary. Untie the bandage or adhesive plaster & remove them. Turn the head of the patient to one side, so that patient may not see the wound & get worried about it.

Articles required for the procedure: A sterile tray containing1) Artery Forceps To clean the wound.

2) Dissecting Forceps To clean the wound.

3) Scissors For the debridement of the wound, if necessary or to cut the gauze pieces and plasters.

4) Small Bowl To take the cleansing solutions.

5) Gloves, Mask & Gown To provide proper asepsis & to use when large wounds are dressed. 6) Cotton balls, Gauze pieces & Cotton pads To clean & dress the wound.

7) Dressing towel To create sterile field around the wound. A clean tray containing: 1) Cleansing solutions Betadine, spirit, Hydrogen peroxide

2) Ointment & Powder To apply on the wound.

3) Bandages, Adhesive plasters & scissors

4) Kidney tray & Paper bag To collect waste

5) Mackintosh & Towel To protect bed garments

PROCEDURE:
S.N Steps of Procedure o 1. 2. 3. 4. 5. Tie the Mask Wash hands thoroughly Put on gown, gloves, mask Open the sterile tray, spread the towel around the wound Rationale/ Reasons To prevent wound infection or contamination with droplets To prevent cross infection To ensure asepsis (as necessary for large wounds) To create a sterile field around the wound

Pick up a dissecting forceps & remove To prevent contamination of hands the dressings & put it in paper bag. with soiled dressings Discard the dissecting forceps into

the bowl of lotion 6. 7. Ask assistant to pour small amount of cleansing solution into the bowl Clean the wound from centre to periphery, discarding used swabs for each stroke To prevent contaminating the hands of nurse by outside bottle Cleaning should be done from cleanest area to less clean area. Wound line is considered cleaner than the surrounding area if wound is infected. T o keep the wound dry as possible

8.

After thorough cleaning of the wound, dry the wound with dry swabs using same precautions. Discard the forceps in the bowl of lotion Apply medications if ordered

9.

To apply ointment directly to the wound may be difficult. Apply a small portion on dressing that goes directly over the wound Cotton placed directly on the wound may stick on wound when discharge dries Gloves worn during dressing will be highly contaminated

10.

Apply the sterile dressings, apply gauze pieces first & then cotton pads. Remove gloves & discard it into bowl of lotion
Secure dressings with bandage or adhesive tapes & record the procedure

11. 12.

After care of patient & articles: 1) Help patient to dress up & to take a comfortable position in bed. Change garments if soiled with drainage. 2) Replace bed linen 3) Remove mackintosh & towel 4) Take all articles to utility room. Discard soiled dressings into a covered container & send for incineration. 5) Remove the instruments & other articles from disinfectant solution 7 clean them thoroughly.

6) Dry them & reset the tray & send it for auto claving 7) Replace all articles at proper place. 8) Wash hands 9) Record the procedure on nurses record with date & time. Record the condition of wound, type. 10) Keep the unit tidy & clean