Advanced Nursing Skills 1: Wound Care

Question 1

What is the general purpose of wound care?

Answer 1

• Keep the wound clean
• Absorbing drainage
• Controlling bleeding
• Protection the wound from further injury
• Holding medication in place
• Maintaining a moist environment

Question 2

What are the different types of dressing applications? Identify the type of wound that would benefit from it.

Answer 2

• Sterile dressing
• Dry, sterile dressing
• Wet to dry dressing or packing
• Wet to wet dressing
• Gel/Hydrocolloid dressings
• Stitches and staples
• Transparent dressings
• Dressings with open/closed drains

Question 3

What is wound irrigation and what are the three types?

Answer 3

• Is a sterile technique in which saline or sterile solution is poured into a wound in order to remove debris following injury or surgery.
• Helps prevent microbes to the wound site.
• Process of washing debris, drainage, or exudate out of the wound to promote healing.
• The fluid used varies depending on health care provider’s orders.
• Wound irrigation is a sterile procedure.
• Three types
  
  • Manual
  • Continuous
  • Intermittent

Question 4

What type of wound would benefit from an irrigation?

Answer 4

• Almost every type of wound should be irrigated, unless otherwise specified by your doctor.
• The only types of wounds that you should avoid irrigating are those that are actively bleeding.
  
  • If you irrigate a bleeding wound, you may actually dislodge clots and elongate the healing process.
• When taking care of chronic wounds, irrigation is essential.
• The key is keeping the irrigation gentle and light and then adhering the proper wound dressing once you’re done.
• When done correctly, this speeds up the healing process and reduces your risk of complications.

Question 5

What should be documented down when performing wound care?

Answer 5

• Client response
  
  • reports of pain
• Type of dressing
• Cleansing / Irrigating agent
• Characteristics of wound and surrounding skin
  
  • Color
  • Exudate
  • Swelling
  • Odor
  • Presence of necrosis
  • Size

Question 6

What equipment is needed for a nurse to maintain sterile field?

Answer 6

• Sterile field
• Hair covering
• Surgical mask
• Sterile gown
  
  • Can only touch the inside
  • Strings tied by another person and considered contaminated.
• Sterile gloves