OSCE: Wound Care (most likely advanced) Flashcards
What comes in the sterile dressing kit tray?
1) White sheet/drape
2) 2x2 gauze pads
3) 4x4 gauze pads
4) Green tweezers
5) Metal forceps
6) Scissors
What supplies are needed?
1) Sterile dressing kit
2) Sterile gloves
3) Extra 4x4 and 2x2 gauze pads
4) Abdominal pad (useful if pt’s wound is draining a lot)
5) Measuring tape (for dimensions of the wound)
6) Hypafix tape (helps secure dressing on pt)
7) Sterile saline (to cleanse wound)
8) Pen (to make when dressing was changed)
What’s the first thing you need to do?
Check MAR for order
The patient has an order to clean the surgical wound with NS 0.9% and apply a dry dressing, which is due to be changed twice a day.
1) Gather supplies
- Sterile kit
- Sterile gloves
- Extra 4x4 and 2x2 gauze pads
- Abdo pads
- Measuring tape
- Hypafix tape
- 0.9% NS
- Pen
2) Check progress notes of previous dressing change and see how that went
3) Walk into pt’s room, do hand hygiene, check ID band and ask for 2 pt identifiers
4) Raise bed to appropriate height (waist level)
5) Ask pt if they need pain meds prior to starting this
6) Expose area (ex: abdomen), provide privacy and put blue pad underneath
7) Put on clean gloves
8) Remove dressing by applying light pressure and pull the tape TOWARDS the incision (pulling away can separate the wound)
9) Assess the dressing:
- Drainage?
• Colour?
• Ex: purulent, sanguineous, serosanguinous and serous drainage
- Blood?
- Odour?
10) Wrap up dressing in one hand and take the glove off doing the inside-out method then remove the other glove
11) Do hand hygiene
12) Assess what the wound looks like
- Are the sutures well-approximated?
- Redness?
- Signs of infection?
- Drainage?
- Necrosis?
- Odour?
- Measure wound length w/ tape
13) Open sterile field. Make sure you have enough room (could be on bedside table or bed, whatever works best). Ensure you can visualize pt and sterile field at the same time. Make sure garbage is nearby or underneath table
14) Hand hygiene again
15) You can touch the 1-inch border of the white sheet of the tray since it is non-sterile.
- Open it by the 1-inch margin going forward (away from you) first, then side by side then towards you.
- Grab the green tweezers by the bottom (the tips are still sterile) and use it to hold down the ends to prevent them from going up again.
• Place the tweezers on the edge of white sheet so the bottom of the tweezers are on the non-sterile side while the tip is in the sterile field
16) Using the green tweezers, move the sterile drape to an area in the white sterile sheet
17) Open packages of 2x2 and 4x4 and drop them into sterile field w/o touching them. Then drop abdo pad in there too
- You can use tip of green tweezers to grab them and put them in the sterile field if needed
18) Pour sterile saline into the basin in the tray (10cm above the tray so it is not touching)
19) Hand hygiene
20) Put on sterile gloves
- Open up sterile sheet in the same way (1-inch border)
- Use dominant hand first then non dominant hand
- Grab cuff of first glove you’re gonna put (dom) on & slip on the glove while holding cuff
- Then put glove of dominant hand into the other glove so it’s touching the sterile part (non-dom) and fit it onto other hand
- Fix the cuffs and get the glove to fit comfortably
- Put hands up while putting gloves since it’ll be easier (it’s tight)
21) You want to clean the wound from least to most contaminated
- Wet some of the 2x2 gauze pads
- Use your hands or fingers to clean the wound
- Do one full swipe then throw it away (never use the same gauze pad twice)
- Clean downwards (one full swipe then discard)
- Designate one dirty hand (non-dom -> if needed)
- Then clean the sides of the wound
22) Dry wound
- Least to most contaminated
- Use 2x2 or 4x4 gauze pad
- Do one full swipe downwards then discard
23) Since it’s a dry dressing, use 4x4 gauze pads that aren’t soaked in sterile saline
- Fold 2 4x4 gauze pads in half and put them over the incision
24) An abdo pad is typically used when there is a lot of drainage (the blue line points to the sky)
- Put it over the gauze
25) Remove gloves (inside out)
26) Hand hygiene
27) Secure dressing w/ hypafix tape
- Cut it to the right size
- You may need 2-4 pieces (depends on size and type of wound)
28) Mark on dressing the date
29) Clean station
30) Check if pt is okay and if they tolerated it well
31) Document
- Old dressing
- The wound
- The fact that the wound was cleaned and a sterile technique was used
- How the pt tolerated it
- Ex:
• Pt tolerated dressing change well
• The old dressing was removed and there was no drainage
• The wound measurement
• No redness
• No signs of infection
• No scent
• Wound looked well approximated w/ sutures
What are the 4 main types of drainage? Describe them.
1) Serous drainage: it’s clear, thin, and watery.
- The production of serous drainage is a typical response from the body during the normal inflammatory healing stage.
- Yet, if there is a large amount of serous drainage, it can be the result of a high bioburden count.
2) Sanguineous drainage: regular blood
- It’s only normal in occurrence during the inflammatory stage of healing where a small amount of this blood may leak from a full- or partial-thickness wound.
- If it is seen outside of the inflammatory phase, sanguineous drainage can be a result of trauma to the wound.
3) Serosanguinous drainage: it’s thin, pink, and watery in presentation.
- It’s the most common type of exudate that is seen in wounds.
4) Purulent drainage is milky, typically thicker in consistency, and can be gray, green, or yellow in appearance.
- If the fluid becomes very thick, this can be a sign of infection.
Describe the process of performing a wound assessment on advanced wounds.
It’s pressure ulcers or surgical sites that heal by secondary intention
1) Note its anatomical location
2) Measure dimensions
- Length (longest part of wound) and width w/ measuring tape
- Use cotton swab to measure depth (in the deepest part of the wound)
- Discard in biohazard bag
3) Assess for undermining or tunneling using a cotton swab to gently probe beneath the edges of the wound
- Indicate the location of the undermining using a clock face (12 is the head of the patient and feet is 6)
- Document how many cm the undermining extends beneath the intact skin
4) If wound is a pressure ulcer, assess the extent of tissue loss by determining the deepest viable tissue layer in the wound bed
- Keep in mind that necrotic tissue can prevent you from seeing the base of the wound
5) Identify tissue type, note what % is intact and what is present:
- Granulation tissue
- Slough
- Necrotic tissue
6) Exudate
- Colour
- Consistency
- Odour
- Amount (expressed as a proportion of the dressing or in descriptive terms) -> ex: 1/3 of dressing is saturated OR scant, moderate, or copious exudate
7) Inspect skin adjacent to wound
- Colour
- Texture
- Temperature
- Integrity
How do you perform wound irrigation?
1) Protect bedding by putting the blue pad under the pt
2) Adjust gown/bedding to expose the wound
3) Open irrigation kit
4) Apply sterile gloves
5) Irrigation technique depends on size and depth of the wound
Wide Wound Irrigation:
- Fill 10cc syringe w/ prescribed irrigating solution
- Attach a sterile 19 gage angiocatheter or a 19 gage needle to the syringe
- Set collection basin on the pad
- Hold the tip of the syringe 1in above the upper end of the wound and flush it using steady pressure
- continue to refill the syringe and flush the wound until fluid going into the collection basin is clear
In this circumstance, the old dressing is removed, everything is prepared in the sterile kit and you just did hand hygiene. What do you need to do next for an advanced wound?
Assess wound and skin around it
- Ex: red tissue is granulation tissue = good sign
The patient’s order is:
- do a dressing change twice a day to the right hip
- irrigation with NS
- cleanse the periwound area with NS
- pack with NS soaked gauze
- apply a wet-to-dry dressing
Go through the steps
1) Hand hygiene and gloves
2) Put blue pad under pt and collection basin under wound
3) Remove old dressing and assess that then the wound and periwound
- When removing the previously packed gauze, make sure to check the last progress note for how many gauze pads were added so that you get them all out
4) Open sterile kits and add everything you need inside
5) Irrigate the wound, which has 2 ways:
- Non-sterile hands (w/ regular gloves):
• Irrigate w/ bottle of saline (provides appropriate pressure)
• Start at top of wound bed and go down (irrigate until it runs clear)
- Sterile hands
• Use a 60cc syringe w/ a blue tip to irrigate the wound
• Draw up NS from tray
• Irrigate from top to bottom until drainage runs clear
6) Hand hygiene and sterile gloves
7) Cleanse periwound area
- Wet a few 2x2 gauze pads and wring them out
- Cleanse area around wound and discard after each swipe
- Least to most contaminated
8) Dry wound
- Blot dry wet areas inside wound w/ dry 4x4 gauze pads
9) Dry periwound area
- Same method you used to clean it
10) Pack wound w/ wet dressing
- Wet some 4x4 and 2x2 gauze pads w/ NS
- Remember how much of each you’re putting in (ex: 6 of 2x2 and 3 of 4x4)
- Wring them out and flush them out a little bit
- Take tweezers and lightly pack the wound
- If there is undermining, make sure there is a piece of the gauze sticking out so it doesn’t get stuck or lost during the next dressing change
- Ensure none of the gauze is touching the “good” skin since it can prevent the periwound area from healing
11) Now it’s the dry part of the wet-to-dry dressing
- Put 2 dry, folded 4x4 gauze pads over the wet dressings
12) Remove gloves (inside out method), discard then hand hygiene
13) Get hypafix tape and measure it then secure the dressing with it
14) Put the date of the dressing change
15) Document
- Irrigated
- What wound looked like
- Old dressing
- How pt tolerated (pain?)
- # of gauze pads (ex: 3 4x4 gauze pads to pack)
