Skills check off Flashcards
What equipment is necessary for a for dry sterile dressing?
Biohazard/waterproof bag clean gloves sterile gloves 3 package 2x2's 1 package 4x4's 1 package of drain sponges 1 ABD Tape or Montgomery straps Additional supplies req. for a particular dressing
How do you assess a wound?
Assess:
1) Size
2) Appearence;
3) Characteristics of drainage
4) Signs of infection
5) Complaints of pain
6) Inspect drain
7) Assess for allergy to latex or wound cleaning agent
How do you assess size?
length, width, depth
How do you assess appearance?
Color of wound
Approximation of wound edges
Wound bed
Dehiscence
How do you assess characteristics of drainage?
Location Consistency Odor Degree of saturation Color Serous Sanguineous Serosanguineous Purulent & color
How do you assess for infection?
Swelling
Heat
Pain
Purulent drainage
Complaint of pain during procedure:
level, location, durationetc
Pre-medication maybe necessary 30-60 min b4.
Inspecting drain?
Assess drain security Placement Amount characteristics Function of collecting apparatus
Assessment for allergies?
rash itching( pruritus) Sneezing difficulty breathing cramps vomiting
You have explained the procedure and raised bed and lowered side rails, what is the next step?
Assist the patient to a comfortable position that provides easy access to the wound.
You have doned a pair of clean gloves, removed tape and dressing and discarded in biohazard bag, what is next?
Assess the wound:
size, appearance of the wound, characteristics of drainage, signs of infection, c/o pain, drainage system, allergies.
What is the objective for dry sterile dressing?
Provide wound healing by primary intention
Prevent infection
Protection of wound from mechanical trauma
