WOUND/ABDO Flashcards
How would you explain to client
What I’ll be doing next is inspecting and assessing the wound is this okay with you
How would you begin the sterile process
Hand hygiene.
Wipe down trolley using SINGLE downward strokes
Attach a rubbsih bag to put dressing in
Place sterile pack on top - opens the sterile field using the corner/edges
WASH HANDS
Puts on non sterile gloves before removing old dressing
Removes old dressing gently pulled towards wound
Removes and disposes gloves OVER the old dressing and dispose both in a dirty bag
What assessment are you using for wound checking and what does it stand for + what are you looking for in each one
TIME
T - Tissue - looking for viable tissue. not looking for non viable, or necrotic tissue or any slough (yellowish puss).
I - Infection - looking for no
redness, inflammation and is not malodorous, no oedema on wound bed
M - Moisture - medium moisture is important for healing, so ensure wound is not too dry but not overly moist
E - Edge - edge of wound is not migrating and is contracting, dryness
What dressing would you use for a necrotic wound?
Non adherent dressing + surgical debridement
How would you explain an abdo ax to pt and what is important in asking prior to ax
What we’ll be doing now is an abdominal assessment - this will involve me inspecting then listening to your abdomen for bowel sounds, I will then percuss and palpate your abdomen. Is this okay with you
ASK if they have any abdo pain and WHERE
How would you inspect the abdo
Colour - uniform Symmetry - Aligned Umbilical position Contour Lesions/Scars
How would you auscultate? + normal/abnormal finding
Advise that I will n0ow be auscultating the abdomen
Warm the bell for the pt
Start in the RLQ (bottom R of pt).
Auscultate 4 areas.
Goes RLQ, RUQ, LUQ, LRQ.
Listen for up to 5 mins if bowel sounds not heard - once heard move to next quadrant
Normal finding - I heard active bowel sounds in all 4 quadrants
Abnormal - hypoactive, absent sounds
How would you percuss? And what sounds will u state
Snail or vertial/horizontal lawnmower
Tympany - T for Tummy, or dull (over bone or liver).
Where is the liver located
RUQ and slightly in LUQ
In which pattern do you do the abdo ax?
1 - inspect
2 - auscultation
3 - percussion
4 - palpation
How would you do the palpating part?
Ask about tenderness first and palpate tender areas LAST. Observe facial expression Use three middle fingers, only one hand Light palpation 1-3cm Deep palpation 5-6cm
Norma findings - no guarding or tenderness, no large or superficial masses palpated. nil pulsations sighted
