Wound Care Flashcards
What types of supplies would you need for a wound care dressing change?
- Gloves (Clean and Sterile)
- Dressing Materials (if no wound dressing kit, get two 4x4 gauze packs, and one abdominal pad)
- Sterile saline
- Measuring device (Q-tip, ruler)
- Forceps/Q-tip
- Tape
- Scissors
What are the 3 dimensions that you should measure for a wound?
- Length
- Width
- Depth
Prior to dressing change, it is important to assess the pt’s pain level and administer analgesia _____ minutes beforehand.
30
When assessing a wound bed, what are you inspecting for?
- Color
- Odor
- Exudate or drainage
- Presence of sinus tracts or tunneling
- Presence of granulation tissue
What allergies should you assess for prior to performing a dressing change?
- Latex
- Adhesive
- Iodine
What patient education regarding wound car, would you provide?
- Practice good hygiene
- Ask for analgesia before the pain becomes unbearable
- Know s/s of infection and when to notify HCP
Other than pain assessment (before and after) and date and time dressing change was performed, what other documentation should you include?
- Why you changed the dressing (saturated, not intact?, per facility policy)
- Assessment of dressing and wound location
- Color, odor, exudate/drainage of wound
- Size of wound, presence of tunneling or sinus tracts, and approximation
What is the purpose of fluffing the 4x4 gauze in a wet-to-damp dressing change?
To increase the surface area for contact with the wound
If there is a drain present along with the wound, you should assess the drain insertion for _____ and _____.
Erythema; edema
Why is it important for the person who performed the dressing change to write the date, time and initials on the edge of the dressing?
To inform everyone who is caring for the patient, who performed the dressing change and when.
What is the purpose of using an abdominal pad in addition to the 4x4s gauzes ?
- Help provide extra pressure to wound to slow drainage
- Help seal wound area and keep moisture from seeping out
Describes the steps that you would take when removing an old wound dressing?
- Perform hand hygiene
- Don clean gloves
- Loosen the tape on the old dressing by gently pulling it from each side towards the wound
- Remove the old dressing and packing material from inside of wound into the biohazard bin
What side of the abdominal pad should be facing the wound?
The plain, white side faces the wound and the side with the blue line (radiopaque) facing outwards/upwards.
