Wound Care / Dressing Change Flashcards
Purpose of wound care
Enhance healing Remove MOs Protection Control bleeding and edema Comfort
Types of wound dressings
Gauze dressings
Telfa
Self-adhesive
Hydrocolloid (HCA)
Types of gauze dressings
Wet-dry
Dry-dry
Sterile vs clean
Telfa
Non-adherent gauze
Self-adhesive dressings
Acuderm
Opsite
Tegraderm
Hydrocolloid dressings
Biofilm
Duoderm
Restore
Tegrasor
Securing methods
Tape
Ties
Binders
Types of binders
Ace
Elastic
Montgomery straps
Type of ties
Types of tape
Paper
Silk
Transpore
Wound closure
Staples
Sutures
Steristrips
Dressing complications
Pathogen growth
Skin breakdown (tape, drainage)
Decreased circulation
Trauma
RN role in wound care
Nurse may reinforce first dressing and change after per order, or more frequent if necessary with notifying provider
Types and functions of drains
Mechanical suction (Wound vac, chest tube) Self suction (Jackson Pratt, Hemovac) Gravity (penrose)
Drains nursing care
Ensure patency
Monitor, empty, and document
Prevent complications
Sterile technique rules
Above waist and within site No talking Do not cross over Sterile touches sterile only Check expiration dates Do not use if wet or open
Heat effects
Vasodilation Increased capillary permeability Increased tissue metabolism Reduced muscle tension Decreased blood viscosity
Cold effects
Vasoconstriction Pain relief Reduced tissue metabolism Reduced muscle tension Increased blood viscosity
Types of heat and cold therapy
Compresses
Water-flow blankets
Soaks/Sitz baths
Risks of heat/cold therapy
Tissue damage
Guidelines for heat/cold therapy
Provider order
Assess risks
Monitor time and temperature
Aseptic/Clean technique
Clean gloves Dressings sterile No talking Do not use if we or open Keep in sight above waist Used for low infection risk wounds
Principles of wound cleansing
Maintain sterility
Clean from least contaminated to most contaminated from wound/incision toward surrounding skin
Gentle friction
Linear wounds-work straight along incision
Irregular wounds-circular motion from wound/drain site to surrounding skin
Increasingly larger concentric circles
Equipment for wound care
Clean gloves Saline Sterile gloves Paper tape Trash can Tape measure 1 pkg dressing sponge 4 pkgs gauze
Dressing removal
Don clean gloves
Remove old dressing
Assess wound
Remove gloves correctly
Cleaning the wound
Wash hands Open equipment Pour normal saline Don sterile gloves Cleanse using wet gauze Dispose of gauze correctly Do not allow hands to drop below waist
When cleaning a drain
Move from incision area to drain site
Wound ABCDE
Approximate size Body location Color Drainage Edges
