Component Task: Dressing of Complicated Wound (With Assistant)

It is the process of aseptically caring for an injury to body tissues or break in the continuity of the skin or mucous membrane.

Aims

·         Remove exudates

·         Support injured part and hold the skin tissue in place

·         Prevent further injury and infection

·         Obtain wound swab for laboratory investigation

·         Promote healing

Requirements

A trolley containing the following:

a.      Top shelf (a Sterile field with the following sterile items)

·         Two (2) or three (3) gallipots for lotions

·         Two (2) kidney dish

·         Two (2) pairs of dressing forceps

·         Two (2) pairs of dissecting forceps

·         Sinus forceps

·         Probe

b.      Bottom shelf with the following:

c.      Dressing lotion

d.      Sterile cotton and gauze swab in a drum/pack

e.      Mackintosh and dressing towel

f.        Adhesive tape/strip

g.      Bandage

h.      Scissors

i.         Apron

j.         Disposable gloves

k.       Sterile gloves

l.         Receiver for used dressings

Steps

1.        Establish rapport (Refer to steps)

2.      Explain procedure to patient (Refer to steps)

3.      Ensure privacy

4.      Put on mask and perform hand hygiene

5.      Prepare and send trolley aseptically to the patient’s bedside

6.      Protect the bed with mackintosh and dressing towel

7.       Ask assistant to:

·         Put patient into desired position

·         Protect bed clothes and exposes wound

8.      Ask assistant to:

·         Pour out lotions into gallipots

·         Wear gloves and remove plaster or bandage and discard

9.      Remove soiled dressing with dissecting forceps or disposable gloves, assess for the type of exudate and discard

10.    Assess the state of the wound for exudates, granulation and depth

11.      Perform hand hygiene

12.    Dab or clean wound with sterile forceps/gloves using prescribed lotion from within outwards

13.    Where necessary gently irrigates wound with syringe and saline

14.    Clean or dab wound with series of swabs until wound is clean

15.    Clean the surrounding skin

16.    Apply sterile dressing using prescribed dressing lotion

17.    Add enough sterile dressing and secures into position or leaves exposed where necessary

18.    Ask assistant to help apply the adhesive tape or bandage to the site where necessary

19.    Remove mackintosh and dressing towel

20.  Reposition patient in bed with the help of the assistants

21.    Inform patient about the state of the wound

22.  Dispose off used items, decontaminate used instruments and trolley

23.  Perform hand hygiene

24.  Document and report state of the wound in the nurse notes (manually or electronically)  

25.  Report findings to the appropriate officer


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