Sunday, March 7, 2010

Selected Areas of Care - Wound Management

Wound Management
  1. Complies with established guidelines
  2. Assesses wound location, type, appearance, and presence or absence of drainage
  3. When irrigation is designated:
    • selects the designated solution
    • determines the appropriate temperature of the solution (approximate)
    • uses an appropriate irrigation delivery system
    • positions a receptable for return flow
    • irrigates without contaminating the wound
    • protects the surrounding skin from contact with the drainage
  4. Cleanses the wound with the designated solution
  5. Applies the designated topical preparation
  6. When wound protection is required
    • removes the dressing without contaminating the wound
    • removes the dressing without injuring the surrounding skin
    • disposes of the soiled dressing in the designated container
    • applies the dressing without contamination the wound
    • secures the dressing
    • labels the dressing with the date, time, and their initials
  7. Records
    • Data related to wound
      • location
      • type
      • appearance
      • presence or absence of drainage
    • measures implemented to cleanse, irrigate, and protect the wound and surrounding skin
    • patient response to measures implemented

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