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