aseptic technique standard wound dressing procedure · pdf filep a tie n t z one p r epa r a...
TRANSCRIPT
Pati
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1. Clean the equipment/work space
2. Perform hand hygiene
1. Consult wound chart 2. Clean equipment with clean hands
3. Gather supplies & waste bag
2. Position towel/drape under the wound, remove old dressingand place into waste bag
4. Perform hand hygiene
5. Prepare equipment> attach waste bag > open dressing pack> assemble equipment/supplies ready for use
6. Dress the wound using a non touch aseptic technique
7. Dispose of gloves and waste, perform hand hygiene
5. Cleanse the wound using a non touch aseptic technique
3. Dispose of gloves and perform hand hygiene
1. Put on gloves and further PPE if required
4. Put on gloves
*MR4
6Bn*
MR46Bn
07/12
Location of wound and wound numberAssessment DateWound MeasurementsMax Length
Max Width
Depth
Photograph Yes/ NoClinical AppearancePink (epithelisation)/ Red (granulating) Yellow (slough)/Green (infected)/Black (necrotic)Exudate % volume and colourWound stageHypergranulationOdour Yes/No
Swab taken? Y N Date ....../...../.....Surrounding Skin
Healthy/ intact/ Fragile/ Macerated/ Oedematous/ Cellulitic / Erythema / Inflamed / Dry / Scaling / Eczema
Pain at wound site Score 0 - 10& document if: Analgesia required
At specific time; Continuous; Nocturnal
Aim of TreatmentDecrease Infection /Debride/ Absorb excess exudates/ Promote granulation/ Hydrate / ProtectNegative pressure wound therapy
Continuous/Intermittent Pressure ____mmHg Foam Type Black White Silver Number of foam pieces in wound ______
Frequency of Dressing Change
Dressing plan
Include in your description: - cleaned with;
- covered with;
- secured with.
Dressing changed- Date and sign when dressing was attended to.
Date Wound Number Sign Date Wound Number Sign Date Wound Number Sign Date Wound Number Sign Date Wound Number Sign
Pressure Ulcer StagingStage 1
The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues.
Stage 2Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Stage 3Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to underlying fascia. Ulcer presents as a crater with/without undermining of adjacent tissue.
Stage 4Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (eg. tendon or joint capsule). Undermining/sinus tracts may also be present.
Page 2 Page 3
Suspected Deep Tissue Injury
Unstageable Pressure Injury
*MR4
6Bn*
MR46Bn
07/12
Location of wound and wound numberAssessment DateWound MeasurementsMax Length
Max Width
Depth
Photograph Yes/ NoClinical AppearancePink (epithelisation)/ Red (granulating) Yellow (slough)/Green (infected)/Black (necrotic)Exudate % volume and colourWound stageHypergranulationOdour Yes/No
Swab taken? Y N Date ....../...../.....Surrounding Skin
Healthy/ intact/ Fragile/ Macerated/ Oedematous/ Cellulitic / Erythema / Inflamed / Dry / Scaling / Eczema
Pain at wound site Score 0 - 10& document if: Analgesia required
At specific time; Continuous; Nocturnal
Aim of TreatmentDecrease Infection /Debride/ Absorb excess exudates/ Promote granulation/ Hydrate / ProtectNegative pressure wound therapy
Continuous/Intermittent Pressure ____mmHg Foam Type Black White Silver Number of foam pieces in wound ______
Frequency of Dressing Change
Dressing plan
Include in your description: - cleaned with;
- covered with;
- secured with.
Dressing changed- Date and sign when dressing was attended to.
Date Wound Number Sign Date Wound Number Sign Date Wound Number Sign Date Wound Number Sign Date Wound Number Sign
Pressure Ulcer StagingStage 1
The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues.
Stage 2Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Stage 3Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to underlying fascia. Ulcer presents as a crater with/without undermining of adjacent tissue.
Stage 4Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (eg. tendon or joint capsule). Undermining/sinus tracts may also be present.
Page 2 Page 3
Suspected Deep Tissue Injury
Unstageable Pressure Injury
Aseptic technique Standard wound dressing procedure
NP
1082
_091
5