Redness Drainage, particularly if purulent (pus-like) or foul smelling Heat Edema Increased pain or tenderness Fever Edema of tissue surrounding the wound Separation of wound edges Trauma or injury Maceration, or a waterlogged appearance of the wound edges Bruising Frank bleeding
4 stages Determined by the depth and degree of involvement of the underlying structures.
Wash hands, apply clean gloves Loosen the edges of the tape Pull the tape ends toward the wound while holding traction on the skin with your other hand. Lift the dressing off If the dressing sticks to the wound, pour a small amount of sterile saline o the dressing to loosen it. Let it sit for a minute, then gently pull dressing off. Discard according to facility. (if traces of adhesive remain on the skin, remove them with tape remover or baby oil)
If signs/symptoms of infection are present, alert the nurse. Cover the wound and wait for RN (use signal button)
Use normal saline. Antiseptic products harm healing tissue and should not be used. Always work from the clean area near the wound outward to less clean areas. Use gauze or swab for one stroke, then discard it. (this avoids contaminated the cleansing solution)
Cleanse a linear wound or surgical incision from top to bottom. Work outward from the wound in parallel lines
To cleanse open wound, such as an injury or pressure ulcer, work in half circle or full circles. Begin in the center of the wound and work outward.
https://www.youtube.com/watch?v=G9N 9-3QyESs https://www.youtube.com/watch?v=G9N 9-3QyESs Used to pull fluid out of drain. Measured at end of each shift Then pour into toilet. JP Drain remains connected to patient. Rolls up to expel air Once very little drainage is collected the wound is ready to be sutured.
Used for healing surgical incisions. Occasionally used for removing necrotic tissue from pressure ulcers. The dressing is damp when applied to the wound This is a Sterile Procedure