666
UNIT 4 Supporting Physiological Functioning
Procedure 32-3 ■ Taping a Dressing (continued)
7. Smooth tape in place with your fingertips. To maximize the tape’s adhesion to the skin surface. 8.Replace tape if site becomes edematous or the skin is not intact. What if . . . ■ The tape will not adhere to the patient’s skin because of excess hair? Remove the hair with clippers or scis- sors. Do not shave the site with a razor.
Shaving can cause nicks or abrasions to the skin that could become a portal of entry for bacteria. ■ The patient’s skin is diaphoretic or excessively oily? Cleanse the skin with soap and water before the dressing change. Allow the skin to dry before applying the dress- ing and tape.You may also use polymer skin barriers to place a seal over the skin and allow the tape adhesive to adhere.
■ The patient has fragile skin (e.g., is an older adult)? Use skin sealant preparations under adhesives. Use the least adhesive product possible. The junction between the epidermis and dermis on an older adult is not as strong as it is in a younger person. ■ The patient is allergic to tape adhesives? Use hypoallergenic products. Circular wraps, ace bandages, or other such products may be used to secure dressings.
Evaluation ■ Verify type of tape that is appropriate for the patient and dressing. ■ Note whether the tape adheres comfortably to the skin. ■ Ensure that the patient verbalized understanding of the treatment. ■ Inspect the dressing daily for intactness, edema, or hematoma. Patient Teaching ■ Teach the patient about the expected healing process. ■ Educate the patient about the purpose of the procedure. ■ Instruct the patient to keep the dressing dry.
Documentation Document the following information (many agencies use a wound/skin flow sheet): ■ Type of dressing and tape applied ■ Location and characteristics of wound Dressing applied to left hip incision using conformable cloth tape.Wound edges are well approximated with no drainage noted. Periwound skin is dry and intact without erythema, induration, or odor. Wound cleaned with normal saline using sterile technique. Educated patient about the purpose of the dressing and expected course for wound healing.Will continue to monitor —B. Hopkins, RN ■ Education given to patient Sample Documentation 00/00/0000 0815
Procedure 32-4 ■ Removing and Applying Dry Dressings ➤ For steps to follow in all procedures, refer to the Universal Steps for All Procedures on the inside back cover. ➤ Note: This procedure uses clean technique because wound care is now usually performed using clean rather than sterile technique.
Equipment ■ Three pairs of clean nonsterile gloves ■ Normal saline solution for irrigation, warmed to body tem- perature when possible Cold solution lowers the temperature of wound bed and slows the healing process. ■ Tray of sterile 4 in. × 4 in. gauze. ■ Sterile gauze for dressings ■ Tape ■ Adhesive removal pads Delegation This procedure requires knowledge of wound healing. It should be performed by a registered nurse. Do not delegate this skill.
Preprocedure Assessments NOTE: When you begin, the wound will likely be covered with a dressing. You will make these assessments when you remove the soiled dressing and after cleansing the wound. ■ Assess for pain at least 30 minutes before performing the procedure. Wounds may be painful. Provide pain medication 30 minutes before performing the procedure, if needed, to allow the medication time to be distributed in target tissues. Changes in the quality or severity of
pain are some symptoms linked with infection. ■ Assess the type and amount of exudate. Exudate may be a sign of infection. ■ Assess the wound for odor.
A foul odor may indicate infection. Clean wounds before you assess for odor, because some dressings interact with wound drainage to produce an odor.
78
Powered by FlippingBook