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UNIT 4 Supporting Physiological Functioning
Procedure 32-6 ■ Applying a Negative Pressure WoundTherapy (NPWT) Device (continued)
Sample documentation for Procedure 32-6B: Chariker-Jeter Dressing Application 00/00/0000. 1010 Patient reported pain rating 5 on a scale of 1 to 10.Administered hydrocodone 5.0 mg PO for pain at 0815 before initiation of negative wound pressure therapy. See eMAR. Stage 4 pressure injury to coccyx surgically debrided.Wound is 4 × 6 × 2 with no appreciable undermining.Wound bed is now clean of necrotic tissue with 100% pink tissue noted. Periwound has 2 cm of erythema to wound edges. Scant malodorous serosanguineous drainage. Using sterile technique, moistened saline gauze applied to wound bed with fenestrated drain. Ostomy paste applied at wound edge to assist in seal. Pump activated to 80 mm Hg continuous pressure. Patient rated pain in wound area as a 2 postprocedure. Plan: Begin dressing changes every 48 hours. —L. Opperta, RN
Practice Resources Bukovcan et al. (2016); Bayer (2018); European Pressure Ulcer Advisory Pane (EPUAP), National Pressure Injury Advisory Panel (NPIAP), and Pan Pacific Pressure Injury Alliance (PPPIA) (2019); Gabriel & Schraga (2021,August 27 updated).
Thinking About the Procedure
The video Open-Pore Reticulated Polyurethane Foam Therapy, along with questions and suggested responses, is available on the Davis’s Nursing Skills Videos Web site on FADavis.com.
Procedure 32-7 ■ Applying and Removing aTransparent Film Dressing ➤ For steps to follow in all procedures, refer to the Universal Steps for All Procedures on the inside back cover.
high-risk intact skin; for superficial or partial-thickness wounds that have little to no drainage (i.e., stage 1 or 2 pressure injury); and to assist in debriding eschar by autolysis. Films may be used as a sec- ondary dressing to protect other types of dressings from bodily fluids (i.e., wounds near the perineum). ■ Assess the wound to determine whether use of a transpar- ent film is contraindicated. Films are contraindicated in third-degree burns, arterial ulcers, and infected wounds. Films should not be used to fill dead space. ■ Determine the size of the wound. Film dressings are available in many sizes. Select the appropri- ate size based on wound measurements, allowing for a 2.5-cm (1-in.) perimeter of intact skin around the wound for the adhe- sive to stick. ■ Assess the periwound area. Film dressings should be attached to intact skin.The adhesive is not waterproof and will not adhere to wet or moist skin.
Equipment ■ Clean nonsterile gloves ■ Sterile gauze ■ Normal saline solution or specified cleansing agent, warmed to body temperature when possible Cold solution lowers the temperature of the wound bed and slows the healing process. ■ Scissors (if needed) ■ Liquid skin preparation (if needed) ■ Transparent film dressing Delegation Because assessment of the wound and knowledge of clean technique are important, you should not delegate this proce- dure to a UAP. Preprocedure Assessment ■ Assess the area to determine whether a transparent film dressing is appropriate. Transparent film dressings are indicated as primary dressings (dressings that touch the wound or area to be treated) to protect
➤ When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation.
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