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UNIT 4 Supporting Physiological Functioning
Procedure 32-7 ■ Applying and Removing aTransparent Film Dressing (continued)
Evaluation ■ Verify the transparent film dressing is appropriate for the wound. ■ Determine whether the dressing adheres comfortably to skin. ■ Ensure that the patient verbalizes understanding of treatment. Patient Teaching ■ Educate the patient about the expected healing process. ■ Teach the patient about the use of transparent film dressings. ■ Inform the patient and caregiver about signs and symptoms of infection and the need to report these findings. Documentation Document the following information (many agencies use a wound/skin flow sheet): ■ Wound assessment: location of the wound, size (length × width × diameter), undermining or tunneling, amount and
character of drainage, odor, wound bed including type and percentage of tissue seen, and periwound appearance. ■ Appearance and location of the wound, type and amount of exudate, and odor, if present, after cleansing. ■ The patient’s pain level before the procedure. If the patient has been medicated for pain, document the drug and dose used, time given, and the patient’s response to analgesia. ■ Method of cleansing the wound and surrounding skin. ■ Type of dressing applied to the wound. ■ Education provided to the patient. ■ Preventive measures taken. Practice Resources Association of periOperative Registered Nurses (2022); Bryant & Nix (2023, April).
Procedure 32-8 ■ Applying a Hydrating Dressing (Hydrocolloid or Hydrogel) ➤ For steps to follow in all procedures, refer to the Universal Steps for All Procedures on the inside back cover.
Equipment ■ Clean nonsterile gloves ■ Hydrating dressing 3 to 4 cm (1.5 in.) larger than the wound ■ Moisture-proof bag Obtain the following items, only if needed: ■ Normal saline solution warmed to body temperature when possible Cold solution lowers the temperature of wound bed and slows the healing process. ■ Emesis basin ■ Sterile gauze for cleansing ■ Disposable clippers or scissors (to trim hair or dressing) ■ Skin prep ■ Measuring device ■ Tape Delegation This procedure requires knowledge of wound healing, dress- ings, and infection control and prevention.You should not del- egate this procedure to a UAP.
Preprocedure Assessments ■ Assess the area to determine whether a hydrating dressing is appropriate. Hydrating dressings are appropriate for wounds with small amounts of drainage. These dressings autolytically debride necrotic tissue from the wound bed.They may also be used to protect skin at risk for breakdown. ■ Determine the size of the wound. Allows you to select a dressing of the appropriate size. Choosing a dressing size that extends beyond the ulcer ensures complete coverage.
➤ 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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