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UNIT 4 Supporting Physiological Functioning
Procedure 32-8 ■ Applying a Hydrating Dressing (Hydrocolloid or Hydrogel) (continued)
dressing if it begins to leak, develops an odor, or begins to separate from the skin.
Sample Documentation Practice Resources
Aderibigbe & Buyanna (2018);Armstrong & Meyr (2022, June 9, updated); Bryant & Nix (2023,April); Ghomi et al. (2019);WOCN (2010, updated 2017, May/June).
Documentation Document the following information (many agencies use wound care flow sheets): ■ Appearance and location of the wound, type and amount of exudate, and odor, if present, after cleansing. Include wound measurements, if taken, and condition of surrounding skin. ■ 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 patient response. ■ Method of cleansing the wound and surrounding skin. ■ Type of dressing applied to the wound. ■ Use of skin prep. ■ Education provided to the patient.
Thinking About the Procedure
The video Applying a Hydrating Dressing (Hydrocolloid or Hydrogel) , along with questions and suggested responses, is available on the Davis’s Nursing Skills Videos Web site on FADavis.com.
Procedure 32-9 ■ Placing Skin Closures ➤ For steps to follow in all procedures, refer to the Universal Steps for All Procedures on the inside back cover.
■ Assess the wound for skin edge approximation. Wounds that are gaping or appear to have undermining should not be closed using adhesive closures. ■ Assess the wound for drainage, amount, type, and odor. Wounds that are draining heavily might not be suitable for adhesive skin closures because the adhesive would not stick to the skin. ■ Assess the periwound area or surrounding skin.Assessment should include skin color, texture, temperature, and integ- rity of the surrounding skin. Look for maceration (caused by heavy drainage), excoriation (from caustic effluent), stripping (from inappropriate adhesive removal), pustules, papules, or lesions. Adhesive closures should be placed only on intact skin. ■ Assess the length of the wound, the location (over a joint), or whether edema may occur to determine the size of the skin closure used. Consider elastic skin closures if disten- tion or movement is anticipated. Closures come in several lengths, widths, and flexibility capabilities to meet elasticity and conformability needs.
Equipment ■ Adhesive skin closures ■ Tincture of benzoin or skin protectant pads ■ Forceps ■ Normal saline ■ Gauze ■ Gloves (sterile if indicated)
Delegation This procedure may be delegated to a UAP with the required training unless it is a new wound requiring sterile technique or has developed complications (e.g., dehiscence). Assess- ment of the incision line or wound is a licensed professional’s responsibility and cannot be delegated.
Preprocedure Assessments ■ Assess the type of wound to be closed.
Adhesive closures are frequently used to keep surgical incisions well approximated.They may be used in conjunction with staples or sutures or after early staple/suture removal. Closures may be used to approximate the edges of lacerations or skin tears.
➤ 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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