Cleaning, monitoring and promoting healing of a wound that closes by second intention.
Objectives:
– Facilitate wound healing. – Prevent infection. – Educate patient and family on wound protection measures.
Equipment:
– Dressing trolley or trough. – Sterile drapes. – Dressing equipment: tweezers with teeth, without teeth, sterile scissors, mosquito, scalpel handle, kocher forceps and needle holder.
Material:
– Sterile gloves. – Non-sterile gloves.
– Scalpel blade. – Sterile gauze. – Alcoholic hand disinfection solution. – Soaker. – Bag for waste. – Anti-allergic plaster. – Stitches adhesive approach. – Antiseptic solution. – Physiological saline solution. – Creams, ointments, gels, hydrocolloid dressings, etc. – Sterile dressings. – Bandages. – Nursing records.
Procedure:
– Perform hand washing. – Prepare the material. – Preserve the patient’s privacy. – Inform the patient of the procedure. – Ask the patient and family to cooperate. – Place the patient in a suitable position to have access to the area to be treated. – Put on non-sterile gloves. – Place the dressing under the area to be treated. – Remove the dressing in the direction of the hair, wetting the dressing with saline if it is very adherent. – Inspect the incision site and wound for redness, swelling, signs of dehiscence or evisceration or exudate. – Monitor the healing process. – Remove gloves. – Proceed to alcohol disinfection of hands. – Prepare sterile field and place on it all the necessary material for healing. – Put on sterile gloves. – Clean the wound with physiological saline solution by dragging it from the center of the wound to the ends, from the cleanest to the least clean area. – Dry with sterile gauze. – Apply ointment, gel, gauze dressings soaked in solutions, as appropriate. a) Check the perilesional skin (fedpalla scale) and protect if necessary. b) If the wound bed looks fibrinous, apply a hydrocolloid.
c) Put hydrogel or enzymatic ointment and cover with hydrocellular dressing if the wound has slough. d) If the wound bed presents a necrotic plaque: 1) make an incision with a scalpel and inject hydrogel or enzymatic ointment. 2) Cover the wound with hydro-cellular or hydrocolloid. e) Put a calcium alginate dressing in very exudative lesions. f) In exudative lesions and with slough put hydrocolloid hydrofiber to promote autolytic debridement. g) In cavitated lesions and with granulation tissue, alginates or hydrocolloid hydrofiber will be used for filling impregnated with hyaluronic acid or collagen powders. h) Use silver dressings when the wound shows signs of contamination or infection. – Cover wet dressing with a dry dressing. – Massage the area around the wound to stimulate circulation. – Fix the dressing with adhesive tape. – Collect the material. – Leave the patient in a suitable position. – Remove gloves. – Wash hands. – Instruct the patient on how to care for the wound during bathing or showering. – Teach patient and family how to care for the wound including signs or symptoms of infection. – Record in nursing documentation: procedure, wound characteristics, wound assessment, date and time, and patient response.
– Observations: – Maximum asepsis. – Wash hands with antiseptic. – Regularly compare any changes in the wound. – Change the dressing according to the manufacturer’s instructions or when it is stained or wet. – Use gauze dressings, not cotton. – Notify the physician if signs of infection are observed. – Do not use hydrocolloid dressing in case of infection.[/et_pb_text][/et_pb_column][/et_pb_row][/et_pb_section]
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