The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [639]
A list of variables that require regular assessment is shown in Table 15.1. Figure 15.5 is an example of a wound assessment chart. Teare and Barrett (2002) recommend that the underlying cause of the wound should also be assessed, with the primary focus on details such as size and depth as well as the stage of healing. Links can then be made between the wound dressing and the optimal healing environment. The use of this type of documentation to assist in the assessment process is recommended to:
Figure 15.5 Wound assessment chart.
Reproduced courtesy of the Royal Marsden Hospital NHS Foundation Trust.
facilitate continuity of care by providing a central reference point for wound progression
facilitate appropriate evaluation of all relevant parameters
fulfil legal and professional requirements (Teare and Barrett 2002).
Procedure guideline 15.1 Dressing a wound
Essential equipment
Sterile dressing pack containing gallipots or an indented plastic tray, low-linting swabs and/or medical foam, disposable forceps, gloves, sterile field, disposable bag
Fluids for cleaning and/or irrigation
Hypoallergenic tape
Appropriate dressing
Appropriate hand hygiene preparation
Any other material will be determined by the nature of the dressing; special features of a dressing should be referred to in the patient’s nursing care plan
Detergent wipe
Total traceability system for surgical instruments and patient record form
Optional Equipment
Sterile scissors
Preprocedure
Action Rationale
1 Explain and discuss the procedure with the patient.
To ensure that the patient understands the procedure and gives his or her valid consent (NMC 2008a, C; Wilson 2005, E).
2 Clean hands with bactericidal alcohol rub.
Hands must be cleaned before and after every patient contact and before commencing the preparations for aseptic technique, to prevent cross-infection (Fraise and Bradley 2009, E).
3 Clean trolley with detergent wipe.
To provide a clean working surface (Fraise and Bradley 2009, E).
4 Place all the equipment required for the procedure on the bottom shelf of the clean dressing trolley.
To maintain the top shelf as a clean working surface. E
5 Screen the bed area and provide privacy. Position the patient comfortably so that the area to be dealt with is easily accessible without exposing the patient unduly.
To allow any airborne organisms to settle before the sterile field (and in the case of a dressing, the wound) is exposed (Fraise and Bradley 2009, E). Maintain the patient’s dignity and comfort. E
6 If the procedure is a dressing and the wound is infected or producing copious amounts of exudate, put on a disposable plastic apron.
To reduce the risk of cross-infection (Fraise and Bradley 2009, E).
7 Take the trolley to the treatment room or patient’s bedside, disturbing the screens as little as possible.
To minimize airborne contamination (Fraise and Bradley 2009, E).
Procedure
8 Loosen the dressing tape.
To make it easier to remove the dressing. E
9 Clean hands with a bactericidal alcohol handrub.
To reduce the risk of wound infection (Fraise and Bradley 2009, E).
10 Check the pack is sterile (i.e. the pack is undamaged, intact and dry), open the outer cover of the sterile pack and slide the contents onto the top shelf of the trolley.
To ensure that only sterile products are used (Fraise and Bradley 2009, E).
11 Open the sterile field using only the corners of the paper.
So that areas of potential contamination are kept to a minimum. E
12 Where appropriate, loosen the old dressing.
The dressing can then be lifted off without causing trauma. E
13 Clean hands with a bactericidal alcohol handrub.
Hands may become contaminated by handling