The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [640]
14 Using the plastic bag in the pack, arrange the sterile field. Pour cleaning solution into gallipots or an indented plastic tray.
The time the wound is exposed should be kept to a minimum to reduce the risk of contamination. To prevent contamination of the environment. To minimize risk of contamination of cleaning solution. E
15 Remove dressing by placing a hand in the plastic bag, lifting the dressing off and inverting the plastic bag so that the dressing is now inside the bag. Thereafter use this as the ‘dirty’ bag.
To reduce the risk of cross-infection. To prevent contamination of the environment. E
16 Attach the bag with the dressing to the side of the trolley below the top shelf.
Contaminated material should be below the level of the sterile field. E
17 Assess wound healing with reference to Table 15.2.
To evaluate wound care (Dealey 2005, E; Hampton and Collins 2004, E; Hess 2005, E).
18 Put on gloves.
To reduce the risk of infection to the wound and contamination of the nurse. Gloves provide greater sensitivity than forceps and are less likely to traumatize the wound or the patient’s skin. E
19 If necessary, gently clean the wound with a gloved hand using 0.9% sodium chloride, unless another solution is indicated. If appropriate, irrigate by flushing with water or 0.9% sodium chloride.
To reduce the possibility of physical and chemical trauma to granulation and epithelial tissue (Hess 2005, E).
20 Apply the dressing that is most suitable for the wound using the criteria for dressings (see Table 15.3).
To promote healing and/or reduce symptoms. E
21 Remove gloves; fasten dressing as appropriate with hypoallergenic tape/Netelast/bandage/tapeless retention dressing.
To prevent irritation of skin and to avoid trauma to wound. E
22 Make sure the patient is comfortable and the dressing is secure.
A dressing may slip or feel uncomfortable as the patient changes position. E
Postprocedure
23 Dispose of waste in orange plastic clinical waste bags. Remove gloves.
To prevent environmental contamination. Orange is the recognized colour for clinical waste (DH 2005, C).
24 Draw back curtains and ensure the patient is comfortable.
25 Check that the trolley remains dry and physically clean. If necessary, wipe with detergent wipe.
To reduce the risk of spreading infection (Fraise and Bradley 2009, E).
26 Record assessment in relevant documentation at the end of the procedure.
To maintain an accurate record of wound-healing progress (NMC 2009, C).
Problem-solving table 15.1 Prevention and resolution (Procedure guideline 15.1)
Postprocedural considerations
Ongoing care
Dressings need to be changed when ‘strike-through’ occurs, that is, the dressing becomes soiled and damp at the surface or edge or leakage of wound exudates occurs (see individual dressing packs for instructions to guide practice). The medical team may take the dressing down to view the wound and the nurse should be present to monitor this and reapply an appropriate dressing. Record any changes and/or instructions in the patient’s notes or wound care plan (NMC 2009). Included in the notes should be the amount of exudate, any signs of inflammation or odour and appearance of the tissue (Lippincott Williams and Wilkins 2008). Measuring or photographing the wound can also benefit ongoing assessment as long as this is appropriate and acceptable to the patient
Pressure ulcers
Definition
A pressure ulcer usually results from compromised circulation secondary to pressure over time and is a local site of cell death (Hess 2005).
Measures for preventing and detecting pressure ulcers have been discussed in Chapter 4 and are briefly described here to facilitate dressing choices.
Anatomy and physiology
The European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (2009) classify ulcers according to depth in four stages. The first is superficial damage which is characterized by local inflammation and may present as a persistent area of redness