How to Clean Wounds (Wound Dressing)

Procedure:

• Observe and assess old dressing for presence of blood and discharges.
• Assess clients condition prior to procedure.
• Prepare materials needed.
• Wash hands
• Explain the procedure to the client.
• Provide privacy
• Apply protective barrier if needed
• Position the client comfortably and drape to expose only the wound side, put on disposable gloves.

• Remove soiled dressing

- moisten plaster using cotton balls with alcohol.
- remove plaster by holdign down the skin and pulling the tape gently but firmly towards the wound.
- remove dressing and place it in a waterproof container.
- Note the type of discharges present and the appearance of the wound.
- Remove soil gloves, apply sterile gloves to remove transmission of microorganisms.
- Get cotton balls with antiseptic solution using pick-up forceps.

• Cleanse the wound

- Using cotton balls and antiseptic solution, cleanse the wound going outward in a circular motion.
- Cleanse the area of the wound towards the center of the wound in circular motion using several cotton balls for each stroke.

• Apply slight pressure around the wound with dressing to observe for drainage, exudate unless contradicted.
• Dry the area around the wound with operating sponge pad.
• Apply ointment if needed.
• Apply sterile dressing pad one at a time over the wound.
• Secure the dressing with tape correctly
• Remove the materials and dispose soiled dressing properly.
• Asses client to a comfortable position
• Wash hands
• Document

Bed Bath

Beth Bath is a type of bath where the nurse washes the entire body of dependent patient in bed.

Purpose:

• To cleanse, refresh and give comfort to the patient who must remain in bed.
• To stimulate circulation and aid in elimination
• To provide an opportunity to inspect the patients body for any sign of abnormality.
• To help the patient have some movement and exercise.
• To provide an opportunity for nurse- patient interaction.

Categories of Bath


1. Cleansing Bath - usually given in the morning before scheduled test or procedure.

Types:

1. Complete bed bath- for totally dependent patients.
2. Partial bed bath- bathing only body parts such as hands, face, axillae and perineal area.
3. Tub bath - client is immersed in a tub of water and allows more through washing and rinsing than a bed bath.
4. Shower- client sits or stands under a continuous stream of water.

2. Therapeutic Bath - generally ordered by physician for a special effect such as soothing the skin or promoting healing.

Types:

1. Sitz Bath- cleanses and reduce pain and inflammation of perineal and anal.
2. Medicated Bath- aids relief of skin irrintation and creates an antibacterial and drying effect.

Special Consideration:

• Avoid unnecessary exposure and chilling expose, wash, rinse and dry only. Use correct temperature if water.
• Observe the patients body closely for physical signs like rashes, discoloration, pressure sores, discharges.
• Give special attention to the following areas: ears, axilla, under breast, umbilicus public region and spaces between the fingers and toes.
• Do the bath quickly but unhurriedly and use even smooth but firm strokes.
• Use adequate of water and change it as necessary.
• If possible, do such procedure as enema, shampoo and oral before bath.
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Vital Signs

- Also known as Cardinal Signs w/c includes body temperature, pulse, respiration's and blood pressure.


A. Body Temperature (36.5C - 37.5C)

- Reflects the balance between the heat produced and the heat lost from the body measured in heats called degrees.

Core temperature- is the temperature of the deep tissue of the bidy, it is under the control of the hypothalamus.

PURPOSE:

• To establish baseline data
• To identify whether the core temperature is with in the normal range.
• To determine changes in the core temperature in response to specific therapies.
• To monitor clients at risk for imbalanced body temperature.

B. Pulse (60 - 100 BPM)

-Is a wave of blood created by contraction of the left ventricle of the heart.

PURPOSE:

• To establish baseline data.
• To identify whether pulse is in the normal range.
• To determine whether pulse rhythm is regular and the pulse volume is appropriate.
• To compare the equality of corresponding peripheral pulse on each side of the body.
• To monitor and assess changes in the client's health status.
• To monitor client's @ risk for pulse alterations.

C. Respirations (16-20 CPM)

-Is the act of breathing.

External Respiration- interchange of gases between aveoli of the lungs and pulmonary blood.

Internal Respiration- interchange of gases between circulating blood and cells of the bdy tissues.


PURPOSE:

• To acquire baseline data.
• To monitor abnormal respiration's and respiratory patterns and identify changes.
• To assess respiration's before the administration of a medication.
• To monitor client's @ risk for respiratory alteraton.

D. Blood Pressure (120/ 80)

-Is the force exerted by the blood against the vessel wall.

Arterial BP- is a measure of the blood as it flows through the arteries.

Sstolic Pressure- pressure of the blood as a result of the contraction of the ventricles.

Diastolic Pressure- the pressure when the ventricles are at rest.

PURPOSE:

• To obtain a baseline measure of arterial BP.
• To determine the client's hemo dynamic status.
• To identify and monitor changes in blood pressure resulting from a disease process and medical therapy.

Total Bed Bathing

Last Monday we had learned how to do total bed bath to a patient. Our prefessor shows us how to do it first then she gave us 30 mins for us to review it then we need to do it as what she did (return demo). Every student spend 20- 30 mins before we finish it. I got 99% in my grade and this grade is for our prelim exam. I ask my self, why is can't get perfect 100% in my fundamentals of nursing?

Bed Making

Purpose:

1. Promote client's comfort.
2. Provide clean and neat environment for the client.
3. Provide smooth, wrinkle- free bed foundation thus minimizing sources of ski irritation.

Considerations:

1. Hold soiled linen away from uniform.
2. Do not shake soiled linen in the air because it can disseminate secretions an micro-organisms they contain.
3. Linen for one client is never placed on another client's bed.
4. To avoid unnecessary trips to the linen supply area, gather all linen before to strip a bed.

Equipments: In order of Use:

1. Bottom sheet- Folded @ right side in
2. Rubber sheet- Folded @ right side in
3. Draw sheet- Folded @ right side in
4. Top sheet- Folded @ wrong side in
5. Pillow case

Surgical Asepsis (Sterile Technique)

Includes procedures to eliminate micro-organisms from an area.


Principles of Aseptic Technique

1. All objects used in a sterile field must be sterile.
2. Sterile objects become unsterile when touched by unsterile objects.
3. Sterile objects can become unsterile by prolonged exposure to airborne micro-organisms.
4. If there's any question or doubt of an item sterility, the items is considered to be unsterile.
5. Once a sterile package is open 1 inch border around the edge are unsterile because the edges are in contact with unsterile surfaces.
6. The skin cannot be sterile and is unsterile.
7. Movement around and in the sterile field must not contaminate the sterile field.
8. Conscientiousness, alertness and honesty are essential guidelines in maintaining surgical asepsis.

Handwashing

- is the vigorous, brief rubbing together of all surfaces of the hands lathered in soap followed by rinsing under a stream of water.



Purpose:

1. To remove soil and transient organisms from the hands.
2. To reduce total microbial counts over time.
3. To prevent pathogenic micro-organisms from spreading patient to patient.
4. To protect the healthcare provider.

Handwashing Should be done in all of the ff:

1. At the beginning of every work shift.
2. Before and after client contact.
3. Before and after the performance of invasive procedure.
4. Before and after handling dressing or touching open wounds.
5. After contact with body substances even when gloves are worn.
6. After handling contaminated equipment.
7. At the end of every shift before leaving the health facility.

CONSIDERATIONS:

• Provide a wide base of support and move closer to the sink during the activity but making sure your clothes doesn't touch the sin.
• Friction, running water and a cleansing agent are necessary to remove micro-organisms or other material that may present on the hands.
• Assemble all articles needed near the sink.
• Use lotion if needed for dry skin although it is not recommended because it is excellent medium for bacterial growth.