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Is a Wound present?, PATIENT EDUCATION, colonized INFECTIONS, , , , , , , …

- - - - free of marks or stains
      - maintain clean environment and use sterile equipment
  - - - maintain column of sterileness (prevent non-sterile items from passing over sterile field)
      - don sterile PPE
      - use sterile equipment
- - - - Protect Periwound
        
        Debridement if necessary
        
        Filler if necessary
        
        Apply Primary Dressing
        
        Apply Secondary Dressing if necessary (for dressings that are not self adhesive)
        
        Assess Periwound
        
        7 more items...
        
        Evaluate Wound Healing Progress During Changing of Dressings
        
        3 more items...
        
        patient is allergic to adhesives
        
        1 more item...
        
        tunneling present
        
        do not perform debridement
        
        patient has low platelet count, on anticoagulants, or has medical condition that interferes with clotting
        
        wound depth >2 cm
        
        undermining present
        
        if infected, antimicrobial agent may be indicated as a filler
        
        Necrotic Tissue present
        
        dry (eschar)
        
        avascular, loose
        
        Perform Selective Debridement
        
        finish with Nonforceful Low Pressure Irrigation
        
        2 more items...
        
        for thick eschar, cross hatch with scalpel
        
        1 more item...
        
        prevent maceration and prevent wound from increasing in size
        
        clean with normal saline solution and apply a non-alcohol based skin prep solution
      - removes loose debris, pus, and free-floating bacteria
      - increases wound visability and easier to evalulate
      - swab with dampened gauze and irrigate
    - - type
        
        serous (thin, watery, clear
        
        treat according to amount
        
        amount
        
        saturated wound (moderate exudate)
        
        (primary) foam sponge with no adhesive
        
        (primary and secondary) foam sponge with foam in middle and self-adhesive
        
        (primary and secondary) hydrocolloid
        
        drainage obvious (large exudate)
        
        (primary) alginate
        
        1 more item...
        
        none (dry wound)
        
        (primary) Vaseline impregnated gauze
        
        (primary) hydrogel in wound bed
        
        1 more item...
        
        scant or moist wound (normal exudate)
        
        (primary and secondary) transparent film
        
        (primary) non adherent pad (similar to middle part of Band-Aid)
        
        wet wound (small exudate)
        
        (primary) gauze
        
        2 more items...
        
        serosanguious (thin, watery, pale red)
        
        monitor for signs of infection, especially if after inflammatory stage (day 4)
        
        purulent (thin or thick opaque yellow)
        
        green
        
        emits odor
    - - measure wound
        
        measure depth
        
        gloved hand, hold swab perpendicular and place in deepest part of wound, grasp swab at level of periwound, and measure with a rule
        
        wound DEPTH >2 cm
        
        measure tracing
        
        lay grid over wound, trace over grid, mark grid indicating clock positioning, greatest length and greatest width can be determined from tracing, undermining and erythema determined
    - - erythema
      - warmth
      - pain
      - edema
      - induration
      - especially when not in inflammatory stage (past day 4) and found collectively, notify physician and staff of cardinal signs of INFECTION
        
        if sample needed for collection to determine presence or type of bacteria, clean wound first
      - patient has a fever
    - - measure tunneling wound
        
        insert cotton tipped applicator into tunnel, grasp applicator where it meets wound edge, and record measurement and area on measuring guide with arrow indicating clock position
        
        TUNNELING present (wound burrows under skin)
      - UNDERMINING present (wound rim has eroded beneath surface)
    - - Observation and Palpation
        
        dermis destroyed, full thickness skin loss with subcutaneous tissue damage
        
        pressure injury stage III
        
        extensive skin damage that extends into deeper layers of skin and soft tissue, exposing tendon, muscle, and bone
        
        pressure injury stage IV
        
        non-blanchable erythema of intact skin
        
        pressure injury stage II
        
        epidermis broken or destroyed, partial skin loss
        
        pressure injury stage I