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NURS 275 SKILLS CHECK OFF TEST 1 STUDY GUIDE WITH COMPLETE SOLUTION!!
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NURS 275 SKILLS CHECK OFF TEST 1 STUDY GUIDE WITH COMPLETE SOLUTION!!
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NURS 275 SKILLS CHECK OFF TEST 1 STUDY GUIDEWITH COMPLETE SOLUTION!!
Wound Care: MOIST-to-MOIST PACKING Primary Dressing (for wounds healing
by secondary intention)
answers: Purpose/outcome is to maintain moist wound environment to contain
natural therapeutic wound chemicals; speed granulation tissue proliferation;
provide barrier to bacterial contamination
Protocol method & frequency of wound packing (without specific physician
prescription): dressing change Q 8 hours with primary layer [touches tissue] of
saline-moistened sterile gauze & dry secondary dressing layer; increase to Q 6
hours if gauze dries between changes
answers: Patient preparation: assess need for analgesia (painkillers); medicate 30
minutes before procedure; evaluate effectiveness
Essential wound assessments:
- Anatomic location; size dimensions of wound surface: diameter or length/width;
depth measured in centimeters and/or estimate of extent of tissue layer
involvement-full or partial thickness
answers: - Presence of undermining or tunneling- Appearance of wound base:
granulation, epithelialization, muscle, subcutaneous tissue, nonviable tissue, color,
exudate amount/odor/color;
- Appearance of open wound edge; condition of surrounding skin
Current evidence suggests no greater contamination using clean gloves compared
with sterile gloves to pack
wounds; *consult agency policies to direct choice of gloves
answers: Removing soiled dressing: if dressing sticks to wound bed, moisten
primary dressing that touches tissue with
, sterile normal saline; bleeding indicates disruption of new capillary beds
Standard Documentation
answers: date, time, signature, procedure; skin/wound/drainage observations per
above criteria; type & location of dressing applied; solution type used to moisten
gauze; patient tolerance
Verifies physician's order
answers: Performs standard greeting & prep
Gathers supplies: sterile 4X4 gauze to fill wound bed (e.g. Kerlix fluffs); cover
gauze (e.g. ABD pads); sterile saline at room temperature; clean gloves (2 pairs);
cotton-tipped applicators (swabs) X2
answers: Raises bed to comfortable height; positions patient for wound access
Performs hand hygiene; applies moisture-impervious gown, face shield/goggles,
clean gloves
answers: Removes soiled dressing & disposes in biohazard waste; removes gloves
& performs hand hygiene
Primary Dressing Layer (Moist):
Performs hand hygiene
answers: Without contamination, opens packages & places supplies on work
surface that has been cleaned with disinfectant using twice-wipe procedure;
aseptically pours sterile normal saline into sterile bowl (or plastic Kerlix gauze
container)
Performs hand hygiene & applies clean gloves*
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