Secure the dressing with medical tape or a bandage
9
Document the wound condition and treatment provided
10
Monitor the wound for signs of infection
11
Dispose of used materials properly
12
Wash and sanitize hands
13
Update patient's medical record
14
Inform patient/caregiver about the wound care
15
Schedule next dressing change
16
Prepare for wound dressing post-care
17
Approval: Registered Nurse for dressing application
18
Handoff patient to caregiver if applicable
Evaluate the wound condition
Assess the severity and characteristics of the wound to determine the appropriate treatment. Consider the size, depth, and location of the wound, as well as any signs of infection or complications. What are the key indicators of a healthy wound? What are the signs of infection? How will this information guide the overall wound care process?
1
Size
2
Depth
3
Location
4
Infection signs
5
Complications
1
Healthy
2
Infected
3
Compromised
4
Healing
5
Delayed healing
Check patient's allergy history
Ensure the patient does not have any known allergies that could react to the dressing materials or antiseptic solutions used. Please explore any previous experiences with wound dressing or allergies. How will this information help in selecting appropriate materials? How can you address potential allergies or sensitivities?
1
Latex
2
Adhesive
3
Iodine
4
Antibiotics
5
Other
1
No known allergies
2
Mild
3
Moderate
4
Severe
5
Unknown
Select appropriate dressing materials
Based on the wound condition and patient's allergy history, choose the most suitable dressing materials. Consider factors such as breathability, absorbency, adherence to the wound, and availability. How will the chosen dressing materials promote healing? What alternative options can be used?
1
Gauze
2
Foam
3
Hydrogel
4
Alginate
5
Hydrocolloid
1
Transparent film
2
Non-adherent pad
3
Dry gauze
4
Hydrogel sheet
5
Adhesive island dressing
1
Tape
2
Adhesive strips
3
Compression bandage
4
Self-adherent wrap
5
Cohesive bandage
Cleanse the wound area with saline solution
Thoroughly cleanse the wound area using a saline solution to remove debris, bacteria, and other contaminants. Describe the cleansing process, including the technique and the necessary precautions. How does proper wound cleansing contribute to infection prevention and wound healing?
1
Irrigation
2
Soaking
3
Spray
4
Wipe
5
Whirlpool bath
1
0.9%
2
0.45%
3
3%
4
0.22%
5
Other
1
Wear gloves
2
Use sterile equipment
3
Maintain aseptic technique
4
Apply gentle pressure
5
Protect surrounding skin
Approval: Physician to verify wound cleanliness
Will be submitted for approval:
Cleanse the wound area with saline solution
Will be submitted
Apply antiseptic to the wound
Once the wound is cleansed, apply an antiseptic solution to further inhibit the growth of bacteria and reduce the risk of infection. Provide instructions on the proper application technique and the desired outcome. How does the antiseptic benefit wound healing? What are the potential adverse effects?
1
Povidone-iodine
2
Chlorhexidine
3
Hydrogen peroxide
4
Silver-based
5
Honey-based
1
Once
2
Twice
3
Thrice
4
Four times
5
Other
Apply the selected dressing to the wound
Properly apply the chosen dressing materials to cover and protect the wound. Describe the correct technique, ensuring proper adherence and avoiding pressure on the wound bed. How will this dressing promote healing and create an optimal wound environment?
1
Position the patient
2
Prepare the wound bed
3
Apply primary dressing
4
Secure with secondary dressing
5
Inspect for proper fit
1
Wound bleeding
2
Excessive exudate
3
Uneven wound surface
4
Patient discomfort
5
Inadequate material size
1
Excellent
2
Good
3
Fair
4
Poor
5
Not applicable
Secure the dressing with medical tape or a bandage
Ensure proper fixation of the dressing by using medical tape or a bandage to prevent accidental displacement. Describe the appropriate technique for securement, considering the wound location and patient comfort. What factors should be considered when selecting the type of fixation?
1
Medical tape
2
Adhesive bandage
3
Cohesive bandage
4
Elastic wrap
5
Tubular bandage
1
Wound location
2
Patient mobility
3
Allergy history
4
Adhesive sensitivity
5
Ease of removal
Document the wound condition and treatment provided
Accurately record the wound condition, the applied dressings, and any other relevant information. Emphasize the importance of detailed documentation for future reference and continuity of care. How will this documentation aid in assessing progress and identifying necessary adjustments?
1
Improving
2
Stagnant
3
Deteriorating
4
Closed
5
Other
Monitor the wound for signs of infection
Regularly assess the wound area for any signs of infection, such as redness, swelling, increased pain, or pus formation. Explain the significance of early detection and prompt intervention in preventing complications. How should the monitoring frequency and duration be determined?
1
Redness
2
Swelling
3
Increased pain
4
Warmth
5
Pus formation
1
Daily
2
Twice a day
3
Every other day
4
Weekly
5
Other
1
Inspect wound site
2
Measure wound size
3
Document findings
4
Assess pain level
5
Assess surrounding tissue
Dispose of used materials properly
Safely dispose of any used dressing materials, gloves, and other contaminated items to prevent cross-contamination and infection spread. Provide instructions on how to dispose of different types of waste materials. How does proper disposal contribute to infection control?
1
Remove gloves and PPE
2
Segregate waste items
3
Dispose of sharps in designated container
4
Place non-sharp waste in appropriate bin
5
Properly seal waste bags
1
Biohazard waste
2
General waste
3
Recyclable waste
4
Sharps waste
5
Other
Wash and sanitize hands
Thoroughly wash hands using proper handwashing techniques, followed by the application of hand sanitizer. Emphasize the importance of hand hygiene in preventing the spread of pathogens and maintaining a clean wound environment. When should hand hygiene be performed?
1
Wet hands with water
2
Apply soap and lather
3
Rub hands palm to palm
4
Clean between fingers
5
Rinse and dry hands
1
Alcohol-based
2
Non-alcohol based
3
Foam
4
Gel
5
Spray
1
Before wound dressing
2
After wound dressing
3
Before and after glove use
4
After waste disposal
5
Other
Update patient's medical record
Record the wound care provided and any relevant information in the patient's medical record. Explain the significance of maintaining an accurate and up-to-date medical record for the continuity of care. What are the essential components to include in the record?
1
Patient demographics
2
Allergy history
3
Current medications
4
Previous wound care
5
Assessment findings
Inform patient/caregiver about the wound care
Educate the patient and/or caregiver about the wound care process, including dressing changes, signs of infection, and when to seek medical attention. What are the key points to cover in the patient/caregiver education? How can you ensure understanding and compliance?
1
Verbal instructions
2
Written instructions
3
Demonstration
4
Video tutorial
5
Other
Schedule next dressing change
Set a specific date and time for the next dressing change based on the wound condition and expected healing progress. How should the dressing change interval be determined? How can you ensure the availability of necessary resources and personnel for the next dressing change?
1
Morning
2
Afternoon
3
Evening
4
Night
5
Other
1
Ensure availability of supplies
2
Notify healthcare professional
3
Coordinate with caregiver, if applicable
4
Update calendar or scheduler
5
Provide patient/caregiver with reminder
Prepare for wound dressing post-care
Organize any necessary follow-up procedures, such as diagnostic tests or consultations, to ensure comprehensive wound care management. How will the post-care preparations support ongoing wound healing and patient well-being?
1
Laboratory tests
2
Consultations/appointments
3
Imaging studies
4
Medication review
5
Other
1
Schedule appointments
2
Arrange transportation, if needed
3
Notify healthcare professional
4
Prepare necessary documents
5
Inform patient/caregiver
Approval: Registered Nurse for dressing application
Will be submitted for approval:
Apply the selected dressing to the wound
Will be submitted
Handoff patient to caregiver if applicable
If the patient has a primary caregiver, communicate relevant information and instructions regarding wound care, signs of complications, and emergency contacts. How can you ensure a smooth and effective handoff process? What should be included in the handoff communication?