ACTIVE LEARNING TEMPLATE: Nursing Skill
Husna Ismailee
STUDENT NAME _____________________________________
Wound care
SKILL NAME____________________________________________________________________________ REVIEW MODULE CHAPTER ___________
Description of Skill
Managing wound care successfully and to abate or reducing the potential for infection and increased tissue
damage.
Indications CONSIDERATIONS
Wound care per orders Nursing Interventions (pre, intra, post)
Replacement of solid dressing
wound harbors a biofilm Pre: Assess the appearance of dressing
wound contains excessive exudate Assess wound for condition, size, color, drainage,
wound contains necrotic tissue or debris in wound smells.
bed Intra: Maintain sterile field for wound care and
the sterility of wound and dressing, note presence
of tunneling, collect required samples before
cleaning, rinse from clean to dirty, apply clean
dressing with date and time.
Post: Document your findings
Outcomes/Evaluation
Client Education
The client's wound will be free from worsening
infection for duration of care. Monitor the client for increased pain at the wound
wound is going to show improvement within couple or close to wound.
of days usually 5 days. Check for increased drainage of foul odors
Wound will be free from necrotic tissue and debris check for sudden bleeding from the wound
for duration of care. keep clean and dry dressing
Client will demonstrate wound care using aseptic client should maintain dietary recommendation of the
procedure before discharge. provider including protein needs
Potential Complications Nursing Interventions
infection worsened, introduction of microbes into Cleanse wound
wound, damage to the wound bed increasing wound use gentle friction when cleaning or when applying
healing time solution to skin. isotonic solutions are preferred.
reactions to cleansers or medications never use same gauze across the wound more than
once.
do not use materials that shed fibers
use piston syringe or sterile straight catheter for
deeper wound irrigation
use 0.9% normal Salin NS, lactated ringers or
antimicrobial solutions
ACTIVE LEARNING TEMPLATES THERAPEUTIC PROCEDURE A9
Husna Ismailee
STUDENT NAME _____________________________________
Wound care
SKILL NAME____________________________________________________________________________ REVIEW MODULE CHAPTER ___________
Description of Skill
Managing wound care successfully and to abate or reducing the potential for infection and increased tissue
damage.
Indications CONSIDERATIONS
Wound care per orders Nursing Interventions (pre, intra, post)
Replacement of solid dressing
wound harbors a biofilm Pre: Assess the appearance of dressing
wound contains excessive exudate Assess wound for condition, size, color, drainage,
wound contains necrotic tissue or debris in wound smells.
bed Intra: Maintain sterile field for wound care and
the sterility of wound and dressing, note presence
of tunneling, collect required samples before
cleaning, rinse from clean to dirty, apply clean
dressing with date and time.
Post: Document your findings
Outcomes/Evaluation
Client Education
The client's wound will be free from worsening
infection for duration of care. Monitor the client for increased pain at the wound
wound is going to show improvement within couple or close to wound.
of days usually 5 days. Check for increased drainage of foul odors
Wound will be free from necrotic tissue and debris check for sudden bleeding from the wound
for duration of care. keep clean and dry dressing
Client will demonstrate wound care using aseptic client should maintain dietary recommendation of the
procedure before discharge. provider including protein needs
Potential Complications Nursing Interventions
infection worsened, introduction of microbes into Cleanse wound
wound, damage to the wound bed increasing wound use gentle friction when cleaning or when applying
healing time solution to skin. isotonic solutions are preferred.
reactions to cleansers or medications never use same gauze across the wound more than
once.
do not use materials that shed fibers
use piston syringe or sterile straight catheter for
deeper wound irrigation
use 0.9% normal Salin NS, lactated ringers or
antimicrobial solutions
ACTIVE LEARNING TEMPLATES THERAPEUTIC PROCEDURE A9
