Lesson plan

on
wound care

Submitted to: Mrs. T.Uma Devi, Department of obg

Submitted by: J.Pathivardhani, B.sc., nursing 4th year, 2016 batch.

 Wound care

Introduction:

Wound care refers to specific types of treatment for sores, skin ulcers and other wounds that
break the skin. Pressure ulcers also called bed sores.

Purpose:

* To relieve pressure on a weight-bearing part of the body.

* To treat the ulcerated wound itself when skin has become weakened, inflamed and possibly
infected.

* To promote wound granulation and healing

* To promote undue contamination of wound.

* To decrease purulent wound drainage (dressings material absorb the drainage)

* To apply medication to the wound

* To provide comfort.

* To relieve pressure on weight-bearing part of the body.

Types of wound care:

 Hydrocolloid - commonly used for burns, pressure ulcers and venous ulcers.

 Hydro gel - used for wounds with little secretions and infected wounds

 Alginate - used for wounds with high amount of wound drainage

 Collagen - used for wounds such as bed sores transplant sites and large wounds.
Articles needed;

* Gauze sponges

* Medical tape

* Non-woven sponges

* Alcohol pads

* Ear loop face mask

* Bandages and dressings

* Suture removal kits

* Medical gloves

* Gauze rolls

* Cotton balls

Indication:

* Fungating wounds

* Acute wounds

* Diabetic foot ulcers

* Leg ulcers

* Pressure ulcers

Contraindication:

* Malignancy of the wound

* Untreated oestomylities

* Non enteric or unexplored fistulas

* Known allergies or sensitively to acrylic adhesives

 * Placement of negative-pressure dressings directly in contact with exposed blood vessels,
organs, or nerves

Procedure:

S.NO. Steps of the procedure Rationale

1. Tie the mask To prevent wound contamination with

droplets
2. Wash hands thoroughly To prevent cross infection

3. Put on gown ,Gloves To ensure asepsis

4. Open the sterile tray. Spread the
sterile towel around the wound.
5. Pick up a dissecting forceps and
remove and put into kidney tray.
Discard the dissecting forceps in the
bowel of lotion
6. Note the type and amount of drainage
present
7. Ask the assistant to pour small
amount of cleansing solution into the
bowl.
8. Clean the wound from centre to
periphery discarding each swab after
each stroke
9. After thoroughly cleaning of the
wound, dry the wound with dry swabs
using the same precautions. Discard
the forceps in the bowl of lotion.
10. Apply medications if ordered.
To create a sterile field around the
wound
To prevent contamination of the hands
with solid dressings. if the dressing is
adherent to the wound, pour physiologic
saline and wet it before removal
To prevent contaminating the hands of
the nurse by the outside of the bottle.
Cleaning the wound should be done from
the cleanest area to the less clean area.
Wound line is considered cleaner than
the surroundings area even if the wound
is infected.
To keep the wound as dry as possible.
To apply the ointment directly to the
wound may be difficult. Apply a small
portion on the dressing that goes directly
 over the wound.

Nurse’s responsibility

* Provide excellent nursing care to patients suffering from wounds.

* Assess and evaluate patients with wounds and injuries

* Obtain cultures to assess wounds and injuries.

* Evaluate wounds and injuries for infections

* Initiate nursing care procedures in managing acute and traumatic wounds.

* Coordinate with rehab, traumatic and nutritional nurses in nursing patients with
Wounds

* Ensure optimum patient care delivery in wound care nursing procedures.

* Educate and counsel patients and their families on wound care processes.

* Demonstrate wound care procedures to other care givers.

* Sanitize and maintain the premises of wound care neat, clean and hygienic.

Reference: