WOUND DREESING

A. Assessment of wound care needs

1. Therapeutic greetings are conveyed to the patient
2. the presence of wound data and the need for wound care is ensured
B. Prepare tools for wound care

The tools that are prepared according to the standard include:

1. Trolly
2. Sterille Instrument Box, contain:
- 1 piece of Anatomi tweezers
- 1 piece of chirurgi tweezers
- 1 peace of sterile scissors
- 1 piece gallipot
- Sterile gauze,
3. Steril gloves
4. Nacl 0,9%
5. Sufratul
6. Alcohol swab
7. Bandage
8. Lister’s bandage scissors
9. 1 piece of clean tweezers
10. 1 pair of clean gloves
11. Receiver
12. Face mask
13. Rubber mat
14. Trash infection

The tools are neatly arranged on the trolley

C. Prepare the patient for wound care

1. The therapeutic environment includes a physical and psychological environment created to
maintain patient privacy
2. Actions and action objectives are properly explained
3. Position of the patient is adusted comfortably and correctly
D. wound care procedures
1. Wash hands with the six-step technique
2. Equipment is brought to the bedside of the patient
3. Clean gloves are worn properly
4. Rubber mat must be assembled properly
5. Place receiver near to patient bed
7. Plaster and bandages are removed properly using clean tongs
8. After removing the bandage and wound dressing, assess the wound state properly:
cleanliness, swelling, pus, redness, wound edges, drainage sutures
9. The sterile tray is opened and kept sterile, then the antiseptic solution is poured into a
sterile compress using the correct technique.
10. Remove clean gloves and put on sterile gloves properly
11. The wound is cleaned properly using 0.9% NaCL and maintains sterility. The wound is
cleaned from the inside out using sterile tweezers, once wiped it clean, then given sufratul.
12. After the wound is cleaned, the wound is properly covered with sterile gauze
13. Then the dressing is properly taped
14. Rubber mat is lifted carefully, so that the patient does not feel pain
15. The patient is returned to a comfortable position
16. Tools that have been used are tidied up again
17. Remove the gloves that have been used
18. Hand washing is done using the six-step technique

E. Conduct evaluation and follow-up

1. Patient response after wound dreesing is properly evaluated
2. The condition of the wound and follow-up efforts are well communicated
3. Therapeutic greetings done right

F. Doing documentation
1. The state of the wound and the patient's response correctly
2. Date, working hours, TT, name are recorded correctly