Nursing With Regards to Pressure Ulcer and Wounds

¶ … performing a clean and sterile technique wound dressing change. The term sterile refers to being free from microorganisms, making the sterile technique method one that reduces exposure to microorganisms in a comprehensive way. Sterile wound dressing changes would mean meticulous hand washing, the use of sterile field, use of sterile gloves, and sterile instruments (Wound, Ostomy and Continence Nurses Society (Potter, et al., 2013; WOCN, 2012). The sterile techniques would be important in acute care and other settings in which patients may be at high risk for infection (WOCN, 2012).

The clean wound dressing change techniques imply methods that are sensible for reducing overall exposure to microorganisms or exposure to infections, but which do not count directly upon "sterile to sterile" rules (WOCN, 2012). Thus, meticulous hand washing and sterile environment are called for, but the process does not strictly deny contact between sterile instruments and non-sterile surfaces or products. While the clean wound dressing procedure minimizes exposure to microorganisms and reduces chances for infection, it is not as rigorous as the sterile method.

The clean wound dressing change techniques are effective for home health care and for patients receiving routine dressings who are not at high risk for infections. 2. Describe the steps you will use to perform a clean dressing change. Clean dressing begins with meticulous hand washing. Hand hygiene goes beyond just washing with soap and water, though. The hands need to be washed with an antiseptic agent such as antimicrobial soap, which would reduce bacterial counts on the hands for a long period of time (Perry & Potter, 2012).

Alcohol-based products can be extremely helpful at this initial step. The next step would be to remove the soiled dressing gently. This may entail rolling it, or it might require lifting it, but when possible, the movement should be in the direction of hair growth to minimize discomfort. An inspection would be then required prior to cleaning, to make sure that color and drainage are normal for the stage of healing. Then, I would clean the wound using pads pre-moistened with the cleaning solution or by using a spray solution.

The appropriate movement would be moving from the least contaminated to the most contaminated area, using a clean pad for each wipe (Lippincott Nursing Center, 2008). After cleaning the wound, I would dry the wound using sterile gauze pads, and dress the wound appropriately while taking into account its conditions and any complications. 3. What is a wound dehiscence? What nursing interventions can prevent wound dehiscence? Wound dehiscence occurs when the layers of the wound start to part or split open. The condition can become severe, leading to complications and infections.

Causes of wound dehiscence range from pressure on the sutures to weak tissue or vitamin deficiencies. Therefore, each instance of wound dehiscence would be treated individually. Interventions that can prevent wound dehiscence include ensuring that sutures are applied properly, not too tight and without too much pressure. Closing procedures need to be particularly careful. The patient also needs to be informed about how to avoid placing too much pressure on the wound.

Furthermore, the patient would need to know about interference with medications that might lead to wound dehiscence and other problems. 4. What are the important aspects to document when assessing a patient's wound? When assessing a patient's wound, the health care worker needs to be observant of various problems. The healing process occurs in stages, which may vary according to the individual. It is therefore critical that the healthcare worker ascertain the patient's history with wounds, demographics, and background.

For example, with age, the healing process slows and increases the risk of contamination and dehiscence (Perry & Potter, 2012). Acknowledging pressure points would be essential when documenting wounds, as some would be located in areas that receive more pressure than others. Pressure generally complicates wound healing. Size of wound is one of the most obvious notations, and changes to size are especially noticeable even when measurements are not precise. The bed of the wound should be healthy, more light pink than red in color. 5.

Which factors are taken into consideration when determining a patient's pressure ulcer risk score using the Braden scale? What interventions can be used if a patient is determines to be at high risk. The Braden Scale for Predicting Pressure Sore Risk indicates six subscales for degree of sensory.