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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Chapter 26
Wound Care
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Terminology Related to
Wound Healing
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Dehiscence: separation of outer wound layers
Evisceration: rupturing of a wound
Eschar: hard, dry, leathery dead tissue
Granulation tissue: new tissue growing on a
wound
 Sinus tract: tunnel developing between two
cavities in a wound
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Classification of Wounds
 Contusions—closed discolored wound
caused by blunt trauma—bruise
 Skin intact—injury beneath epidermis
 Blood leaks from broken blood vessels
 Extra fluid in interstitial space—pressure on
nerve endings—pain or tenderness
 Blood—skin discoloration
 Ecchymotic area----ecchymosis
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Surgical Incisions
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Sharply defined edges
Under sterile conditions
Well approximated—close together—touching
Incision closed with sutures, staples, steristrips, or skin adhesive
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Classification of Wounds
 Abrasions—superficial open wound
 Scrapes or rub-type wound
 Superficial
 Heal well when kept clean
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Classifications of Wounds
 Puncture wounds—open wound when a sharp
item pierces the skin
 Round hole that penetrates into deeper tissue
 Dependent on the length and diameter of the
sharp item
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Classifications of Wounds
 Penetrating wounds—similar to a puncture
wound
 Object remains embedded in tissue
 Degree of damage depends upon size of the
object and the tissues or organs affected by the
penetration
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Classification of Wounds
 Lacerations—open wound made by accidental
cutting or tearing of tissue
 Common—knives, pieces of glass and metal
 Jagged edges
 Closure more difficult and less anesthetically
pleasing than a surgical incision
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Classifications of Wounds
 Pressure Ulcers—wound resulting from
pressure and friction
 Skin may be intact and erythemic or skin may be
broken
 May be superficial or very deep
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Multiple Choice Question
A nurse is caring for a patient in the ER who
cut his hand with a kitchen knife and needs
stitches. The nurse documents this wound as
A. Contusion
B. Laceration
C. Puncture wound
D. Penetrating wound
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pressure Ulcers
 Aka decubitus ulcer or bedsore
 Occurs when external pressure is exerted on
soft tissue—esp. over bony prominences
 For a prolonged period of time
 Tissues and capillaries compressed—reduced
blood flow—ischemia
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pressure Ulcers
 Direct result of friction or shearing force
 Bony prominences—sacrum, buttocks, greater
trochanters, elbows, heels, ankles, occiput,
and scapulae
 Longer the pressure is maintained—the worse
the extent of necrosis
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Risk Factors for
Pressure Ulcer Development
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Being elderly
Being emaciated or malnourished
Being incontinent of bowel or bladder
Being immobile
Having impaired circulation or chronic
metabolic conditions
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Stage of Pressure Ulcers
 Deep tissue injury: area over a bony prominence that
differs from surrounding tissue; may be blister-like or
a discoloration
 Stage I: erythema
 Stage II: partial-thickness loss of dermis
 Stage III: full-thickness loss; damage to epidermis, dermis,
and subcutaneous tissue
 Stage IV: full-thickness loss; damage to deep tissue,
muscle, fascia, tendon, joint capsule, and/or bone
 Unstageable: eschar covers the wound, making it
impossible to tell the depth
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Stage of Pressure Ulcers
 Deep tissue injury
 Area over a bony prominence that differs from
surrounding tissue
 Temperature, firmness, or discomfort
 May be blister-like or a discoloration
 Dark burgundy, purple, or maroon color, like a bruise
 Represent injury to the underlying soft tissue
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Stage of Pressure Ulcers
 Stage I
 Erythema—generally over a bony prominence
 Remains for at least 15 to 30 minutes after
relieving the pressure—will not blanch
 Dark skinned individual—darker than normal
 May feel warm, firm, soft, or boggy, pain, tingling
 Do not massage area
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Stages of Pressure Ulcers
 Stage II
 Partial thickness loss
 Intact serum filled blister or shallow, pink or red
ulceration can be either shiny or dry
 Usually erythema surrounding
 Possible infection
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Stages of Pressure Ulcers
 Stage III
 Full-thickness skin loss
 May go to subcutaneous tissue—not involving
muscle or bone
 May have undermining or tunneling
 Slough may be present
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Stages of Pressure Ulcers
 Stage IV
 Full-thickness skin loss
 Involves muscle, fascia, tendon, joint capsule, and
sometimes bone
 May have tunneling or undermining
 Infection—possible osteomyelitis
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Stages of Pressure Ulcers
 Unstageable
 Involve full-thickness tissue loss but impossible to
accurately stage due to inability to view wound
base—eschar or excessive slough
 Eschar—hard, dry, dead tissue—leathery
appearance—can be black, brown, or tan
 Cannot stage until base of wound is viewed
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Stages of Pressure Ulcers
 Unstageable
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If eschar remains intact and stable
Completely covering heel
Do not remove it
Nature’s band-aid
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Prevention
 Braden scale
 Predicts pressure sore risk
 Six categories—sensory perception, moisture,
activity, mobility, nutrition, and friction and shear
 Figure 26-4, pg. 562
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Prevention
 MAJORITY of pressure ulcers can be prevented
 Good nursing care
 Thorough skin assessment—esp. high risk areas
 How often?
 Dry, flaky, peeling—non-intact skin—excoriated—
blistered—color—temperature…….
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Prevention
 Good nursing care
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Skin turgor—will tell you?
Edema?
Reposition q 2h
Keep skin clean and dry
Keep linens free of wrinkles
Lotion to dry skin
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Prevention
 Good nursing care
 Use lift sheet or mechanical lift
 Do not pull anything out from under patient—roll
patient—then remove
 Adequate fluids and nutrition
 Supplements?
 Specialty beds and pressure relieving devices
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Stasis Ulcer
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Develop when venous blood flow is sluggish
Usually in lower extremities
Blood pools in veins
Resulting edema damages surrounding tissue
Ulcers develop
Chronic condition and difficult to heal
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Venous Ulcer
 Pretibial area of lower leg or above the medial
ankle
 Usually large
 Shallow with diffused edges
 Exudation/granulating
 Generalized edema
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Venous Ulcer
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Staining
Ankle-brachial index—greater than 0.8
Normal pulses
Some dependent pain
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Venous Ulcer Treatment
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Conservative management
Compression treatment
Elevate legs
Surgery in selected patients to re-establish
valve function and resolve venous
hypertension
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Arterial Ulcer
 Distal portion of the lower extremity, over
ankle or bony areas of foot (top of the foot or
toe, outside edge of the foot)
 Usually small
 Deep with “cliff”edges
 Dry (necrotic)
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Arterial Ulcer
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Localized edema
Never staining
Ankle-brachial index—less than 0.8
Reduced or absent pulses
Pain present especially at night (elevated)
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Arterial Ulcer Treatment
 Re-establish arterial supply by surgical or
pharmaceutical intervention
 Do not use compression therapy
 Protect the wound and surrounding skin from
trauma until arterial supply is re-established
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Diabetic Ulcer
 On the foot—at mid-foot, ball of the foot, over
the metatarsal heads, or on the top of toes
with Charcot deformity
 Often very small
 Deep with “cliff” edges
 Dry (necrotic)
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Diabetic Ulcer
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Localized edema
Never staining
Ankle-brachial index—not reliable
Pulses—not reliable
No pain--neuropathy
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Diabetic Ulcer Treatment
 Redistribute pressure below the ankle through
orthotics
 Aggressive debridement to reduce the very
high incidence of infection experienced in
diabetic ulcers
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Three Phases of Wound Healing
 Inflammatory
 Occurs when the wound is fresh; includes both
hemostasis and phagocytosis
 Reconstruction (proliferation)
 Occurs when the wound begins to heal, about 21
days after injury
 Maturation (remodeling)
 Occurs when the wound contracts and the scar
strengthens
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Types of Wound Closures for Healing
 First intention
 Wound is clean with little tissue loss, edges are
approximated, and wound is sutured closed
 Second intention
 There is greater tissue loss, wound edges are
irregular, and wound is left open
 Third intention
 Wound is left open for some time to form
granulation tissue and then sutured closed
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Factors Affecting Wound Healing
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Age
Chronic illness
Diabetes mellitus
Hypoxemia
Lifestyle choices
Lymphedema
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Factors Affecting Wound Healing
(cont.)
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Medications
Multiple wounds
Nutrition and hydration
Radiation exposure
Wound tension
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Complications of Wound Healing
 Complications can occur as wound heals
 Differentiate between normal healing and the
presence of complications
 Assess wounds every shift
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Assessment Parameters
for Wound Healing
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Site
Wound type
Wound closure
Drainage—color, amount, odor?
Condition of wound bed—measure—
tunelling or undermining
 Condition of skin surrounding wound
 Pain
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Normal Findings
 Surgical Incision
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Skin edges well approximated
Staples or sutures intact
Serosanginous drainage
No odor
Surrounding skin fleshtone (peri-wound area)
Pain decreasing as days pass
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Assessment
 Surgical Incision
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Incisional site
Sutures or staples
Drainage—odor
Peri-wound
Pain
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Findings
 Surgical incision
 Dehiscence or evisceration
 Sutures or staples not intact
 Surrounding skin
 Color (pink, red, ecchymotic), edema, ↑temperature
 Drainage (sanginous, purulent)
 Odor
 Increased pain
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Wound Closure
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Sutures or staples
Absorbable sutures on inner layers
Well approximated
Removed approximately 7 to 14 days
Steri-strips—gives support to incision
Do not remove—Do not soak
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Care for Sutures/Staples
 Assessment of sutures every 8 hours
 Note loosening, gaps, redness
 May be responsible for removing
suture/staples when wound is healed
 Skill 26-1, pg. 578
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Wound Drainage
 Sanguineous—red, bloody
 Serous—clear to pale yellow
 Serosanguineous—blood and serous fluid—
light red to pink
 Purulent—thick drainage—various colors
 Bilious—dark greenish—often after
galllbladder surgery
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Normal Findings
 Open Wound
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Wound base (granulation tissue)
Skin edges straight
No undermining or tunneling
Surrounding skin fleshtone
Pain decreasing
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Assessment
 Open Wound
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Wound base
Skin edges
Undermining or tunneling?
Drainage—odor?
Peri-wound
Measurement
Pain
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Findings
 Open Wound
 Wound base: Infection, necrotic tissue, slough, no
granulation tissue
 Skin edges curled
 Undermining or tunneling
 Surrounding skin: red, ecchymotic, warmer or
cooler to touch, edema
 Increased pain
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Signs of Wound Infection
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Redness or increased warmth
Swelling
Wound drainage
Unpleasant smell
Pain around wound
Fever above 100°F
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Obtaining a Wound Culture
 C&S of wound
 Determine effective antibiotic treatment
 If irrigation also ordered—perform irrigation
first
 Skill 26-4, pg. 582
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Care
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Monitor vital signs
Monitor laboratory test results
Monitor pain level
Description of wound and S/S
Notify physician—have all your ducks in a row
What information will you need?
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Patient Teaching
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Signs and symptoms of wound infection
Notify physician if any occur
Proper use of antibiotics
Dressing change—involve family members—
demonstrate—have them return
demonstration
 Instructions verbally and in writing
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Cleansing an Incision
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When ordered
Superior end of incision to inferior end
Drainage usually flows downward
Long strokes—new swab for each stroke
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Cleaning a Wound
 Dissolved necrotic tissue or pus
 Tissue fluid and blood
 Cleansing methods
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Whirlpool
Irrigation
Gauze moistened with sterile saline
Careful not to damage healthy granulation tissue
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Irrigation
 Nursing care
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Remove surface debris without injuring tissue
Varying degrees of pressure
Wear appropriate PPE
Position patient correctly
Collection container
Most common irrigant—Sterile normal saline
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Types of Drainage Tubes
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Hemovac: active drain uses suction
Jackson-Pratt: active drain uses suction
T-tube: passive drain uses gravity
Penrose: open drain; not commonly used
because can provide pathway for pathogens
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Drainage Tubes
 Nursing care
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Empty q 8h or when ½ to 2/3 full
No compression—no suction
Measure drainage—I&O—individual containers
Note type, amount, odor
Careful dressing change with penrose drain
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Cleaning a Drain Site
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When ordered
Circular motion
Innermost aspect to outer aspect
Each motion—one swab—then disposed
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Purposes of Dressing
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Protect the incision
Absorb drainage as the wound heals
Protect the wound from further injury
Provide moist environment for healing
Fill the open space within the wound
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Types of Dressings
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Alginate
Gauze
Hydrocolloid
Hydrofiber
Negative pressure wound therapy
Polyvinyl
 Table 26-2, pg. 573
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Wet-to-Damp/Wet-to-Dry
 Maintain moist wound bed
 Wick out drainage from wound
 Changed frequently to prevent total drying
out of gauze
 Debridement
 Wet-to-Damp are favored—they preserve
granulation tissue
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Securing Dressing
 Tape
 Silk
 Paper—thin, fragile skin or allergic
 Foam--thicker
 Tape superior and inferior edges of dressing
 Working laterally
 Extend beyond dressing 1 ½ to 2 inches
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Securing Dressings
 Dressing over joint
 Place tape parallel to the bend of the joint
 Allows movement without dislodging dressing
 Montgomery Straps
 Frequently changed dressings
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Securing Dressings
 Abdominal binders
 Abdominal dressings
 Provide support to incision
 Ace wrap or gauze
 Secures dressing without the use of tape
 Elastic netting
 Secures dressing without the use of tape
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Bandage Turns
 Circular
 Beginning and end of application
 Spiral
 Overlap each turn by 50%
 Provides equal compression
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Bandage Turns
 Figure eight
 Over joint
 Recurrent
 Head or stump
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Applying Bandage on Extremity
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Elevate extremity
Hold roll of bandage in dominant hand
Roll on top
Always move distal to proximal
Never stretch bandage
Apply with even pressure—not tight—two
fingers
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Responsibilities for
Applying Dressings
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Open wound = sterile procedure
Clean versus sterile technique
Handwashing
Gloves should always be worn
Additional PPE if excessive drainage, isolation,
splashing….
Copyright © 2011 F.A. Davis