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Real Nursing Skills 2.

0 Specimen Collection: Collecting a Specimen for Culture: Wound Culture Purpose

To obtain samples for microscopic examination from wound or body site such as eyes, ears, nose, throat, rectum, or vagina To irrigate wound to clean away organisms and dead tissue and promote healing

Delegation Wound cultures and wound irrigations can be performed by licensed medical personnel (Registered Nurses and Licensed Practical Nurses)* *Always check agency policy and applicable scope of practice Preparation

Consult hospital or institution procedure manual or other references for more detailed and specific information when needed Identify child and introduce self; use at least two client identifiers when providing care, treatment, or services Explain the purpose of the procedure Provide for client privacy Check physicians order for need for culture or what type of irrigation and dosage Perform hand hygiene and adhere to standard precautions Prepare equipment: o Sterile gloves o One culturette swab o Irrigation solution as ordered o Irrigation set or sterile syringes with irrigating tip o Sterile basin o Method for protecting bed o Clean linens o New topical medications and sterile dressing as ordered Page 1 of 2

Pediatric Nursing Skills - 2012 Pearson Education, Inc.

Real Nursing Skills 2.0 Post-Procedure Assess childs response to procedure Tell child to inform you of any discomfort (these instructions should be given before, during, and after procedure); if child is too young to verbalize discomfort, observe for signs or cues of discomfort Provide any instructions for child Clean work area and provide for child comfort Perform hand hygiene and adhere to standard precautions Expected Outcome Appropriate sample will be obtained Wound will be cleansed and dressed appropriately Sterility will be maintained Unexpected Outcome Wrong sample will be obtained Wound will not be dressed appropriately Sterility will not be maintained and procedure will have to be repeated Wound will be contaminated as result of poor sterile technique Documentation Follow institutional guidelines Label wound culture and promptly send to laboratory Document: o Type and amount of drainage o Observations of wound and childs responses to procedure Sample Documentation 1750: Dressing change to left thigh wound completed as ordered. Child pre-medicated 30 minutes prior to dressing change with PRN pain medication. Old dressing and inner packing removed. Outer parameter of wound presents with beefy, red tissue. Scant amount purulent exudate noted at center. Culture obtained from wound bed and wound cleansed with 0.9% normal saline. Wound bed packed with moist Kerlex and covered with (2) 4x4 gauze pads. ABD pad covered entire wound and then secured with paper tape. Child tolerated well. N. Nurse, RN. Resources and References Ball, J.W., Bindler, R. C. & Cowen, K. J. (2010). Child health nursing: Partnering with children and families (2nd ed). Upper Saddle River, NJ: Pearson Education, Inc. Binder, R. C. & Ball, J. W. (2008). Clinical skills manual for pediatric nursing: Caring for children (4th ed). Upper Saddle River, NJ: Pearson Education, Inc.

Pediatric Nursing Skills - 2012 Pearson Education, Inc.

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