WOUND CARE

DEFENITION

Wound care is replacement bandage to assist in the wound healing process.

INDICATION

1. Prevent infection
2. Keep the wound dry
3. Provide comfort
4. Decrease pain

CONTRA INDICATIONS

1. Bandages can cause a dark, warm and humid situation so that microorganisms can live.
2. Bandages can cause irritation to the wound through frictions pads.

THINGS THAT MUST BE CONSIDERED

1. Review the history of plaster allergy or medication

2. Assess the extent, location and condition of the incision wound
3. Reviewing medical instruction program related to wound care procedure, dressing
frequency and dressing type

INSTRUMENTS

1. Gloves
2. Mask
3. Betadine in container
4. Kidney basin and basin
5. Instruments tray
6. 4 by 4 sterile gauzes in container
7. Alcohol swab
8. Plaster
9. Under pad
PROCEDURE

1. Washing hands.
2. Prepare and approach the equipment.
3. Wear a clean handscoen.
4. Laying the towel closes the open body of the client privacy.
5. Put the perl under the wound.
6. Set a comfortable and appropriate position for wound care
7. Opening the plaster in the direction of hair growth and opening the bandage carefully, put
a dirty bandage into the plastic bag that has been provided.
8. Open the handscoen clean and replace with sterile handscoen.
9. Cleaning around the wound with alcohol swab.
10. Smear the wound with bethadine starting from the middle of the wound.
11. Closes the wound with sterile gauze, and fixation with plaster on the margin of the
dressing bandage.
12. Write down the date and time to change the bandage on the plaster and stick it on the
bandage.
13. Tidy up clients and clean up the tools.
14. Release handscoen and wash hands.

INSTRUCTION

1. Lay down on your back

2. Raise your right arm, I’ll place this under pad

3. Lower down your arm

4. Take a deep breath if you feel pain

5. I’ll start , now

6. Don’t touch your wound

7. Immerse you leg in this basin for 15 minutes

 8. Don’t move

9. Don’t touch it

10. I will wrap you wound, now

11. If your dressing is to thigh, please let me know

12. do you feel comfort, now ?

13. If you have any complaint, please let me know

DOKUMENTATION

1. Recording location, type of injury and state of injury incision.

2. Record the state of the previous wound.
3. Record fluids or medications used to treat wounds.
4. Record the response and tolerance of clients during, and after the procedure.
DIALOG

NURSE : Knock ....

Excuse me, may i come in please?

PATIENT : Please come in..

NURSE : Good morning, miss ana, I am nurse bella, i am the nurse on duty this morning.
It is time for me to clean your wound and do wound cleaning, now. It is
purposed to clean your wound, prevent infection, do you agree?

PATIENT : yes, nurse.

NURSE : Please follow me this way.

PATIENT : Okay miss.

NURSE : lay down on your bed, please.

PATIENT : yes, nurse.

NURSE : Lift your right hand.

PATIENT : This nurse.

NURSE : Immerse your hand in this basin for 15 minutes

PATIENT : Okay nurse.

NURSE : I will clean your wound, if you fell pain, be relax and take a deep breathing.

PATIENT : Yes nurse.

NURSE : Don’t touch and don’t move your wound.

PATIENT : Yes, nurse.

NURSE : I will cover you wound now. If your dressing is to thigh, please let me know.

PATIENT : Okay nurse.

NURSE : Well, it is finished already. Do you feel comfort now?

PATIENT : Yes, nurse.

NURSE : if you have any complaint, please let me know. I will be at nurse station.

PATIENT : Yes nurse, thank you nurse.