-
DRY DRESSING AND PENROSE DRAIN
-
*SAFETY PROCEDURES*
- check dr. orders / hospital protocol
- gather supplies:
- >drape (absorbent),
- >4x4 sterile gauze sponges (several pkgs)
- >drain sponge
- >ABD abdominal dressing
- >sterile NS
- >tape
- >sterile gloves
- >clean gloves
- wash HANDS
- KNOCK
- ID self
- ID patient
- EXPLAIN procedure
- PRIVACY
-
*OPEN PKGS AND SOLUTION, MAINTAINING STERILITY OF CONTENTS
- open sterile NS
- open 4x4 pkgs (use pkgs as sterile field)
-
*MOISTEN STERILE GAUZE SQUARES WITH STERILE SOLUTION
- moisten 2 pkgs gauze with sterile NS for cleaning
- leave 1 dry for dressing
-
*POSITION AND DRAPE PATIENT*
- bed at comfortable working height
- HOB about 30 degrees to reduce tension on dressing
-
*DON CLEAN GLOVES*
to remove dressing
-
*LOOSEN AND REMOVE OLD TAPE AND DRESSINGS*
- loosen tape pulling towards dressing and parallel with skin
- apply slight traction to tape by pressing on pt skin to reduce tugging
- lift off ABD pad and remove drain sponge
-
*ASSESS DRESSINGS AND WOUND; INSPECT CONDITION OF SAFETY PIN AND DRAIN SITE*
- drainage: sanguinous, serosanguinous, serous drainage;
- strikethrough (on ABD pad)
- edges well-approximated
- sutures intact and #
- erythema
- wound site tension, hardness, odor
-
*DISPOSE OF SOILED TAPE, DRESSINGS AND GLOVES*
-
*PERFORM HAND HYGIENE*
ring out wet gauze to prepare for cleaning
-
*DON STERILE GLOVES*
- away from sterile field
- do not adjust fingers until both are on
- keep hands above waist
-
*CLEAN SURGICAL INCISION WITH MOISTENED GAUZE*
- clean away from incision
- turn gauze over and swipe again with fresh surface.
- discard.
- repeat with other gauze.
-
*CLEAN AREA AROUND PENROSE DRAIN*
- clean around penrose drain in circular motion
- use fresh surface of gauze if necessary to go around again
- discard
-
*REMOVE AND DISCARD GLOVES. PERFORM HAND HYGIENE*
-
-
*APPLY DRY STERILE DRESSINGS TO WOUND AND DRAIN SITES*
- drop and apply dressing on site. DO NOT TOUCH patient skin
- try to keep gauze from touching to prevent seepage
-
*APPLY ABD PAD OVER GAUZE DRESSINGS*
- blue stripe up
- do not touch side that goes against patient
-
*TAPE ACROSS THE DRESSINGS; LABEL WITH DATE, TIME, INITIALS*
- have prepared tape for easy access
- label before applying to patient
-
*DISPOSE OF SOILED MATERIALS; PERFORM HAND HYGIENE*
- remove drape.
- put pt gown back down
-
*DOCUMENT ASSESSMENTS, PROCEDURE, AND PT RESPONSE*
- "dressing change on abdominal incision and drain site performed using aseptic technique. cleaned with sterile NS. amount, color of drainage, odor.
- wound assessment: erythema, suture line and edges well approximated.
- pt. reported no pain during procedure"
|
|
