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Step 1
place a pad under wound area
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Step 2
wash hands. Put on clean gloves
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Step 3
remove soiled dressing
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Step 4
- assess the wound for size, appearance, and drainage on the dressing.
- assess the appearance of the surrounding tissue (was it saturated through)
- (describe in chart)
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Step 5
Discard the dressing in the trash receptacle. Remove gloves and put them in the trash receptacle
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If irrigating, follow step 6-11. If not irrigating, skip step 6-11
step 6
Position the client so that the irrigation solution will flow from the clean to dirty end of the wound
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Step 7
wash hands. Put on clean gloves
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Step 8
Gently direct a strem of solution into the wound. Kepp the tip of the syring at least 1 inch above the wound. Watch for solution to flow smoothly and evenly
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Step 9
- dry the surrounding skin with a guaze sponge
- Note: if irrigation did not occur, wearing clean gloves, clean the wound from top to bottom and from center to the outside using gauze. Following this pattern, use a new gauze for each wipe, placing the used gauze in the trash receptacle. Once the area is cleansed, dry the area using a gauze sponge in the same manner.
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Step 10
- Saline-moisten dressing:
- a. soak gauze with saline
- b. squeeze excess fluid from the gauze dressing. Unfold and fluff the dressing
- c. gently press to loosely pack the moistened gauze into the wound
- d. apply dry gauze pads over the wet gauze
- e. apply tape to secure the dressing
- f. date, time, and initial the dressing
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Step 11
- Dry dressings:
- a. apply two layers of dry gauze over the wound
- b. apply tape to secure the dressing
- c. date, time and initial the dressing
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Step 12
Remove gloves and wash hands
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