Chapter 4: Wound Care
4.6 Advanced Wound Care: Wet to Moist Dressing, and Wound Irrigation and Packing
Critical Thinking Exercises: Questions, Answers, and Sources / References
Critical thinking questions are in bold type, and the answers are italicized. Additional resources or references are provided below.
- Provide a rationale for selecting PPE when performing a wound irrigation: eye protection, gown, non-sterile gloves, or sterile gloves.
- When irrigating, splashing might occur thus exposing the HCP to BBF.
- Sterile gloves may be used on wounds (surgical) that pose significant risk to the patient. In this case sterile gloves are protecting the patient AND the HCP.
- Which elements are important to consider when assessing a closed surgical incision?
- Are the edges approximated?
- Is there drainage?
- Is there redness or swelling to the surrounding tissue?
- Where is it?
- Are staples, sutures, or Steri-Strips present?
- Pain?
- What elements are important to consider when assessing an open wound?
- Where is it?
- What is the size (length/width/depth)?
- What does the wound bed look like (red / black / slough/ other)?
- What does the peri-wound skin look like (intact / macerated)?
- Is there redness or swelling to the surrounding tissue?
- What type of drainage is present (sanguinous, serosanguinous, serous, purulent)?
- Is there tunneling (where and what length)?
- Drainage (type and amount)?
- Is there odour after the wound has been cleansed?
Source:
British Columbia Provincial Nursing Skin and Wound Committee. (2011). Guideline: Assessment and treatment of surgical wounds healing by primary and secondary intention in adults and children. https://www.clwk.ca/buddydrive/file/guideline-surgical-wounds-primary-secondary-intention/
British Columbia Provincial Nursing Skin and Wound Committee. (2014). Guidelines: Braden scale for predicting pressure ulcer risks in adults and children/infants. https://www.clwk.ca/buddydrive/file/guideline-braden-risk-assessment/
Perry, A., Potter, P., & Ostendorf, W. (2017). Clinical nursing skills and techniques (9th ed.). Elsevier; Mosby.
Sample Quiz Question
- Which PPE is appropriate when performing a wound irrigation? Select all that apply.
- Eye protection (Answer: yes)
- Gown (Answer: possible)
- Gloves (Answer: yes)
- Foot protectors (Answer: no)
Source:
Centers for Disease Control and Prevention (CDC). (2007). Part III: Precautions to prevent the transmission of infectious agents. http://www.cdc.gov/hicpac/2007IP/2007ip_part3.html