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PROCEDURE |
PROCEDURE: |
134 |
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EFFECTIVE: |
8/82 |
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REVISION: |
9/06 |
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APPROVAL: |
9/06 |
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PROCEDURE FOR APPLICATION AND REMOVAL OF TRANSPARENT DRESSING ON DERMAL WOUND PURPOSE: To promote dermal wound healing, and prevent skin stripping. SUPPORTIVE DATA:
Transparent dressings support the body’s mechanisms for dermal wound healing
by creating a clean moist environment. This clean, moist environment is
possible because the dressing is impermeable to bacteria, but permeable to
oxygen and moisture vapor. EQUIPMENT: 1.
Transparent
dressing - to fit at least 2 inches beyond the area to be covered 2.
Saline 3.
4x4 gauze 4.
Paper tape 5.
Skin sealant/protectant wipes 6.
Scissors 7.
Ink pen 8.
Non-sterile
gloves NURSING ACTION: PROCEDURE STEPS: A. Application
1.
Inspect wound for signs and symptoms of active
infection, and assess for necrotic tissue. KEYPOINT: If present, refer to MD or enterostomal
therapist. 2.
Apply
non-sterile gloves. 3.
Prepare skin by
cleaning wound with saline. Let surrounding skin dry, or pat dry with 4x4. 4.
Apply skin
sealant on healthy skin around wound where dressing or tape will be applied
to prevent skin stripping (tape burns). Let dry. 5.
Pull off the
paper backing and anchor to the skin. KEY POINT:
Remember to clear the wound by 2 inches. 6.
Remove top and
edge portions of the paper backing. 7.
Date, time, and
initial dressing. KEY POINT: Remember long term dressings are not appropriate on
sacral ulcers of incontinent patients. B. Maintenance/Changing the Dressing 1.
Remove dressing
q 48° -72° or earlier, if needed. 2.
Hold skin with
one hand and pull gently with the other hand. KEY POINT: Exudate will
accumulate under the dressing as this is part of the healing process. REFERENCES: RESOURCE PERSON: Joyce
Randof, RN, MNSc; Donella
Doctor, RN, MNSc, CWOCN: Amanda Pennington BSN, RN,
WOCN |
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