unit of competency

Apply principles of wound management &

assist in advanced procedure

LO 3: Contribute to the planning of appropriate

care for a patient with a wound
 3.1. Identify patient comfort need
MANAGING PATIENT SAFETY AND COMFORT

• There are many devices to help maintain good

body alignment and muscle tone while the client
is in bed and to alleviate discomfort or pressure
on various parts of the body.
 APPLYING COTTON RINGS
• Cotton rings are small circles of cotton & rolled
with gauze or bandage with hole in the middle.

Purpose
• used to relieve pressure from small bony
prominent areas as the elbows and heads.

● Cotton rings can be prepared in different sizes

depending on the size of the part to be applied.
• Body – Prominence – is a bony prominence,
which are most susceptible to pressure ulcer
development.
• These prominences are covered by skin and small
amounts of subcutaneous tissue.
Susceptible areas includes

Sacrum and coccygal

Ischialtubersites
Greater trochanter,
Heel & knee
Mallelous
Medial condyle of the tibia
The fibular head
Scopula and elbow.
 Equipment

- Cotton
- Bandages
- Chart showing human body prominent area’s
 Procedure

- Arrange the necessary equipment

- Prepare cotton ring based on the size of body to
be applied.
- Place cotton ring under the bony prominence
such as elbow and heel.
 APPLYING – FOOT BOARD / FOOT REST

Definition:-Footboard is a flat plane, often made

of wood or plastic, placed at the foot of a bed.

• It is used for comfort and to prevent foot drop.

• Footboard or sand bag can be used.

 Purpose

• To provide support for the client’s feet, and

maintain a natural foot position while the client is
in bed.

• To keep the top bed covers off the client’s feet,

relieving the pressure of the weight of the covers.

• To make the foot comfortable and prevent foot

drop.
 Equipment

• Box or board /sand bags

• Firm pillow
• Sheet of cloth /cotton
• Bandage
 Procedure

• Prepare the equipment.

• Place footboard between the mattress and foot

of the bed against which the patient’s feet rest.

• If a board is not available, sand bags and rolled

pillows or blankets can be used to fill the space
between the client’s feet and the board.
 APPLYING PILLOWS

• Pillow is advices to maintain the client’s comfort

while the client is in bed.

• It is used to provide support or elevation of a

body part and to alleviate pressure.
There are different sizes of pillows, which are
useful for different body parts.

1. Full or large sized pillows - For the head.

2. Small sized pillows - For Support or elevation of

extremities, shoulders and incisional wound.

3. Special designed heavy pillows – to elevate the

upper body part. When an adjustable bed is not
available.
 INDICATIONS
1. To relieve pressure over the body prominences.
Such as
- The heels – Placed under & superior to the heel
- The sacrum – placed under the back, superior &
inferior to the sacrum.
2. To support & to elevate the clients body parts on
different positions.

For Supine position

- Full or large pillow – under the head & shoulder

- Small pillow – given under knees.
For Prone position

- Large pillow – under the head.

- Small pillow – under the ankle
For Lateral position

- Large pillow – under the head

- Small pillow – at the back & front to support
the arms & abdomen.
For Fowler’s position

- Specially designed pillow – supports for the back

& the head.
- One pillow on each lateral side to support the
arms.
- Under the knee to raise the knee.
 APPLYING AIR RINGS

Defn. Air ring is a circular rubber bag with central

hole, filled with air.

Purpose - Used to relieve pressure from the buttock.

Precautions
- The bag should be filled with air & covered with
pillow case while it is applied.
- Should be changed frequently.
 Procedure

- Assemble the necessary equipment.

- Plastic air ring
- Covering towel
- Applying air ring to body prominent area.
 APPLYING BED CREADLE

Defn Bed cradle – also called Anderson frame.

It is a frame made up of wire, wood or iron, which

are designed to keep the top bed linens off the
injured body part.

Purpose – It prevents the weight of the bedding

from resting on some part of the body.
 Indications

- In case of abdominal & lower extremities injury /

as fracture, burn & skin lesions/.

- To provide privacy & warmth.

 Procedure

- Prepare equipment
Bed cradle of different size & shape.

- Apply bed cradle.

 ADJUSTING SIDE RAILS OF BED’S
Defn: side rails is so called safety sides, usually they
are made up of metal.

The beds with side rails have one or two knobs.

which are been pulled to release the sides and

allow it to move either to raise or to lower the
side rails
 Purpose

- To prevent the clients from rolling or falling

out of bed at night time.

- To confine the patient to the bed.

- To give the client sense of security. Example. In

aged patients
 Position of side rails
Some beds have two positions:
- Up position
- Down position

The others have three positions:

- High position
- Intermediate positions
- Lower position
 Indication for bed readjustment
Bedside rails readjustment is indicated to the
patients who need safety such as.

- Restless
- Aged
- Anesthetized
- Heavily sedated
- Irrational patients
 Procedure
- Raising and lowering of bed side rails
 APPLYING SAND BAG
Defn. Sand bags are cylindrical or rectangular
sand filled bags.
Purpose
- Use for supporting or immobilizing a body part.

- To immobilize & to relieve discomfort in case of

fracture

- To prevent foot drop & wrist drop.

 Precautions
- Sand bag should be covered with towel.

- Sand bag should be placed on either side of a

limb or part to be immobilized.
 Procedure
- Assembling the necessary equipment, that are…
bags filled with sand
weight scale
covering towel
rope
adhesive plaster for labeling.
- Applying the sand bags on either side of the
limb or the intended part to be immobilized.
 APPLYING SPLINT

Defn Splints are firm supports made up of metals or

wood material.

Splint provide immobilization and support to the

body part in functional position.
 Indication

- For conditions that do not require rigid immobilization.

Example for those body parts swelling may be

anticipated.

- Dislocation of Joints

- In case of sprain and strain Immobilize a body part to

prevent further injury after soft tissue injury of
fracture.
 Precautions

- The splint must be well padded to prevent pressure, skin

abrasion & break down.

- The splint should be secured by over wrapping with

elastic bandage.

- The bandage is applied in a spiral fashion, & the

pressure is uniformly age distributed.

- The circulatory status of the splinted extremity should

be assessed frequently.
 Procedure

- Prepare necessary equipment.

• Wire or wood splint
• cotton
• bandage & safety pin.

- Apply splint
• Applying a wrist, ankle or knee splint
1. Explain the procedure

2. Place the client's affected joint in the prescribed joint

position, usually extension.

3. Place the parts of the splint in position around the joint

and fasten.

4. Assess the client's limb to determine if the correct

degree of immobilization is achieved.

5. Assess the underlying soft tissues, pad with soft fabrics

or cotton if fit is correct
6. Teach the client how to apply and remove splint.

7. Explain to the client how to assess neurovascular status.

8. Instruct abs encourage the client to actively exercise

body parts that are not immobilizer.

9. Remove the splint every two hours, if not

contraindicated by the physician's orders,

10. stimulate the underlying skin surfaces through

washing and gentle massage.
 APPLYING FRACTURE BOARD

Fracture – is a break in the continuity of bone that

occurs when the bone is subjected to a stress
greater than that it can absorb.

It can be caused by
direct blow
crashing force
sudden twisting motion and so on.
 Fracture board

- Is a board made up of – wood or some other

firm composition which is placed under the
mattress of patients with fracture.
 Purpose

- To provide flat & unyielding surface to support

the fracture part
- To make the bed firm & to prevent the bed
from sagging.

Indications
- Indicated in case of spinal bone, hip & lower
limb bone fractures as well as slipped disc.
 Procedure

- Place fracture board under the mattress.

 APPLYING BACK REST

Defn. Back rest is a mechanical device, which is

used to give support for the patient in the
sitting position

- Most hospital beds have gatches. If no bed with

gatche,

• Use pillows or boards to elevate head of the

bed.
 Purpose

- To elevate and support the head & back of the

patient in fowler’s position (semi sitting
position).
 Precautions

- If back rest is used for the patients, He/she is liable

to slip down to the foot of bed there fore foot rest
should be used.

- In high fowler’s position, place the over bed table

with a pillow on top in front of the client.

- In using backrest the buttocks; sacrum, heels & the

scapulae bear the main body weight so that they
need careful assessment & massage
3.2 equipements used for appropriate
wound care
 3.3 apply sterile technique of dressing
• Dressings are a fundamental part of caring for a wound,
but can cause great distress to the patient if the desired
effects are not achieved.

• Dressings do not heal wounds, but play a vital role by

providing the optimum environment for the
physiological process of wound healing to occur.

It is paramount that every patient has both a holistic and a

wound assessment to determine the cause and influential
factors important for wound healing.
Three principles of aseptic dressing technique

• Maintain asepsis
• Expose the wound for the minimum time
• Employ an efficient procedure
• Treating the underlying cause will often address
and promote wound healing.

• Pressure ulcers will not heal by dressings alone,

but need the pressure eliminated, while venous
leg ulcers will not heal without compression.

• In essence, dressings are only one element of

caring for a wound.
• Without reassessment in cases where there is
no wound progress, wounds can become
chronic, deteriorate and are prone to recurrent
infections that can threaten good health.

• As healing is physiological, patients need to be

well informed about the expectations of a
dressing and the actions they can take to
influence healing, such as exercise and eating a
well-balanced diet.
 Aseptic Dressing Technique
1. Preparation of Patient
• Explain the procedure, to gain consent and co-operation.
• Draw screens around the bed and ensure adequate light.
• Clear the bed area, close windows, turn off fans, etc.
• Adjust bedclothes to permit easy access to the wound but
maintain warmth and dignity.
• Assess the wound dressing.
• Check patient comfort, e.g. position, convenience, need for
toilet, etc.
• Administer analgesics as appropriate and allow time to take
effect.
 2. Preparation of Nurse
• Consult the care plan to determine the type
of dressing required, frequency of change, etc.
• Make sure hair is tied back securely.
• Wash and dry hands thoroughly.
• An apron should be worn.
• Additional protective clothing may be
necessary if indicated by the patient’s
condition
 3. Preparation of Equipment
You would need:
- Dressing trolley or other suitable surface
- Dressing pack,
- syringe (for irrigating the wound),
- cleansing solution and new dressing according
to the care plan/local policy
- Alcohol hand-rub or hand washing facilities
 Clean the Surfaces
• Clean the trolley or other appropriate surface
according to local policy
 Equipment

• Gatheer the equipement

• check sterility & expiry date of all equipement &

solution.
 Procedure

• Take the trolley to the bed area.

• Adjust the bed to a safe working height to avoid

back strain.

• Opening Dressing Pack.

• Remove the dressing pack from its outer packaging, place it on

the clean trolley/surface.

• Using your fingertips and touching the edges of the paper

only,open the pack and lay it flat to create a sterile field.
 Arranging the contents

• Remove the yellow waste bag and place it to one side.

• Touching only the wrist part of the gloves (or edge of

glove pack) move them to the edge of the sterile field.

• Taking care not to contaminate the sterile field,

carefully pour the cleansing solution into the tray.

• Open the dressing, syringe, etc., onto the sterile field.

 Loosen Dressing

• Adjust any remaining bedclothes to expose the

wound.
• then loosen the existing dressing but do not
remove it.
• Disinfect hands. Ensure your hands are
completely dry before proceeding.
Remove old Dressing
• Open the yellow waste bag and put your hand
inside so that the bag acts as a glove.
• Use this to remove the soiled dressing
Inspect Dressing
• Inspect the dressing to determine the type
and amount of exudates.

Dispose of Old Dressing

• Turn the bag inside out so that the dressing is
contained within it
Attach the Waste Bag

• Use the self-adhesive strip to attach the bag to the side

of the trolley or other convenient place close to the
wound

Put on Sterile Gloves recall gloving & degloving

• Taking care not to touch the outside of the gloves, put

on the sterile gloves.
• Take your right hand glove in your left hand and place
more than half way up and over your right hand
• Take the cuff of your left hand glove with your
right hand and put your left hand fingers inside
the glove Adjust

• Adjust the gloves over your hands while

maintaining sterility
Clean around the Wound

• Use a gauze swab dipped in cleansing solution

to clean around the wound to remove blood,
etc.
 Irrigate Wound
• If the wound itself needs cleaning, use a
syringe primed with solution in one hand and
a gauze swab on the skin below the wound in
the other.

• Making sure that neither the syringe nor gauze

come into contact with the wound,
• allow the solution to flow into the wound,
collecting the solution in the gauze swab
• held below the wound.
 Dry around Wound
Apply new Dressing

• Peel off the backing paper and apply the new

dressing.
Waste bag
Wrap all used disposable items in the sterile field
and place in the waste bag
• Remove gloves and discard into waste bag
• Use adhesive strips to seal bag
Post Procedure: Make Patient Comfortable

• When the dressing is secure, make the patient

comfortable and assist the patient as necessary
into a comfortable position.

• Readjust the bed to a safe height.

• Replace bed rails if necessary

Post Procedure: Dispose of Waste

• Dispose of the waste bag in clinical waste.

Post Procedure: Wash hands

• Remove apron and wash hands.

• Return any unused items to the stock cupboard and clean the
trolley according to local policy.

Post Procedure: Documentation

• Document the care given and the condition of the wound.

 Conclusion

• As with all aspects of nursing, if you are a

student it is vital that you are Supervised until
deemed competent to perform aseptic
dressing technique alone.

• Remember also to check your local policy

regarding cleansing solution and types of
dressing used etc.
 LO 4 undertake nursing care to implement
wound care strategy
• 4.1 assisting in assessing wound products
• ???????????
 4.2 appropriate disposal of articles
following the procedure
• May be assignment
• This has redendancy but brief the students
That is b/se of nurses are extremely prone to
different occupational hazards. Including the
contemporary disease ebola.
 4.3 standard precaution in wound
management to minimize risk of infection
• May be assignment