Clinical Assessment Preparation

CPNE Study Guide

3.11 Wound Management • Assess: 1. Determine learner need(s) related to wound management 2. Measure pain using one of the methods below based on patient’s current clinical condition:  Numeric Rating Scale  FACES Pain Rating Scale  FLACC Pain Assessment Tool  Observed behaviors 3. Determine need for pain medication prior to wound care 4. Observe wound for:  Location  Type  Appearance  Presence or absence of drainage • Implement: 1. Provide education based on learner needs 2. Collaborate with assigned nurse to administer pain medication prior to wound management when needed 3. Provide wound care using the assigned technique: a) Prepare dressing supplies using proper technique b) Remove dressing without contaminating wound c) Remove dressing without injuring surrounding skin d) Dispose of soiled dressing in designated container e) Cleanse wound with designated solution 4. Irrigate wound as assigned: a) Use assigned solution b) Use appropriate irrigation delivery system c) Position patient to facilitate irrigation d) Position receptacle for return flow e) Irrigate wound using aseptic technique f) Protect surrounding skin from contact with drainage g) Ensure patient clothing/linen clean dry following irrigation 5. Pack wound as assigned: a) Apply topical preparation as assigned b) Apply dressing without contaminating wound c) Secure dressing d) Label dressing with date, time, and initials • Document: 1. Education provided 2. Learner understanding of education provided 3. Data related to wound: a) Location b) Type c) Appearance d) Presence or absence of drainage

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