Documentation and Evaluation of Wound Care
Documentation and Evaluation of Wound Care ( 3 Questions)
A client is receiving negative pressure wound therapy (NPWT) for a diabetic foot ulcer. Which action should the nurse take when changing the dressing?
Rationale: The nurse should apply sterile saline to moisten the foam dressing before removal, as this helps to prevent trauma and bleeding from adherent dressing. The nurse should also wear sterile gloves and use aseptic technique when changing the dressing.
This is an incorrect action, as the foam dressing should be cut to fit snugly into the wound cavity, leaving no gaps or spaces between the foam and the wound edges. This ensures optimal contact and negative pressure distribution within the wound.
This is an incorrect action, as the transparent film dressing should be secured with an adhesive drape that covers at least 3 cm beyond the edges of the film. This prevents air leaks and maintains negative pressure within the wound.
This is an incorrect action, as the suction tubing should be disconnected from the device before removing the foam dressing from the wound. This prevents accidental suction of air or fluid into the tubing or device.
Correct answer: A) Apply sterile saline to moisten the foam dressing before removal.
Rationale: The nurse should apply sterile saline to moisten the foam dressing before removal, as this helps to prevent trauma and bleeding from adherent dressing. The nurse should also wear sterile gloves and use aseptic technique when changing the dressing.
Incorrect options:
B) Cut the foam dressing to fit loosely into the wound cavity. - This is an incorrect action, as the foam dressing should be cut to fit snugly into the wound cavity, leaving no gaps or spaces between the foam and the wound edges. This ensures optimal contact and negative pressure distribution within the wound.
C) Secure the transparent film dressing with tape around the edges. - This is an incorrect action, as the transparent film dressing should be secured with an adhesive drape that covers at least 3 cm beyond the edges of the film. This prevents air leaks and maintains negative pressure within the wound.
D) Disconnect the suction tubing from the foam dressing before turning off the device. - This is an incorrect action, as the suction tubing should be disconnected from the device before removing the foam dressing from the wound. This prevents accidental suction of air or fluid into the tubing or device.