NURSING CARE

Nursing Care



1. Choose a nursing policy or procedure that is commonly used on your unit (central line dressing change, hand washing, obtaining a lab specimen, pain management, and wound care).

Wound Care

Injury is the answer to an open mechanical injury or trauma that causes discontinuity in the skin or mucous membranes. The production of an injury triggers an inflammatory syndrome, loss of substance, bleeding, separation of the edges and a series of accompanying symptoms depending on the seat topographic and depth of lesions. This is called a wound. Providing proper care to these wounds, by following policies and procedures of the educational setting is called Wound Care (Fiorito, 2011).

2. Locate the written nursing policy and procedure and answer these questions: How easy/difficult was it to find this procedure? Did the RNs know where to find this? Is the policy evidence-based?

How easy/difficult was it to find this procedure?

It was not difficult to find the nursing procedures, as the procedures are of fundamental importance for the nurses working anywhere, in a nursing profession. Furthermore, the nursing guide that has been published for our use and for the new joining nurses makes it even easier to learn about the nursing procedures applied in this unit. The nursing guide provides detail explanation of each and every procedure, and is also easy to access. It is expected that once the nurse gains complete knowledge about the procedures, he / she should follow them (Fiorito, 2011).

Did the RNs know where to find this?

Yes, the RNs knew where to find it, as he / she was provided with a nursing guide, detailing all policies and procedures of this medical setting. He / she knew that the policies and procedures can be found in the nursing guide that was provided to him / her. He / she was expected to go through the nursing guide, in order to become familiar with these policies and procedures (Fischer, Nancy, 2011).

Is the policy evidence-based?

Yes, the policies and procedures that have been applied in this medical setting are all evidence based. The policies and procedures for wound care in this medical setting were first examined to observe the results that were obtained through its application. The results were good enough to show that policies and procedures can be applied in this medical setting (Fischer, Nancy, 2011).

3. Observe the RNs on the unit performing the identified procedure and describe what steps the nurses took and in what ways the nurses deviated from policy. What prompted the nurse to make those deviations? Procedures

1.Inform the patient

2.Ensure patient privacy

3.Wash hands

4.External patch removal with non sterile gloves

5.Monitor possible drainage (placement, permeability)

6.Make sterile gauze swab, cleansed with saline and dry skin

7.With out passing twice through the same area and always from the inside out

8.Observe for signs of: swelling, pain, heat and redness

9.Press the edges of the wound for evidence of workable points or intolerable wall abscess.

a)Discuss with your surgeon the possible debridement or drainage implantation

b)Make taken with swab culture medium, putting the patient's name date and time ...