NURSING MANAGEMENT

OF A PATIENT RECEIVING
INTRAVENOUS THERAPY
Loreiyne Grace Aballe, RN
Ophelia Mae Odtojan, RN
OBJECTIVES: AT THE END OF THIS LECTURE, YOU WILL BE ABLE TO:
◦ DESCRIBE INTRAVENOUS THERAPY
◦ UDERSTAND THE FACTORS AND CONSIDERATIONS IN
CHOOSING AN IV SITE
◦ ENUMERATE THE STEPS IN PREPARING INTRAVENOUS
THERAPY
◦ KNOW HOW TO REGULATE THE INTRAVENOUS FLUID
AT DESIRED RATE
◦ IDENTIFY SYSTEMIC AND LOCAL COMPLICATIONS
◦ ENUMERATE THE PROCEDURE IN DISCONTINUING
INTRAVENOUS THERAPY
◦ LEARN THE PROPER DOCUMENTATION OF
INTRAVENOUS THERAPY.
INTRAVENOUS A VENIPUNCTURE (AN EXPECTED NURSING SKILL)
TO GAIN ACCESS TO THE VENOUS SYSTEM FOR

THERAPY
ADMINISTERING FLUIDS AND MEDICATION
PREPARING TO
ADMINISTER IV
THERAPY
◦ NURSES MUST:
◦ Check doctor's order (ex. Start
venoclysis of D5LR 1L at 120mL per
hour)
◦ Perform hand hygiene
◦ Apply gloves
◦ Informs patient of procedure
CHOOSING AN
INTRAVENOUS SITE

◦ Peripheral sites
◦ mostly arm veins like
metacarpal, cephalic, basilic,
and median veins) are
ordinarily used and are the safe
and easy sites
◦ Legs are used rarely because of
the high risk of
thromboembolism
 VEIN FEELS FIRM,
ELASTIC, ENGORGED,
AND ROUND NOT HARD,
FLAT OR BUMPY
 SITES TO BE AVOIDED
◦ Veins distal to a previous IV infiltration or phlebitic area
◦ sclerosed or thrombosed veins
◦ Arm with arteriovenous shunt or fistula
◦ Arm affected by edema, infection, blood clot, deformity, severe
scarring or skin breakdown
◦ Arm on the side of mastectomy (impaired lymphatic flow)
* antecubital fossa is avoided, except last resort (most distal first
for subsequent IV access progressively upward)
FACTORS TO CONSIDER IN CHOOSING A SITE

Type of fluid or
Condition of the Duration of the Patient's age and
medication to be
vein therapy size
infused

Whether the Patient's Skill of the

patient is left- medical history person
handed or right- and current performing the
handed health status venipuncture
GENRAL GUIDELINES
FOR SELECTING A
CANNULA
◦ LENGTH: 0.75 to 1.25 inches long

◦ DIAMETER: narrow diameter of the cannula to

occupy minimal space within the vein

◦ Should not rest in a flexion area

◦ GAUGE:
◦ 20-22 gauge for most IV fluids; a larger caustic or
viscous solution
◦ 14 to 18 gauge for blood administration and for
trauma patients and those undergoing surgery
◦ 22 to 24 gauge for elderly patients
TEACHING THE
PATIENT
◦ EXCEPT IN EMERGENCY
SITUATIONS, patient should be
prepared for IV infusion
◦ Things to educate:
◦ Venipuncture
◦ Expected length of infusion
◦ Activity restrictions
PREPARING THE
INTRAVENOUS
SITE
◦ Nurse should ask the patient for allergies to
latex or iodine.

◦ Excessive hair at selected site may be

removed by clipping if necessary
(facilitates insertion and adherence
of dressings)

◦ IV set should be remained sterile

◦ Perform hand hygiene

◦ Put on gloves during venipuncture

IV SET
STARTING INTRAVENOUS INFUSION

1. CHECK IV SOLUTION AND MEDICATION ADDITIVES WITH THE

PHYSICIAN'S ORDER.
(Ensures the client receives the correct IV solution and medication)

2. WASH HANDS
(Prevents spread of microorganism)
3. GATHER EQUIPMENT AND PREPARE IV
SOLUTION AND TUBING
a. Maintain aseptic technique when opening sterile packages and IV solution .
(prevents contamination of IV solution and set which can infect the patient rapidly)
b. Clamp tubing, uncap the spike and insert into the entry site.
(Puncture the seal in the IV bag or bottle)
c. Squeeze the drip chamber and allow it to fill at least halfway.
(suction effect causes fluids to move into the drip chamber and also prevents air from
moving down the tubing)
d. Remove the cap at the end of the tubing, release the clamp and allow the fluid to
move through the tubing (this is termed as priming the tubing). Allow fluid to flow
until all air bubbles have disappeared. Close the clamp recap the end of the
tubing, maintaining the sterility of the setup.
(removes air from the tubing which in large amounts, act as an air embolus)
4. Identify and explain the procedure to the patient.
(allays anxiety)

5. Have the patient in a supine or low Fowler's position in bed

(supine position permits either arm to be used and allows good body alignment. Low
fowler's position is usually the most comfortable for the patient)

6. Suspend the bag or bottle of solution in the IV stand.

(fluid height should be 18-24 inches above the level of the vein. This height is sufficient
to overcome venous pressure)

7. Assist physician or nurse with the procedure.

8. Adjust the rate of flow according to the doctor's order.
(Provides appropriate IV therapy as ordered)
9. Complete the label and tape to the IVF bag,
(facilitates assessment and safe discontinuation)
10. Do after care.
(deters spread of microorganism)
11. Document date and time of therapy; type and amount of solution; additives and
dosages; flow rate; gauge; length and type of vascular access device;
Catheter insertion site; type of dressing applied; patient response to procedure;
patient teaching
(promotes continuity of care)
REGULATING INTRAVENOUS
FLOW RATE

Note:BEFORE THE INFUSION OF

IV SOLUTION IS BEGUN,
THE NURSE SHOULD
MATHEMATICALLY
CONVERT THE RATE OF
INFUSION BY THE
PHYSICIAN INTO
COMPARABLE DROPS PER
MINUTE.

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PURPOSES OF REGULATION of IV
FLOW RATE:

✓ To comply with prescribed rate

ordered by the physician.
✓ To maintain an equal and constant
rate of fluid administration
throughout the duration of the
infusion.
✓ To assist in reassessing the progress
of fluid infusion
✓ To prevent circulatory overload or
insufficient correction of
hypovolemia.

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 Nursing
Considerations:

1. Read the current written medical

order for the volume and number of
hours of infusion.
2. Determine the manufacturer’s drop
factor and the ratio of drops per milliliter.

EQUIPMENTS NEEDED!
✓ Jot down notebook and ballpen
✓ Wrist Watch with a second hand
✓ Strip of tape as marker or to be
used as time strip if necessary.

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PROCEDURE:

◂ 1. Check the physician’s order

◂ 2. Check the patency of the IV line and needle
◂ 3. Verify the drop factor ( number of drops in 1ml.) of the
equipment in use.
NOTE: Equipment labeled as MICRO DROP or MINI DROP is standard and delivers 60
mgtts/ml but MACRO Drop delivery system vary.

SOME MANUFACTURER are the following:

✓ Travenol Macro drop = 10gtts/min
✓ Abbott Macro drop = 15 gtts/min
✓ McGraw Macro drop= 15 gtts/min

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 CONT. Example:
How many hours would 500 cc
D5IMB last if the rate is 30
mgtts/min?

DURATION= 500CC X 60mgtts/cc

◂ 4. Calculate the flow rate using the standard formula: 30 mgtts/min x 60
RATE = VOLUME ( CC) X GTT FACTOR (CC) min./hr
DURATION (HRS.) X 60 MIN/HR – = 16.7 hours
constant

DURATION = VOLUME (CC) X GTT FACTOR (CC)

Rate (gtt/min) x 60 min/hr. - constant

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 Cont.

◂ 5. Count the drops per minute in the

drip chamber. Hold the watch beside
the chamber.
◂ 6. Adjust the IV clamp as needed and
recount the drops per minute if
necessary
◂ 7. Monitor the IV flow rate at frequent
intervals. Document the client’s
response to the infusion at the
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prescribe rate. 3
COMPLICATIONS
OF INTRAVENOUS
ADMINISTRATION

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 MANAGING
Air entering into central veins
SYSTEMIC gets to the right ventricle, where
COMPLICATIONS it lodges against the pulmonary
AIR valve and blocks the flow of
Overloading the circulatory - s/sx FLUID EMBOLISM blood from the ventricle into the
system with excessive IV - Moist OVERLOAD SIGNS AND pulmonary arteries.
fluids causes increased blood Crackles SYMPTOMS:
pressure and central venous - -cough - PALPITATIONS
pressure -restlessness - - DYSPNEA
-edema- - JUGULAR VEIN
DISTENTION
weight gain
- -CYANOSIS
-dyspnea
- CHEST,
SHOULDER AND
LOWER BACK PAIN
SIGNS AND -Performing careful hand hygiene before every contact with any part of
SYMPTOMS: the infusion system or the patient
- ABRUPT - Examining the IV containers for cracks, leaks, or cloudiness, which
TEMPERATURE may indicate a contaminated solution
ELEVATION - Using strict aseptic technique Firmly anchoring the IV cannula to
- TACHYCARDIA prevent to-and-fro motion (e.g., a catheter stabilization device will
- BACKACHE help).
- DIARRHEA - Sutureless securement devices avoid disruption around the
- CHILLS
Pyogenic substances in either - GENERALIZE
catheter entry site and may decrease the degree of bacterial
contamination
the infusion solution or the MALAISE - Inspecting the IV site daily and replacing a soiled or wet dressing
IV administration set can with a dry sterile dressing (antimicrobial agents that should be used
INFECTION PREVENTION for site care include 2% tincture of iodine, 10% povidone–iodine,
cause bloodstream infections
In severe sepsis, vascular
: alcohol, or chlorhexidine gluconate, used alone or in combination)
2
- Disinfecting injection/access ports with antimicrobial solution before
and after each use
collapse and septic shock 5
- Removing the IV cannula at the first sign of local inflammation,
may occur. contamination, or complication Replacing the peripheral IV cannula
according to agency policy and procedure
 LOCAL Phlebitis, or inflammation of a
vein, can be categorized as
COMPLICATIONS chemical, mechanical, or
Infiltration and Phlebitis
bacterial
Infiltration is the unintentional Extravasation
administration of a - s/sx
nonvesicant solution or - Edema around SIGNS AND
medication into surrounding the insertion site SYMPTOMS:
tissue. This can occur when the - Leakage of IV -Redness
fluid from site Warm at the area
IV cannula dislodges or
- Discomfort Pain and tenderness at
perforates the wall of the vein. - Decrease flow site
rate Swelling

SIGNS AND
SYMPTOMS: SIGNS AND
-Localized pain Blood clots may form in the IV line as a
SYMPTOMS: result of kinked IV tubing, a very slow
-Redness -Ecchymosis infusion rate, an empty IV bag, or failure
-Warmth -Leakage of to flush the IV line after intermittent
- Sluggish flow rate Blood at medication or solution administrations.
- Fever insertion site Hematoma results when blood leaks into
Thrombophlebitis refers to - Malaise -decrease flow tissues surrounding the IV insertion site.
the presence of a clot plus - Leukocytosis rate Leakage can result if the opposite vein
inflammation in the vein. Thrombophlebitis Clotting and wall is perforated during venipuncture,
-blood back
Hematoma: flow in IV
the needle slips out of the vein, a cannula
is too large for the vessel, or insufficient
tubing pressure is applied to the site2after
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removal of the needle or cannula
INFILTRATION AND EXTRAVASATION MANAGEMENT

✓ -Infusion should be stopped

✓ IV catheter should be discontinued
✓ A sterile dressing applied to the site after
careful inspection to determine the extent
of infiltration.
✓ IV infusion should be started in a new site
or proximal to the infiltration site if the
same extremity must be used again
✓ A warm compress can be applied if the
solution was isotonic with a normal pH
✓ A cold compress may be applied If the
infiltration is recent and the solution was
912 hypertonic or had an increased pH

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 PHLEBITIS
MANAGEMENT:
ASSESSING FOR
PHLEBITIS
❖ Discontinuing the IV line and restarting it in
another site
❖ Applying a warm, moist compress to the
affected site
PREVENTION:
❖ Using aseptic technique during insertion
❖ Using the appropriate-size cannula
❖ Considering the composition of fluids and
medications when selecting a site
❖ Observing the site hourly for any
complications
❖ Anchoring the cannula or needle well
❖ Changing the IV site according to agency 2
policy and procedures 9
PHLEBITIS

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 THROMBOPHLEBITIS MANAGEMENT:

PREVENTION!!
➢ Discontinuing the IV infusion • avoiding trauma to the vein at the
➢ Applying a cold compress first to time the IV line is inserted
decrease the flow of blood and • observing the site every hour
increase platelet aggregation • checking medication additives for
compatibility
➢ Followed by a warm compress
➢ Elevating the extremity
➢ Restarting the line in the opposite
extremity
➢ IV line should not be flushed
NOTE: If purulent drainage exists, the
site is cultured before the skin is
cleaned.

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 HEMATOMA AND CLOTTING MANAGEMENT:

◂ HEMATOMA: CLOTTING AND OBSTRUCTION:

❑ Removing the needle or cannula ✓ Infusion must be discontinued
❑ Applying light pressure with a ✓ Restart in another site with a new
sterile, dry dressing cannula and administration set
✓ The tubing should not be irrigated
❑ Applying ice for 24 hours to the site
or milked
to avoid extension of the hematoma
✓ Clot should not be aspirated from
❑ Elevating the extremity to maximize the tubing
venous return ✓ Not allowing the IV solution bag
❑ Assessing the extremity for any to run dry
circulatory, neurologic, or motor ✓ Maintain patency
dysfunction
❑ Restarting the line in the other
extremity if indicated
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POST- THERAPY PREPARATION:
Peripheral IV
cannulas and the
site are routinely
changed aseptically
and re-sited every
48-72 hours or
when necessary

In the days
that follow
the therapy,
check the
injection site
for bruising
or swelling.
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INDICATION FOR DISCONTINUING AN INTRAVENOUS
INFUSION

◂ 1. The client’s oral fluid intake and

hydration status are satisfactory that
no further IV solutions are ordered.
◂ 2. There is a problem with infusion
that cannot be fixed/ complications
arise with the patency.
◂ 3. The medications administered by
IV route are no longer required.

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DISCONTINUING
IV INFUSION

1. Verify written doctor’s order to discontinue IV

including IV medicines
2.Observe 10 rights.
3. Assess and inform the patient for the
discontinuation of IV infusion and of any
medicine.
4. Prepare the necessary material ( IV TRAY,
STERILE COTTON BALL, ALCOHOL SWAB OR
PICK-UP FORCEPS IN ANTISEPTIC SOLUTION
PLASTER, KIDNEY BASIN/ WASTE
RECEPTACLE)
5. Wash hands before and after the procedure.
6. Close the roller clamp of the IV administration
set.

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Cont. 7. Moisten adhesive tapes around the IV catheter with
cotton ball with alcohol; remove the plaster gently.
8. Use pick-up forceps to get cotton ball with alcohol
and without applying pressure, remove needle or IV
catheter then immediately apply pressure over the
venipuncture site using the swab for 2-3 minutes.
* Hold the client’s arm/ leg above the body if bleeding
persists.
9. Inspect IV catheter for completeness
10. Apply the sterile dry cotton ball over the
venipuncture site
11. Discard all waste materials including IV cannula
according to Health Care Waste Management
12. Document the date and time of termination, status of
insertion site and integrity of IV catheter and endorse
accordingly.

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DOCUMENTATION:
NURSE’S NOTE

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IV FLOW SHEET

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 INTAKE AND
OUTPUT SHEET

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VITAL SIGNS
SHEET:

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 THANKS Does anyone have any questions?

REFERENCES: Brunner & Suddarth's Textbook of

Medical-Surgical Nursing (14th ed.). Philadelphia:
Wolters Kluwer. Ignatavicius, D.D., Workman, M.L., &
Rebar, C.R. (2018).

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 Kozier & Erb's
Fundamentals of
Nursing
Concepts, Process, and
Practice
TENTH EDITION, GLOBAL EDITION

CHAPTER 36
SKIN INTEGRITY AND
WOUND CARE
SKIN INTEGRITY AND
WOUND CARE

BY: KLARISSE AUDREY H. CALLEJO, RN

 Learning Outcomes
▪ Describe factors affecting skin integrity
▪ Identify clients at risk for pressure ulcers
▪ Describe the four stages of pressure ulcer development
▪ Differentiate primary and secondary wound healing
▪ Identify 3 major types of wound exudate
▪ Identify the main complications of and factors that affect wound healing
▪ Identify assessment data pertinent to skin integrity, pressure sites and wounds
 Learning Outcomes
▪ Identify nursing diagnoses associated with impaired
skin integrity
▪ Identify essential aspects of planning care to
maintain skin integrity and promote wound healing
▪ Describe nursing strategies to treat pressure ulcers,
promote wound healing, and prevent complications
of wound healing
▪ Identify purposes of commonly used wound
dressing materials and binders
 Skin Integrity
▪ Intact Skin – Refers to the presence of normal skin and
skin layers uninterrupted by wounds
FactorsAffecting Skin Integrity
1. Age
2. Genetics Internal
3. Underlying Health of the Individual
External
4. Activity
 Types of Wounds
▪ Intentional – occurs during therapy (removing a
tumor)
▪ Unintentional – occurs by accident (fracture of an
arm after a collision)
▪ ClosedWound – tissues are traumatized without a
break in the skin
▪ OpenWound – skin or mucous membrane surface
is broken
 According to the Likelihood and Degree of
Wound Contamination
▪ Clean wounds
– Uninfected wounds in which there is minimal inflammation and
the respiratory, gastrointestinal, genital and urinary tracts are
not entered (generally closed wounds)
▪ Clean-contaminated wounds
– Surgical wounds in which the respiratory, gastrointestinal,
genital or urinary tract has been entered. No evidence of
infection
▪ Contaminated wounds
– Include open, fresh, accidental wounds and surgical
wounds involving a major break in sterile technique or a large
amount of spillage from the GI tract

▪ Dirty or InfectedWounds
– Wounds containing dead tissue and wounds with
evidence of a clinical infection, such as purulent drainage
 According to How they are Acquired
Type Cause
Incision Sharp Instrument
Contusion Blow from a blunt instrument
Abrasion Surface scrape, either unintentional
Puncture Penetration of the skin and often the underlying
tissues by a sharp instrument, either intentional
or unintentional
Laceration Tissues torn apart often from accidents
Penetrating Penetration of the skin and the underlying tissues
wound (from bullet or metal fragments)
 Classifying Wounds by Depth
▪ PartialThickness – confined on the skin, that is the
dermis and epidermis; heal by regeneration

▪ FullThickness – involving the dermis, epidermis,

subcutaneous tissue and possibly muscle and bone;
require connective tissue repair

*This classification excludes pressure ulcers and burns

 Pressure Ulcers
▪ Injury to the skin and/or underlying tissue, usually over bony prominence,
as result of force alone or in combination with movement
▪ Other terms: decubitus ulcer,pressure sore, bedsore
▪ Etiology
▪ Pressure ulcer is due to localized ischemia (deficiency in the blood
supply to the tissue)
 Risk Factors
▪ Friction and Shearing
▪ Immobility
▪ Inadequate Nutrition
▪ Fecal and Urinary Incontinence
▪ Decreased Mental Status
▪ Diminished Sensation
▪ Excessive Body Heat
▪ Advanced Age
▪ Chronic Medical Conditions (DM, Cardiovascular Disease)
 Stages of Pressure Ulcer

Stage 1

▪ Non-blanchable
erythema signaling
potential ulceration
Stage 2
▪ Partial thickness skin loss
(abrasion, blister or
shallow crater)
▪ Involves the epidermis and
possible the dermis
Stage 3
▪ Full thickness skin loss
▪ Involves damage or necrosis of
subcutaneous tissue that may
extend down to , but not
through underlying fascia
▪ Presents as a deep crater with
or without undermining of
adjacent tissue
Stage 4
▪ Full thickness skin loss
with tissue necrosis or
damage to muscle, bone
or supporting structures
(tendon / joints)
▪ Undermining and sinus
tracts may also be present
Unstageable/Unclassified

▪ Full thickness skin or tissue

loss – depth is unknown
▪ Actual depth of the ulcer is
completely obscured by:
▪ Slough – yellow, tan, gray,
green, brown
▪ Eschar – tan, brown or black
Suspected Deep Tissue Injury
▪ Depth – unknown
▪ Purple or maroon localized
area of discolored intact skin
or blood-filled blister due to
damage of underlying soft
tissue from pressure and/or
shear
 Braden Scale for
Predicting
Pressure Sore Risk
Norton’s Pressure Area Risk
Assessment Form
Common Pressure Sites
Wound Healing
 WOUND Healing
▪ Quality of living tissue
▪ Renewal of tissues
▪ Also referred as “REGENERATION”
 Types of Wound Healing
Primary Intention Healing
▪ Tissue surfaces have been approximated
(closed) and there is minimal or no tissue loss
▪ Characterized by formation of minimal
granulation tissue scarring
▪ Other terms: primary union; first intention
healing
Secondary Intention Healing
▪ Wound that is extensive and involves
considerable tissue loss, and the edges cannot
be approximated (example: pressure ulcer)
▪ The repair time is longer, scarring is greater,
susceptibility to infection is greater
Tertiary Intention Healing
▪ Wounds that are left open for 3 to 5
days to allow edema or infection to
resolve or exudate to drain and are
then closed by sutures, staples, or
adhesive skin closures
▪ Other term: delayed primary intention
 Phases of Wound Healing
1. Inflammatory Phase
▪ Begins immediately after injury and lasts 3 to 6
days
▪ Processes that occur
▪ Hemostasis – cessation of bleeding due to the
vasoconstriction of blood vessels in the area and
deposition of fibrin (connective tissue) and formation
of blood clots
▪ Phagocytosis – macrophages engulf microorganism
and cellular debris
2.Proliferative Phase
▪ Extends from 3 or 4 to about day 21 post-injury
▪ Fibroblasts (connective tissue cells) migrate into
the wound and begin to synthesize collagen
(whitish protein substance that adds tensile
strength to the wound
▪ If the wound does not close, the area becomes
covered by dry plasma protein and dead cells
(eschar)
 3.Maturation Phase
▪ Begins on about day 21 and extend 1 or 2 years
after the injury
▪ Fibroblasts continue to synthesize collagen in
a more orderly fashion making the scar more
stronger (but is never as strong as the original
tissue)
Complications of Wound Healing
1. Hemorrhage – massive bleeding
2. Infection – contamination of wound surface
with microorganism
3. Dehiscence - rupturing of a sutured wound
4. Evisceration – protrusion of the internal viscera
through the incision
Factors Affecting Wound Healing
▪ DevelopmentalConsiderations (cell renewal is
slower as we age)
▪ Nutrition (diet high in protein and vit c to
promote healing)
▪ Lifestyle (smoking)
▪ Medications (steroids, aspirin, prolonged use of
antibiotics)
Nursing Management
 Assessment
▪ Location and extent of injury
▪ Bleeding
▪ Size
▪ Condition of the wound margins
▪ Integrity of the surrounding skin
▪ Clinical sign of infection
▪ Immunization (tetanus toxoid)
 Nursing Diagnosis
▪ Risk for Pressure ulcer
▪ Risk for impaired skin integrity
▪ Impaired skin integrity
▪ Impaired tissue integrity
▪ Risk for infection
▪ Acute pain
 Promoting Wound Healing
▪ Discuss the importance of adequate nutrition (fluids, protein,Vit B and C, Iron
and calories)
▪ Instruct in wound assessment and provide mechanism for documenting
▪ Emphasize principles of asepsis, especially hand hygiene and proper methods
of handling used dressings
▪ Provide information about signs of wound infection and other complications
to report
▪ Reinforce appropriate aspects of pressure ulcer prevention
▪ Demonstrate wound care techniques such as wound cleansing and dressing
changing
▪ Discuss pain control measures, if needed
Types of Wound Dressing
Wound Cleaning
 Wound Irrigation and Drainage
▪ Irrigation
▪ Washing or flushing out of an area
▪ Irrigation pressure (4 – 15 psi) (using 30 to 60ml syringe with gauge 1
needle)
▪ Frequently used irrigation (normal saline, lactated ringer, antibiotic
solution)

▪ Gauze Packing
▪ Using a damp to damp technique has been used to pack wounds that
require debridement
▪ Do not allow to dry before removing to prevent pain
Guidelines in Cleaning Wounds
▪ Use solutions such as isotonic saline or wound cleansers to clean or
irrigate the wounds. If antimicrobial solutions are used, make sure they
are well diluted. Warm the solutions to body temperature before use (do
not microwave)
▪ If a wound is grossly contaminated by foreign material, bacteria,
slough, or necrotic tissue, clean the wound at every dressing change
▪ If a wound is clean, has little exudate, and reveals healthy
granulation tissue, avoid repeated cleaning
▪ Use gauze squares or non-woven swabs that do not shed fibers. Avoid
using cotton balls and other products that shed fibers onto the wound
surface
▪ Clean superficial non-infected wounds by irrigating them with
normal saline
▪ Avoid drying wound after cleaning to help retain moisture
▪ Hold cleaning sponges with forceps or with a sterile gloved
hand
▪ Clean the wound in an outward direction to avoid transferring
organisms from the surrounding skin into the wound
▪ Consider not cleaning the wound at all if it appears to be clean
WoundAssessment
Link: https://youtu.be/s76P1DdtBAA
Wound IrrigationVideo
Link: https://youtu.be/QOgA3FcT3aw
Wound Dressing

Link: https://youtu.be/WKGAs9uRlsI
THE
END