Policy Manual sample

MDT Home Health Care Agency, Inc. 146 WOUND CARE PURPOSE: Wound care is provided to clean the wound and protect it from infection, promote healing, apply medication, debride and/or provide physical and psychological comfort to the patient. All care is given in accordance with specific physician's orders. The nurse should assess the wound for symptoms of inflammation or infection on each visit and report any untoward symptoms to the physician immediately. Gloves should be used when handling soiled dressings. Old dressings should be placed in disposable plastic bags and closed before being placed in family trash receptacle. RESPONSIBLE PERSONNEL: RN, LPN EQUIPMENT: Wound care supplies as ordered, gloves SPECIAL CONSIDERATIONS: If a patient or family member has not seen the wound, it is wise to describe it to them first and allow them to ask questions before the dressing is removed. Many caregivers have never provided any type of nursing care and are frightened by the appearance of a wound. Allowing them to ventilate their feelings while providing steady reassurance will accommodate a smooth transition from hospital to home care. Before instituting the dressing change, an appropriate site to perform the dressing should be selected. The site should be well lighted and ventilated, private, free of drafts, able to accommodate supplies and comfortable for the patient.. PROCEDURE: 1. Explain procedure 2. Position patient in desired position and location. 3. Wash hands. 4. Assemble needed equipment 5 . Don gloves. 6. Remove old dressing and place in plastic bag. 7. Remove gloves and use alcohol gel prior to donning clean gloves. 8. Perform wound care as ordered by physician. 9. If patient has multiple wounds, nurse will change gloves and use alcohol gel between dressing changes to prevent cross-contamination. 10. Discard used materials and old dressing by placing in plastic bag and securing prior to placing in patient’s waste receptacle. 11. Remove gloves and wash hands. DOCUMENTATION: Describe the procedure, including description and measurement of the wound, amount of drainage, description of drainage, type of dressing and tolerance of the procedure on the Clinical Visit Note. Also document any teaching performed and the response by the patient or caregiver to the instruction. If further action is indicated, document follow-up/notification of Clinical Manager and/or physician. Wound photograph may be indicated.