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Checks the documentation and orders for task
I have been assessed based on the wound dressing guidelines downloaded from FLO 8/4/2010. See Appendix one for completed checklist. I checked the documentation for change of dressing orders and checked for any specific type of dressing ordered by the doctor.
As a nurse it is important we should inspect the wound and feedback to doctor if the dressing been order by the doctor is not appropriate for the stage of wound.
EB- Granulation of tissue can be damaged if unappropriated dressing material used for dressing and not only damage but can cause infection to the site.
I observed the wound closely for any redness or inflammation.
Collects all the appropriate equipment
Choose appropriate of dressing materials are important and help in time management.
I also collected items that are relevant to the type of wound dressing. Gauze and other dressing materials are meant for single use (one patient use only) so as to prevent from cross infection.
I checked for the expiry date and used a septic technique to open the sterile packages. This reduces the risk of introducing microorganisms.
Explains the procedure to the patient and gains consent.
Shows understanding of nursing theory behind the task.
I informed the patient regarding the wound dressing and consent was obtained. I also encouraged patient to cooperate and prepare the patient for any abnormal appearances on the wound so as to allay the anxiety.
I realised that I didn’t asked the patient regarding the pain. Pain is a subjective experience that bears a variable relationship with tissue damage. I should identify any factor that might contribute to the individual’s pain experience that includes physical, psychological factors, as well as contextual factors, such as situational and cultural considerations.
A proper assessment and administration of medication will minimize the patient’s pain. By doing that, goal of changing dressing can achieve effectively without any distraction.
Performs the task, maintaining:
infection control and standard precautions
I washed my hand according to the infection control guideline, in preventing and controlling transmission of infection (Crisp & Taylor 2009 p. 697).
I used aseptic technique during the wound dressing procedure as aseptic technique refers to practices that keep a patient as free from microorganisms as possible (Crisp & Taylor 2009, p. 694).
I also used gloves and an appropriate protective attire therefore, protecting myself and others from cross infection through vigilant used of infection control guidelines and standard precautions (Crisp & Taylor 2009, p. 682).
I provided patient privacy by drawing the curtain around an area during the procedure thus prevent patient from embarrassment and anxiety.
Completes all elements of the task
I did not inform to the patient that if the patient feel or have any reaction or uncomfortable after the dressing to call for a nurse.
I realised that I didn’t asked the patient regarding the pain.
I always refer to my notes when doing it to as to make sure I’m doing it in correct order and follow the right guidelines.
Concludes the task appropriately
I ensured that the patient safety, by reassuring patient, put the bed side rails up to prevent patient from fall.
I placed the call bell within reached so that the patient can assess and call for the nurse promptly.
According (Crisp & Taylor 2009, p.844) safety defined as freedom from psychological and physical injury and it is a human need that must be met.
I make sure that patient is been properly dressed and placed in a comfortable position before withdraw the curtain to ensure privacy.
I appropriately concluded the task ensuring that the patient appeared comfortable.
Disposes of equipment appropriately
Successfully completed the disposal. Appropriate waste receptacles (Lynn 2008) were used to throw any soiled dressing.
Completes appropriate documentation
I signed that I had performed the dressing and ensured that the RN to countersign it.
I documented the size, wound stages, width, depth, colour, the surrounding skin and wound appearance and type of solution used to clean and type of dressing material used been recorded in dressing chart.
Australian Council on Health Standards (ACHS) specific guidelines are used for the documentation of clinical data by healthcare professional accountability (Crisp & Taylor 2009, p. 616).
I also documented the time, the type of dressing and date change in the MAR and recorded patient’s response to the dressing in the nurse’s notes (Crisp & Taylor 2009, p. 780).
What further research is required?
As shown in overall comments.
Overall, I think that I completed this skill reasonably well – I still need help and practice, understanding and explore more in aetiology of pain. I also thought that I write the documentation as a RN and didn’t ask the RN to counter sign.
My Reflection of giving myself feedback
Observe someone doing it. Knowing what I am doing is not bed of roses and that I have to take chances and live my life with meaning. Need more motivation to gain experience and knowledge. I believe, I can do better with guidance and learn from the mistake that I have done as a student.
I should be more involved in the awareness of judgments, observations and descriptions, evaluations of planning, and assessment of decisions. This is the process of reflection and includes assessment of the need for my further learning, and awareness that routines are not adequate and change in perspective is needed.
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