Nurse Competency in



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Patient Assessment: Identifies the components of history pertinent to the wound and procedure to include: type and duration of the wound and or presence of necrotic tissue, underlying disease/condition, bleeding problems and allergies.










2.b. Determines the location of the peripheral pulses: femoral, popliteal, dorsalis pedis, posterior tibia and radial pulses.










3.a. Wound Assessment: Describe the wound/surrounding skin to include; color, size, drainage, odor, undermining, wound margins, location and depth.










3.b. Recognize abnormal values, findings, and clinical manifestations: cellulites, pain and wound infection










4. Photograph wound (optional)










5. Verify physician orders/referral/clinical judgment.










6. Explain the debridement procedure and purpose










7. Determine if pain medication is needed










8. Assemble necessary equipment










9. Position the patient.










10. Provide for adequate lighting










11.Wash hands










12. Prepare sterile field and equipment.










13. Don gloves.










14. Remove existing wound covering and discard.










15. Cleanse area with appropriate cleanser










16. With pick-up forceps and scissors, lift the necrotic tissue and remove it in layers with sharps.










17. Remove as much necrotic tissue as possible.










18. Recognize two types of bleeding to fear










19. Describe at least 3 methods to stop bleeding to include; pressure, silver nitrate sticks and topical agents.










20. Determine the aggressiveness of debridement to include: amount of necrotic tissue present, pain tolerance, fatigue and bleeding.










21. Determine when to stop debriding: i.e. impending exposure of tendon or bone, location of fascial plane, location of named structure, if field is obscured or bloody, when you get nervous.










22. Request re-evaluation from a physician when: patient febrile, no improvement, cellulites, abscessed area, major vessel encountered, or extensive undermined areas.










23. Post debridement care; Cleanse the wound with normal saline or cleanser and apply an appropriate dressing.










24. Documentation post debridement: record in the patient record on progress notes summary of the procedure: date and time, condition of the wound, problems during debridement and type of dressing used










______________________________Wound Care Nurse Signature ________Date
______________________________Physician Validation Signature ________Date
______________________________Chief Nursing Officer Signature ________Date
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