- Preparation and Introduction:
- Ensure scene safety and privacy.
- Practice hand hygiene if necessary.
- Introduce yourself to the patient, state the purpose of your visit, and gain consent.
- Patient Comfort and Pain Assessment:
- Check if the patient is comfortable and assess their pain level.
- Dressing Removal and Examination:
- Explain the wound assessment process.
- Remove any dressing covering the wound.
- Assessment of Wound Area:
- Look for erythema (redness) around the wound.
- Describe the area around the wound, noting any oedema, scaliness, lesions, excoriation, maceration, or dryness.
- Exudate Examination:
- Describe any exudate, such as purulent, hemoserous, serous discharges, or offensive odour.
- Closure and Wound Bed Examination:
- Assess the closure of the wound, noting if it’s well closed or broken.
- Evaluate the condition of the wound bed, including its colour, presence of sloughy or necrotizing tissue, and epithelization status.
- Tenderness and Pain Assessment:
- Examine for tenderness and assess any pain experienced by the patient.
- Conclusion and Further Action:
- Conclude about the wound condition and state your awareness of the need to collect a swab if necessary.
- Mention sending the sample to the lab and referring the patient to the medical team for further evaluation and treatment.
- Provide health education as needed.
- Patient Comfort and Communication:
- Reiterate the importance of the patient’s comfort and their ability to use the call bell if needed.
- Address any concerns the patient may have.
- Hand Hygiene and Conclusion:
- Remove apron and gloves
- Practice hand hygiene again.
- Conclude by stating that you’ve completed the procedure, discarded used items according to hospital policy, documented as per NMC guidelines, and ensured the patient’s comfort.
ROLEPLAY
Nurse: I enter the room, looking for scene safety, and confirm that the scene is safe for me to approach my patient.
Nurse: I ensure privacy and dignity by closing the doors and drawing the curtains.
Nurse: I perform hand hygiene using hand rub, following the 7 steps of WHO.
Nurse: “Good morning, my name is Isaac Makponga, and I am a registered nurse here. I’m here to assess your wound at the surgical site. Is it the best time to proceed?”
Patient: “Yes, you can.”
Nurse: “What is your name and how may I call you?”
Patient: “My name is Elizabeth; you can call me Lizzy.”
Nurse: “Lizzy, do you have any pain?”
Elizabeth: “Yes.”
Nurse: “Could you please score it between 0 (the least) and 10 (the worst)?”
Elizabeth: “It’s 3.”
Nurse: “Oh, it’s mild. Do you need medication?”
Elizabeth: “No, I don’t. Thank you.”
Nurse: “Are you in a comfortable position?”
Elizabeth: “Yes, I am.”
Nurse: “Can I proceed with your wound assessment?”
Elizabeth: “Yes.”
Nurse: “(I perform hand rub, wear apron & gloves) Can I expose your wound?”
Elizabeth: “Yes.”
Nurse: “Are you okay for me to proceed?”
Elizabeth: “Yes.”
(Nurse removes old dressing prior to the assessment) “
Look for erythema around the wound
Nurse: “I can see mild redness around the wound.”
Describe the area around the wound
Nurse: “I confirm that the wound and its surrounding area look healthy. There is no oedema, excoriation, maceration, dryness, or scaliness around the wound.”
Describe any exudate
Nurse: I can confirm that there is no haemo-serous, serous or purulent discharge or any offensive odour from the wound
Describe the defect of the wound closure
Nurse: “I don’t see any defect in the wound closure; this wound is closing properly.”
Describe the condition of the wound floor
Nurse: “The wound bed appears pink in colour, indicating it is in the healing stage. It is epithelializing properly without any granulation, necrotizing, or sloughy tissue.”
Enquire about pain or tenderness on the wound
Nurse: “Lizzy, do you have any pain or tenderness when I am touching the wound?”
Elizabeth: “No, I am alright.”
Nurse: “So overall, the wound looks healthy. If any abnormality occurs, I will collect the wound swab and send it to the lab. The report will be escalated to the medical team.”
Elizabeth: “Ok.”
Nurse: “Lizzy, are you comfortable?”
Elizabeth: “Yes.”
Nurse: “Do you need anything before I leave?”
Elizabeth: “No.”
Nurse: “Excellent. If you require anything, please call me by pressing the buzzer.”
Elizabeth: “Ok.”
Nurse: “Remove the gloves and apron. Perform hand rub.”
Nurse: “Assessor, I have conducted a wound assessment for Ms. Lizzy. Now, I will document all the findings and discard the waste according to the NMC guidelines and policies.”
