11 Skill Keperawatan Perawatan Luka

Summary

The video script details a nurse's step-by-step process of treating a patient's wound. Nurse Amira introduces herself, explains the purpose of the treatment, and carefully carries out the wound care procedure. This includes cleaning the wound with sterile tools, removing necrotic tissue, and ensuring the wound remains moist for faster healing. Throughout, she reassures the patient, instructing them to breathe through any discomfort. The session concludes with the nurse documenting the treatment in the patient's medical records and reminding the patient to call if needed.

Takeaways

• 👩‍⚕️ The nurse introduces herself as Amira and explains her schedule from 07:00 to 14:00.
• 🩺 The nurse performs a wound care procedure for Mr. Rudi, who has an injury on his right hand.
• 🧼 The purpose of the wound care is to clean bacteria and debris from the wound.
• ✂️ The nurse uses scissors and tweezers to remove the dressing from the wound.
• 📏 The wound is measured at 6 cm in length and 4 cm in width.
• 🧤 Sterile gloves and equipment are used to maintain a sterile environment during the procedure.
• 🧽 The wound is cleaned with NaCl solution and, if necessary, with wound soap.
• 🔪 Necrotic tissue is removed using surgical tweezers and scissors for better healing.
• 💧 The wound is kept moist with a wet dressing to promote faster healing.
• 📋 The nurse documents the procedure in the patient’s medical record, noting the patient's response, wound condition, and measurements.

Q & A

What is the main purpose of the nurse's visit to the patient?

The main purpose of the nurse's visit is to perform wound care on the patient's right hand, clean the wound from bacteria and dirt, and ensure proper healing.

How does the nurse prepare before starting the wound care procedure?

The nurse ensures that all tools are ready, verifies the patient's identity, explains the procedure to the patient, and follows hygiene practices like hand washing and maintaining privacy.

What is the significance of using NaCl in the wound cleaning process?

NaCl solution is used to clean the wound and remove dirt or contaminants, ensuring that the wound is properly cleaned and free of infection.

How does the nurse ensure the patient is comfortable during the procedure?

The nurse checks if the patient is in a comfortable position and advises the patient to take deep breaths through the nose and exhale through the mouth if they experience pain.

What steps does the nurse take to maintain a sterile environment during the wound care procedure?

The nurse uses sterile gloves, ensures the tools are clean, and uses proper sterilization techniques while cleaning the wound and handling materials.

What is done if the nurse observes necrotic tissue on the wound?

If necrotic tissue is present, the nurse performs a necrotomy, using surgical instruments like forceps and scissors to remove the dead tissue.

Why does the nurse use a moist dressing after cleaning the wound?

The moist dressing is applied to maintain a moist environment, which helps speed up the healing process by promoting tissue regeneration.

How does the nurse secure the dressing on the wound after the procedure?

The nurse uses a sterile gauze to cover the wound, then wraps it with a gauze roll and either ties or tapes it securely to ensure the dressing stays in place.

What instructions does the nurse give the patient at the end of the procedure?

The nurse informs the patient that the wound care is complete, reassures them about the healing process, and advises the patient to call for assistance using the bell if needed.

What is the final step in the wound care process for the nurse?

The final step is documentation, where the nurse records the wound care procedure in the patient’s medical records, including the wound's condition, the patient's response, and the nurse’s observations.