Wound Care

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..WITH YOURSELVES.
THAT WAS THE BIG HUGE MODULE

AND THE TRUTH OF THE MATTER
IS WE COULD HAVE SPENT
ANOTHER EASY TWO WEEKS,

DOING CENTRAL LINES AND DOING
OTHER CARE, TPN, BLOOD.

WE COULD SPEND WEEKS AND WEEKS
STILL DOING IV'S.

THE TRUTH IS YOU'VE GOT
ENOUGH FOUNDATIONAL INFORMATION
THAT YOU CAN DO ALL OF THAT.

YOU KNOW HOW TO CLEAN THINGS.
YOU KNOW THAT CENTRAL LINES --

YOU BETTER BE THINKING ABOUT
A MASK. YOU KNOW ALCOHOL
BEFORE BETADINES.

YOU KNOW STERILE
TECHNIQUE PRINCIPLES.

SO, YOU REALLY KNOW ENOUGH
TO PRACTICE IV SAFELY,

ONCE YOU GET DONE
WITH THIS MATH TEST.

SO, YOU'LL BE PASSING
THOSE MEDS NEXT WEEK.

JUST KEEP SYSTEMATIC
AND THAT'S THE THING.

YOU GUYS DID A GREAT
JOB YESTERDAY.

THE AGE OF TECHNOLOGY.
YOU LIKE THOSE PUMPS.

YOU JUST DIAL THEM UP,
LET'S GET ON WITH IT.
THAT'S SWEET.

SO, EVEN THOUGH YOU LOVE
PUMPS AND TECHNOLOGY,

DON'T FORGET THE OTHER STUFF

BECAUSE HONESTLY, HONESTLY,
THERE ARE ENVIRONMENTS

WHERE YOU REALLY ARE DOING
DRIPS AND THERE AREN'T PUMPS.

AND SOMETIMES YOU'RE GRIPPING
TILL YOU CAN GET A PUMP,

AND SO YOU STILL HAVE TO
HANG ON TO THOSE PRINCIPLES
OF SAFE ADMINISTRATION.

SO, ALRIGHT, HERE WE GO
WITH NEW MODULES.

AND I THINK EVERY MODULE FROM
NOW ON IS A ONE-WEEK MODULE.

SO BLACKBOARD IS BACK ON YOUR
AGENDAS AS FAR AS REVIEW

AND GETTING BACK INTO
THE TEXT AND SO FORTH.

SO, THIS WEEK WE'RE DOING
WOUND CARE AND I THINK
YOU'LL ENJOY IT.

IT WILL KIND OF BE A REPRIEVE
BECAUSE THERE WILL BE
A LOT OF PRINCIPLES

THAT ARE SIMILAR
TO WHAT WE'VE DONE.

WE'RE KIND OF PUTTING
IT ALL TOGETHER.

LAST SEMESTER WE TALKED ABOUT
STAGE I AND STAGE II WOUNDS

AND WE LOOKED AT
SOME CARE FOR THEM.

SO THIS SEMESTER, WE'RE GOING
TO FOCUS ON STAGE III, STAGE IV
AND SURGICAL TYPE WOUNDS.

SO, I WANT TO GIVE YOU SOME
INFORMATION PERTINENT TO THOSE
PARTICULAR KIND OF WOUNDS,

AND THEN I'LL DO THE TWO WOUNDS
THAT YOU'RE GOING TO DO
FOR TESTING.

I HOPE THAT YOU INVESTED
AND GOT YOURSELF SOME
PURPLE BOOKS,

OR YOU GOT ONLINE TO GET
YOUR PRESSURE ULCER BOOKS.

YOU'RE ALL LOOKING AT ME,
LIKE, "OH, MAN! CAUGHT AGAIN."

SO, YOU REALLY NEED TO DO THAT.
I PUT IT IN YOUR SYLLABUS.

I BELIEVE I PUT IT
IN YOUR SYLLABUS.

AND THIS IS THE HH CPR BOOK.

AND THE WEBSITE...
I'LL REPOST IT. HOW ABOUT THAT?

I WILL JUST PUT IT ON THE
ANNOUNCEMENTS SO YOU CAN
GET ONLINE TO GET YOUR BOOKS.

ALL YOU HAVE TO DO IS --
YOU CAN GET THE --

YOU CAN DOWNLOAD THE BOOK
OFF THE INTERNET

OR YOU CAN CALL THEM
AND YOU CAN GET FREE BOOKS.

THERE'S THE TWO BOOKS
THAT ARE FOR THE...CLIENTS

AND THEN TWO BOOKS
FOR THE CLINICAL PRACTICE.

AND THERE ARE THE GUIDELINES
THAT GOVERN WOUND CARE
FOR OUR PROFESSION.

I MEAN, THEY ARE THE
CLINICAL GUIDELINES FOR US.

SO THEY'RE A REALLY IMPORTANT
BOOK TO KNOW. QUICK REFERENCE.

AND A LOT OF WHAT WAS IN
YOUR TEXT WAS REFERENCED
TO THESE PURPLE BOOKS.

SO I WAS REALLY PLEASED WITH
THE UPDATE ON THE WOUND CARE.

THAT IT'S CONSISTENT WITH WHAT
THE STANDARD OF CARE IS.

SO, BRIEF REVIEW.
WHAT IS A STAGE III WOUND?

WELL, LET'S JUST START
FROM THE BEGINNING. STAGE I?

RED. BUT SKIN IS INTACT.

STAGE II?

VERY SUPERFICIAL.
JUST SKIN HAS BEEN BROKEN.

WHAT'S STAGE III?

FULL THICKNESS SKIN LOSS.

SO, YOU'RE GETTING DOWN
INTO THE SUBCUTANEOUS TISSUE

AND IT CAN GO THROUGH,
BUT NOT --

I MEAN, IT CAN GO TO, BUT NOT
THROUGH THE UNDERLYING FASCIA.

THAT'S STAGE IV, WHEN IT
STARTS GETTING INTO MUSCLE, BONE
AND THAT KIND OF TISSUE.

SO, DISTINGUISHING
BETWEEN THE TWO.

ON HERE, I JUST WANTED TO POINT
OUT A COUPLE OF THINGS...

RELATED TO ASSESSING
THESE WOUNDS.

WHEN YOU ASSESS A WOUND,
REMEMBER THAT YOU DETERMINE ITS
STAGE BY THE BASE OF THE WOUND.

SO IF YOU CAN'T SEE
THE BASE OF THE WOUND,
YOU CAN'T STAGE THE WOUND.

WHICH MEANS IF THEIR SLOUGH --
WHAT'S SLOUGH?

THIS YELLOWY STUFF,
OKAY?

DEBRIS ON THE SKIN.

IF THERE'S NECROSIS.

IF YOU SAW THIS WOUND,
WHAT STAGE IS IT?

YOU CAN'T STAGE IT
COS YOU CAN'T SEE IT THE BASE.

SO, IT'S UNSTAGEABLE,
UNABLE TO SEE BASE.

AND THAT'S ALL YOU WOULD SAY,
STAGE UNDETERMINED.

YOU CAN MEASURE IT.
HOW DO YOU MEASURE A WOUND?

LENGTH IS...ALWAYS HEAD TO TOE

ON THE PERPENDICULAR,
NOT ON THE DIAGONAL.

ALWAYS THE LONGEST PLACE.
UP AND DOWN, HEAD TO TOE.

AND THEN WIDTH IS ALWAYS
ON THE HORIZONTAL PLANE.

NOT, AGAIN, PERPENDICULAR, BUT
THE WIDEST PLACE HORIZONTALLY.

AND DEPTH, YOU PROBE
WITH A CUE TIP.

CUE TIP? THAT'S THE WHOLE
TRADE NAME APPLICATION

AND YOU WOULD WANT TO
USE THE...CLOTH END

AND PROBE IT TO SEE
HOW DEEP IT IS.

ALRIGHT, ON MR. SEYMORE.
YOU'RE FAMILIAR WITH SEYMORE.

THIS IS HIS STAGE III WOUND,
OKAY?

LET'S TALK ABOUT THIS STAGE
III WOUND A LITTLE BIT

COS WE'RE GOING TO
HAVE TO DESCRIBE THESE.

AND THIS IS WHAT'S GOING TO
HAPPEN, THAT'S WHY I'M STARTING
WITH DESCRIBING WOUNDS.

YOU'RE ACTUALLY GOING TO BE
MEASURING THE SYEMORE BUTT,
INSTEAD OF THE CLIENT.

OUR BEDS GET TOO BOGGED DOWN
IF WE SIT THERE AND
MEASURE, MEASURE.

SO WHEN IT'S TIME TO MEASURE
ON THE CLIENT YOU JUST SAY,
"I'VE MEASURED."

BUT I'M GOING TO SEND
YOU BACK TO THE TABLE
AND YOU'RE GOING TO DRAW --

AND WE'RE JUST GOING TO HAND
YOU A RANDOM WOUND AND YOU'RE
GOING TO GO MEASURE.

IT'LL BE ANYTHING AND ANY
COMBINATION ON MR. SEYMORE.

ALRIGHT. SO, IF YOU
CAME TO DESCRIBE

AND MEASURE THIS
STAGE III WOUND...

YOU'RE GOING TO MEASURE
FROM TOP TO BOTTOM.

WHAT ARE YOU GOING TO
MEASURE IN?

- CENTIMETERS.
- CENTIMETERS.

ALWAYS. NOT INCHES.
WHERE'S MY MEASURING TAPE?

CENTIMETERS ALWAYS.
AND I'M JUST GOING TO
REVIEW THIS.

I DON'T MEAN TO BE INSULTING,
BUT I HAVE YET TO GET
THROUGH A SEMESTER

WHERE PEOPLE DIDN'T SAY
THIS WAS 30CM.

YOU KNOW WHAT 30CM
WOULD LOOK LIKE?

WHERE'S MY 30?

30.
THAT'S 30CM.

THAT'S A HUGE,
BIG DIFFERENCE, RIGHT?

SO WHAT IT MEANS WHEN
YOU GET ON THIS TAPE,

WHEN IT SAYS THE TEN,
THAT'S MILLIMETERS.

THE LITTLE MARKINGS IN
BETWEEN.

SO IT'S 1CM, 10MM.

SO JUST BE CLEAR ON THAT
BECAUSE IF YOU MEASURED IT
AND YOU SAY, "I HAVE 30CM."

THEN I JUST MARK IT WRONG,
BECAUSE THIS IS THE SIZE
OF YOUR WOUND

VERSUS THIS LITTLE TEENY GUY,
OKAY?

SO UP AND DOWN.
YOU FIND THE WIDEST PLACE

AND THEN YOU MARK IT.

SO, LIKE, 3.5 AND THEN
BY THE WIDTH, BY 3.

THEN YOU PROBE THE DEPTH
AND YOU FIND THE
DEEPEST PLACE.

AND I JUST MARK IT
WITH MY FINGER NAIL.

YOU CAN TELL BY PROBING AROUND
IT, IF IT GOES ANY PLACE ELSE.

TOUCHES IT AND YOU NEED
TO GO UP A LITTLE HIGHER.

SO ONCE YOU'VE MARKED IT,
THEN YOU COME OVER HERE
AND YOU FIND YOUR 0.5.

REMEMBER THAT YOU MEASURE
WOUNDS ONCE A WEEK,

NOT EVERY SHIFT
AND NOT EVERY DAY.

TOO MANY MEASUREMENTS CAUSE
TOO MANY DISCREPANCIES.

SO, ESPECIALLY IN NURSING
HOMES AND IN CHRONIC CARE.

LIKE, MONDAY IS
WOUND MEASUREMENT DAY.

IN ACUTE CARE, THEY'RE GOING TO
MEASURE THE WOUNDS ON ADMISSION

AND THEN MAYBE
WITH DRESSING CHANGES.

IF IT'S A DRESSING, LIKE A
HYDROCOLLOID THAT YOU'RE DOING
EVERY FIVE TO SEVEN DAYS.

BECAUSE IT GETS YOU OFF SYNC,
SO YOU CAN'T STAY TRUE
TO THE EVERY SEVEN DAYS,

AND YOU DON'T WANT TO RIP THE
DRESSING OFF AFTER ONE DAY

JUST COS IT'S
WOUND MEASURE DAY.

SO YOU WOULD HIT IT, YOU KNOW,
IN AN APPROPRIATE CYCLE.

THE OTHER THING THAT'S REALLY
KEY ABOUT MEASURING WOUNDS

IS THAT YOU WANT THE SAME
PERSON WHEN POSSIBLE TO DO IT,

AND YOU WANT THE CLIENT TO BE
IN THE SAME POSITION
WHEN IT'S MEASURED.

IF SOMEONE MEASURES THEM,
KIND OF, TWEAKED ON THE SIDE,

COS THAT'S WHERE THEY ARE
AT THE MOMENT,

AND THEN SOMEONE ELSE
GETS THEM TURNED ALL
NICE AND STRAIGHT,

AND SOMEONE ELSE TURNS
THEM ANOTHER WAY,

THAT AFFECTS HOW THE WOUND
IS MEASURED AS WELL,

AND SO YOU GET INCONSISTENCY.

SO IT LOOKS LIKE THE WOUND'S
GETTING BETTER ONE WEEK
AND THEN IT'S WORSE ONE WEEK.

AND IT HAS EVERYTHING TO WITH
THE PEOPLE, NOT THE CLIENT.

AND SO YOU'RE NOT
GETTING GOOD INDICATIONS.

AS WELL AS MEASURING
THE WOUND, YOU HAVE TO
DESCRIBE THE WOUND.

SO YOU WANT TO LOOK AT
THE BASE OF THE WOUND,

YOU WANT TO DESCRIBE
EVERYTHING YOU'RE SEEING

AND YOU WANT TO DESCRIBE IT
TO THE CLOCK.

SO THE HEAD BEING 12 O'CLOCK,
FEET 6 O'CLOCK AND SO FORTH.

SO, IF YOU'RE LOOKING
AT THIS WOUND,

IT LOOKS LIKE FROM 9 O'CLOCK
TO 3 O'CLOCK.

IT'S RED, BEEFY
GRANULATION TISSUE.

RIGHT? DOES THAT, KIND OF,
PAINT A PICTURE IN YOUR MIND?

THEN FROM 3 O'CLOCK TO
9'CLOCK, IT'S YELLOW SLOUGH.

YOU ALSO WANT TO SAY
A PERCENTAGE OF SLOUGH,

BECAUSE THAT WILL DETERMINE
WHAT KIND OF DRESSINGS WE DO.

IF MORE THAT 50% OF THE WOUND
BASE IS SLOUGH OR NECROSIS,

THEN WE MAY DO SOME
MECHANICAL TYPE DEBRIDEMENT.

LIKE A WET TO DRY DRESSING.

WE PUT IN A MOIST DRESSING
AND WE LET IT DRY

AND THEN YOU RIP IT OFF AND
THAT RIPS OFF THE DEAD TISSUE.

IT'S CALLED MECHANICAL
DEBRIDEMENT.

SO THAT THE WOUND BASE
WILL HEAL.

BUT MECHANICAL DEBRIDEMENT
IS INDISCRIMINATE.

IT DRIES ON GOOD TISSUE
AND BAD TISSUE,

SO WE WANT TO MAKE SURE
THAT MORE THAN 50% OF
THE WOUND BASE IS SLOUGH,

SO THAT WHEN YOU'RE
RIPPING IT UP,

YOU'RE ACTUALLY HELPING MORE
OF THE WOUND BED THAN HURTING
MORE OF THE WOUND BED.

IF THE WOUND BED IS 60-70%
GRANULATION TISSUE AND A
LITTLE POCKET OF SLOUGH,

THEN WE'RE NEVER GOING TO DO
THAT MECHANICAL DEBRIDEMENT.

IT'S TOO HARD ON THE TISSUE AND
IT WRECKS THOSE GOOD FIBROBLASTS

THAT CAUSE GRANULATION HERE.
THAT RED, BEEFY TISSUE.

YOU DON'T WANT TO MESS THAT UP.

SO, IN JUST DESCRIBING
THE WOUND,

LOOK AT PERCENTAGE SO THAT
YOU KIND OF GET AN IDEA

OF WHAT KIND OF TREATMENT
IS MOST APPROPRIATE
FOR THAT CLIENT.

YOU'RE GOING TO BECOME
THE WOUND EXPERT.

AS WELL, YOU'RE GOING TO LOOK
AT THE TISSUE AROUND THE WOUND.

THE PERI-WOUND SKIN.
AND YOU WANT TO DESCRIBE THAT.

BECAUSE IT'S REAL IMPORTANT
THAT WE'RE NOT CAUSING THAT
TO BREAKDOWN AS WELL.

ONE OF THE THINGS THAT
HAPPENS IN WOUND CARE

IS THAT WE CREATE THIS NICE,
MOIST ENVIRONMENT

WHICH IS PERFECT
FOR WOUND HEALING,

BUT IF IT ABSORBS TOO MUCH
DRAINAGE AND IT GETS ON TO
THIS OUTER TISSUE,

IT CAN BEGIN TO BREAK IT DOWN
AND MACERATE THAT TISSUE

AND WE BEGIN TO CAUSE MORE
PROBLEM THAN WE'RE SOLVING.

AND SO YOU NEED TO WATCH
YOUR DRESSINGS.

IF YOUR DRESSING IS A NICE,
MOIST DRESSING AND YOU
SET IT UP GOOD

AND IT SHOULD LAST
THREE TO FIVE DAYS,

BUT IN 24 HOURS YOU'RE
STARTING TO GET WHAT WE CALL
A STRIKE THROUGH.

DRAINAGE IS COMING
THROUGH TO THE TOP.

THEN IT NEEDS TO BE CHANGED.

IT'S NOT GOING TO HOLD
ALL OF THAT DRAINAGE
FOR THREE TO FOUR DAYS

WITHOUT GETTING ONTO THIS NICE,
INTACT TISSUE.

SO TO DESCRIBE THIS,
WE GOT OUR MEASUREMENTS,
WE'VE GOT ABOUT --

ACTUALLY IT LOOKS LIKE
THE SLOUGH GOES FROM ABOUT
3 O'CLOCK TO 7 O'CLOCK.

IF I WAS LOOKING
MORE ACCURATELY.

AND I WOULD SAY 35-40%
OF THE WOUND BED IS SLOUGH.

JUST -- I MEAN,
IT'S SUBJECTIVE

AND YOU'RE JUST MAKING
AN ESTIMATE HERE IN DESCRIPTION.

- SO WHAT WOULD YOU DO
FROM THE 7 TO 9?

- THEN I WOULD SAY FROM
7 TO 3 IS RED, BEEFY
GRANULATION TISSUE.

I JUST WASN'T GETTING
A GOOD VIEW OF IT.

OH, SO IF YOU'RE TREATING THIS.
I'M GOING TO TALK ABOUT
THAT IN A MINUTE.

SOME WOUND CARE OPTIONS.
HOW DO WE GET RID OF SLOUGH AND

HOW WE'RE GOING TO DEBRIDE IT
AND SO FORTH? BUT...DESCRIBE IT.

ALRIGHT, ONCE IT'S DESCRIBED,
YOU'RE GOING TO CHART THAT.

I'LL TALK ABOUT
THAT IN A MINUTE.

BUT I WANT TO MOVE ON TO GIVE
YOU SOME OTHER IDEAS

OF SOME THINGS
YOU NEED TO LOOK AT.

STAGE IV WOUND.

THE STAGE IV WOUND HAS GONE DOWN
AND IT'S PASSED THROUGH
THE FASCIA

INTO THE MUSCLE AND IT'S
GONE DOWN INTO SOME BONE.

SO, WE KNOW WE'VE GOT
A PRETTY DEEP WOUND HERE.

SAME MEASUREMENTS. YOU'RE GOING
TO GO FROM THE SKIN TO SKIN.

SKIN TO SKIN...HERE.

AND THE REASON I'M SAYING
SKIN TO SKIN

IS BECAUSE WE'VE GOT SOME
TUNNELING GOING ON HERE.

OKAY? WE GOT A LIP.

SO YOU'RE GOING TO MEASURE AND
THEN WHEN YOU MEASURE DEPTH,

YOU'RE GOING TO MEASURE DEPTH,

THEN YOU'RE ALSO GOING TO
CHECK FOR TUNNELING.

AND PROBE TO
THE DEEPEST PLACE.

AND IT GETS A LITTLE
DEEPER HERE.

ALL MEDICARE, ALL CHARTS
WANT TO KNOW IS WHERE
THE DEEPEST PLACE IS.

SO YOU CAN SAY
THAT THERE'S TUNNELING

FROM THE FULL CIRCUMFERENCE
OF THE WOUND,

WHICH IS INDEED
THE TRUTH HERE.

OR THAT THERE'S MAYBE
A TUNNEL OR UNDERMINING --

ACTUALLY, THIS IS UNDERMINING
FROM 12 TO 6 O'CLOCK.

OKAY, SO YOU PROBE FOR THIS LIP.

AS WELL, YOU WANT TO PROBE TO
MAKE SURE THERE'S NO TUNNELS

OR SINUS TRACKS.
AND I KNOW THERE IS ONE HERE.

AND WHOA! ALL OF A SUDDEN,
IT GOES IN WAY FAR.

AND YOU LOOK AND THERE'S
A TUNNEL IN HERE.

SO YOU HAVE TO MEASURE THE
TUNNEL WHICH IS AT 9 O'CLOCK.

OKAY? AND THEN I --
IT WENT TO ABOUT HERE,

AND SO I WOULD GET MY
MEASUREMENT AS WELL.

AND I THINK THERE'S ONE UP HERE.

OKAY, SO YOU'RE HUNTING --

THIS ONE HAS EVERYTHING THAT
COULD POSSIBLY BE IN A WOUND.

IT CAN BIGGER OR SMALLER,
BUT IT'S GOT IT ALL.

ALRIGHT, SO YOU PROBE TO GET
ALL YOUR MEASUREMENTS.

YOU'VE GOT A TUNNEL,
SINUS TRACK UP HERE AT...

ONE O'CLOCK. YOU'VE GOT ONE
OVER HERE AT 9 O'CLOCK.

YOU'VE GOT A BONE IN THE
CENTER, YOU'VE GOT SLOUGH,

YOU'VE GOT RED, BEEFY
GRANULATION TISSUE

AND YOU'VE GOT UNDERMINING.

WHOA! OKAY.
SO LET'S TALK ABOUT THAT.

YOU KNOW HEAD TO TOE.
YOU KNOW WIDTH. YOU KNOW PROBE.

YOU'RE GOING TO SAY THAT --

IT LOOKS TO ME LIKE 50%
OF THE WOUND BASE
IS COVERED WITH SLOUGH.

RIGHT? FROM 12 O'CLOCK
TO 6 O'CLOCK.

YOU KIND OF AGREE WITH THAT.

YELLOW, MAYBE EVEN A
LITTLE GREENISH SLOUGH.

AND THEN YOU HAVE RED, BEEFY
GRANULATION TISSUE

FROM 6 O'CLOCK TO 12 O'CLOCK.

THEN IN THE CENTER OF THE WOUND,

YOU HAVE A TRIANGULAR
SHAPED BONE.

AND AGAIN YOU'RE JUST GOING TO
TAKE A MEASUREMENT ACROSS.

AND GET THE DESCRIPTION.
YOU HAVE TO DESCRIBE EVERYTHING.

WHAT'S INTERESTING
ABOUT THIS WOUND

IS AS CRUMMY AS THIS WOUND
IS ON THE INSIDE,

THE SKIN AROUND
IT IS BEAUTIFUL.

THE SKIN IS INTACT WITHOUT
REDNESS OR DRAINAGE,
IS WHAT I WOULD SAY.

AS OPPOSED TO THIS ONE,

HAS ABOUT...0.3CM OF REDNESS.

A PERI-WOUND OR FULL CRICUM --
CIRCUMFERENCE OF THE WOUND.

SO, YOU'RE JUST DESCRIBING
WHAT YOU'RE SEEING.

ONE OF THE BEST THINGS TO DO
IS TAKE A PICTURE.

WHENEVER YOU TAKE A PICTURE
AND I THINK I MENTIONED IT
IN THE FIRST SEMESTER,

IS ALWAYS PUT A MEASURING
DEVICE IN THE PICTURE.

SO THAT IT LAYS LIKE THIS
AND PEOPLE HAVE PERSPECTIVE.

BECAUSE WHEN SHANNON TAKES
A PICTURE, SHE LIKES CLOSE-UPS

AND SHE'S GOING TO GET
RIGHT DOWN HERE

AND IT'S GOING TO LOOK BIG
IN THE PICTURE.

BUT I DON'T LIKE THE SMELL, SO I
STAND RIGHT BACK THERE WITH TOM.

YOU KNOW WHAT I'M SAYING?
SO PEOPLE GET DIFFERENT VIEW
POINTS OF THE CAMERA.

AND SO YOU HAVE TO HAVE
A POINT OF REFERENCE HERE

TO SHOW IF THE WOUND
IS GETTING BETTER OR WORSE.

SO ALL PICTURES SHOULD HAVE
A MEASURING DEVICE IN THEM.

PICTURES VARY, THEY MAY
TAKE THEM ONCE A WEEK

OR EVERY TWO TO THREE WEEKS
DEPENDING ON THE PROGRESS.

ONE OF OUR RULES OF THUMB
RELATED TO WOUND CARE

IS THAT IF THE WOUND
ISN'T GETTING BETTER
IN TWO TO THREE WEEKS,

THEN WE CHANGE THE TREATMENT
THAT WE'RE USING ON THE WOUND.

AND IF IT DOESN'T GET BETTER
AFTER THE SECOND OR
THIRD CHANGE,

THEN WE USUALLY CLASSIFY IT
A NON-HEALING WOUND.

WE'VE DONE
ALL WE KNOW TO DO

AND IT'S NOT GETTING BETTER,
THERE'S USUALLY A REASON.

WHAT MIGHT BE SOME REASONS WHY
A WOUND DOESN'T GET BETTER?

- NUTRITIONAL.

- PROTEIN NUTRITIONAL STATUS
IS NOT GOOD.

MAYBE THEY'RE DYING
AND WE'RE CONTAINING DRAINAGE,

JUST SO THAT THEY'RE NOT
LAYING IN THEIR DRAINAGE,

BUT IT'S NOT GOING TO GET
BETTER. WHAT ELSE?

- WHAT ABOUT NECROSIS
AND BACTERIA.

- BACTERIA AND INFECTION.

- PARAPLEGICS WHO ARE
CONSTANT.

- NOT RELIEVING THE PRESSURE.
HMM-MM.

AND THEIR BLOOD COUNT.
THEY JUST MAYBE --

THEY MAY BE ANEAMIC.
THEY MAY NOT HAVE A GOOD
CIRCULATION HAPPENING.

AND SO THERE'S A LOT OF REASONS
WHY IT MIGHT NOT BE HEALING.

AND SO WE NEED TO BE
AWARE OF THOSE

SO THAT WE CAN GET
THE RIGHT THINGS HAPPENING.

YOU MAY NEED TO GET
A DIETICIAN IN THERE

TO DO A NUTRITIONAL CONSULT.

YOU NEED TO MAKE SURE
THEY'RE ON PRESSURE RELIEF.

LOOK AT THEIR TURNING SCHEDULE.

WHAT'S HAPPENING THAT THIS
ISN'T GETTING BETTER?

CULTURING. LET'S TALK
BRIEFLY ABOUT CULTURING.

WHAT DO YOU KNOW
ABOUT CULTURING WOUNDS?

WE DON'T DO IT.
HARDLY AT ALL

BECAUSE THEY'RE ALL GOING TO
HAVE THEIR OWN FLORA ON THEM

AND THEY ALL HAVE
A LOT OF BACTERIA.

SO, WHAT THEY HAVE TO DO
ARE BIOPSIES.

THE DOCTOR HAS TO DO
A BIOPSY OF THE WOUND

TO GET A GOOD CULTURE
TO SEE WHAT'S GOING ON

AS WELL AS THEY'LL DO
A BLOOD CULTURE.

AND THEN THEY'LL TREAT
BOTH SYSTEMICALLY AND
TOPICALLY TO TREAT --

AND IF THEY DO
SOMETHING TOPICALLY,

IF THEY USE DIFFERENT
KINDS OF...

RINSES LIKE ACIDIC ACID
OR SOMETHING TO GET RID
OF THE BACTERIA,

JUST MAKE SURE THAT
PEOPLE ARE KEEPING TRACK

AND WE'RE NOT USING THAT SAME
THING FOR MORE THAN TWO WEEKS.

IT NEEDS TO GO BACK
TO A PLAIN SOLUTION
OF JUST SODIUM CHLORIDE.

WHAT'S THE BASIC RULE
FOR IRRIGATING A WOUND,
FOR CLEANSING A WOUND?

ACTUALLY, THERE'S
TWO BASIC RULES.

- CLEANEST TO DIRTIEST.

WHAT YOU WANT TO BE CLEANEST.
I ALWAYS THINK THE WOUND
IS DIRTIEST.

DOES IT SEEM DIRTY COS
IT'S BLEEDY AND UGLY, KIND OF.

AND YOU JUST KIND OF GO
"URGH."

BUT THAT'S WHAT YOU
WANT TO BE CLEANEST

SO YOU CLEAN FROM WHAT
YOU WANT CLEANEST OUT.

MAYBE NOT WHAT YOU
THINK IS DIRTIEST.

IT MAY LOOK NICE
AND CLEAN OUT HERE,

BUT YOU DON'T WANT TO SCRUB
ALL THAT INTO THE WOUND
THAT YOU WANT TO BE CLEAN.

BETWEEN EVERY DRESSING CHANGE,
A WOUND MUST BE CLEANED.

IT MUST BE RINSED
WITH SOMETHING.

WHETHER IT'S WATER,
SODIUM CHLORIDE...

OR A WOUND CLEANSER THAT'S
BEEN APPROVED FOR WOUND
CLEANSING.

THEY HAVE TO -- THE SKIN
HAS TO BE CLEANED

SO THAT YOU'RE GETTING RID OF
THE MICROBES AND THE BACTERIAS.

OKAY.

- HOW WOULD YOU DESCRIBE
THAT LARGE WOUND.

THE STAGE I WOUND.

- THIS?
- NO, THE ONE IN THE BACK.

YEAH.
- STAGE IV?

- THE RASH?

- OH. I'M GOING,
"WHAT? I JUST..."

OKAY. THIS IS ACTUALLY
A FUNGAL INFECTION.

AND I WOULD SAY
THAT IT'S RED,

AND IT COVERS THE ANUS
INTO BOTH GLUTEI FOLD --

OR OUTSIDE THE GLUTEAL FOLDS AND
THEN I WOULD JUST MEASURE IT.

HOT, BEEFY RED.

THIS NEEDS AN ANTI-BACTERIAL
LIKE MYCOSTATIN OR SOMETHING
ON THERE.

FUNGAL TO TREAT THAT.

- WOULD YOU MEASURE IT
UP AND DOWN?

- UH-HUH.
YEAH.

SAME MEASUREMENTS AS BEFORE.
I WOULD JUST GO --

IT EXTENDS FROM --
YOU MIGHT WANT TO SAY...

HALF OF -- HALF A CENTIMETER.

0.5CM ABOVE THE GLUTEAL FOLD

TO THE PERINEUM.

WHAT'S A PERINEUM?

- THE AREA BETWEEN...

- THE LITTLE BIT OF SKIN
BETWEEN THE ANUS AND THE
VAGINA OR THE SCROTUM.

SO YOU CAN JUST START
PICKING LANDMARKS

THAT GIVE THE BEST DESCRIPTION
OF WHAT YOU'RE SEEING.

AND THEN...LAY HERE
AND JUST MEASURE.

- SO YOU WOULDN'T PUSH DOWN.

- NO, I WOULDN'T PULL IT.

AND YOU CAN SAY THAT
WITH BUTTOCKS AT REST

OR, YOU KNOW, JUST TAKE
A PICTURE AS WELL,

AND LAY YOUR MEASURING DEVICE
HERE SO THAT THEY CAN SEE.

BUT JUST DESCRIBE THAT IT GOES
DOWN INTO THE BUTTOCKS,
GLUTEAL FOLDS.

WHICH IT DOES.

OKAY.

LET'S TALK ABOUT TREATMENTS
A LITTLE BIT.

HOW DO WE DRESS THESE WOUNDS?

DOCTORS TYPICALLY ORDER
THE FIRST ROUND OF TREATMENT,

BUT SOMETIMES THEY'LL SAY,
"WHAT DO YOU THINK?"

AND YOU'RE LIKE,
"NO. I DON'T KNOW."

SO, REMEMBER I GAVE YOU THAT
SHEET OF PAPER LAST SEMESTER

THAT HAD FIRST LINE,
SECOND LINE, THIRD LINE CHOICES.

A GOOD PIECE OF PAPER TO KEEP.

BUT I THOUGHT YOU MIGHT
NOT HAVE KEPT IT.

SO IN YOUR BOOK,
IN YOUR SYLLABUS,
I GAVE YOU A NEW ARTICLE

THAT I THOUGHT WAS JUST
ABSOLUTELY WONDERFUL

AND THEY'RE ALL IN THE BOOK.
TO BE PERFECTLY HONEST.

SHARPEN YOUR WOUND
ASSESSMENTS SKILLS.

TOPICS ABOUT HOW TO ASSESS.

AND -- OH, I GAVE YOU
A T-TUBE. THAT'S NICE.

I TALKED ABOUT
THE DISINFECT SPRAY ONE.

WOUND CARE, I BELIEVE HAS
A CHART IN IT.

DOES IT? DID SOMEONE FINALLY
FIND THE PAGE?

I'M STILL SEARCHING.
AH! THERE IT IS.

THAT TALKS ABOUT ALL THE
DIFFERENT KINDS OF PRODUCTS,

WHAT THEY'RE BEST UTILIZED FOR

AND HOW LONG YOU CAN EXPECT
TO PUT THEM ON A WOUND.

BECAUSE ISN'T THAT
A TRICKY THING?

DO I CHANGE THIS ONE
EVERY 24 HOURS?

AND IS THIS ONE A FIVE DAY?

AND HOW OFTEN DO I RINSE
THIS OUT? AND SO FORTH.

AND SO IT'S A WONDERFUL GUIDE.

AND SO IF YOU CAN FIND
THE ONE I GAVE YOU,

THAT KIND OF GIVES YOU A
FIRST, SECOND, THIRD CHOICE
TO BE THINKING,

BUT THIS ONE GIVES YOU
SOME IDEAS OF PRODUCTS

THAT YOU MIGHT WANT TO CHOOSE.

BECAUSE YOU'RE GOING TO BE
THE ONE THAT CALLS AND SAYS,

"YOU KNOW, THE CLIENT'S BEEN
USING HYDROCOLLOIDS FOR A
MONTH IN HIS HOUSE,

AND THIS WOUND LOOKS BAD.
WHAT DO YOU THINK ABOUT TRYING
A CALCIUM ALGINATE?"

AND THE DOCTOR GOES, "OKAY."

SERIOUS. THEY WANT TO HEAR
WHAT YOU HAVE TO SAY.

OR YOU CAN GET AN OSTOMY NURSE,

AN INTRASTROMAL THERAPIST
TO COME IN AND GIVE
RECOMMENDATION AS WELL

AND THAT'S AN EXCELLENT CHOICE.

I WANT TO INTRODUCE
A COUPLE OF CONCEPTS.

LET'S JUST TALK ABOUT
THIS STAGE III WOUND.

THE IDEA IS THAT WE'RE
MAINTAINING A MOIST ENVIRONMENT.

AND WE WANT A WOUND DRESSING
THAT'S GOING TO COVER THIS

AND NOT LEAVE ANY SKIN
EXPOSED TO AIR.

BECAUSE WHEN AIR GETS TO IT,
THAT'S WHAT DRIES IT UP.

SO COULD YOU PUT A HYDROCOLLOID
DRESSING ON THIS ONE?

ONE OF THOSE LITTLE PATCH --
BROWN PATCHES.

[ALL TALKING AT ONCE]

- YEAH, IT MAY NOT TOUCH.

SO REMEMBER WHEN WE TALKED
ABOUT THE HYDROCOLLOID PASTE

THAT YOU COULD FILL IT UP WITH?

IT'S LIKE A TOOTHPASTE,
BUT IT'S LIKE --

IT'S JUST HYDROCOLLOID GEL.
YOU CAN FILL UP THIS WOUND
WITH THE GEL,

THEN PUT THE HYDROCOLLOID ON AND
YOU'VE SERVED THE SAME PURPOSE.

IT'S A WONDERFUL PRODUCT
AND THAT'LL KEEP --

THAT'LL KEEP THE WOUND EDGES
INTACT COS IT STICKS,

BUT IT'LL ALSO ABSORB
A LITTLE DRAINAGE

AND IT'LL GIVE YOU
A GOOD FILL.

A SECOND FAVORITE PRODUCT
WITH THESE STAGE III

AND STAGE IV WOUNDS
IS CALCIUM ALGINATE.

THIS CALCIUM ALGINATE HAPPENS
TO BE IN A ROPE FORM,

BUT IT ALSO COMES IN SQUARES.

AND IT COMES IN SMALL SQUARES
OR BIG SQUARES.

AND CALCIUM ALGINATE,
IT LOOSELY DESCRIBED
IS JUST A SEAWEED PRODUCT.

IT'S KIND OF GRASSY
AND SEAWEEDY.

YOU CAN PASS IT AROUND.

AND WHAT YOU DO IS,
FIRST OFF YOU HAVE TO KNOW

THAT IT CAN ONLY BE PUT
IN A WOUND THAT IS DRAINY.

BECAUSE THAT'S ITS JOB,
IS TO ABSORB THE DRAINAGE

AND THAT'S WHAT
ACTIVATES THE CALCIUM.

SO YOU WOULD JUST
TUCK THIS IN, DRY.

IT STARTS TAKING ON
THE WOUND DRAINAGE

AND YOU CAN JUST CLIP IT UP
AT ANY POINT.

DON'T WANT IT TOO TIGHT
BECAUSE NEED TO ALLOW IT

TO EXPAND ONCE
THE MOISTURE HAS HIT IT.

THEN YOU CAN PUT A --
LIKE A LITTLE SQUARE OF TELFA

AND THEN A TRANSPARENT
DRESSING ON.

AND THAT WILL HOLD THAT
IN PLACE.

AND THIS CAN ACTUALLY STAY...

FOR 12 HOURS, 24 HOURS
UP TO 5 DAYS

DEPENDING ON HOW MUCH
WOUND DRAINAGE THERE IS.

BECAUSE REMEMBER
WHAT I TOLD YOU,

IF IT STARTS TO STRIKE THROUGH
AND IT'S STARTING TO BLEED OUT,

THEN YOU NEED TO CHANGE IT
BECAUSE YOU'VE GOT TOO
MUCH DRAINAGE.

THIS IS GOING TO ABSORB ABOUT,
AT LEAST TWICE AS MUCH
OF ITS OWN --

THE SPACE THAT'S WHAT'S THERE.

SO IT'LL TAKE ON
QUITE A BIT OF DRAINAGE

AND THEN STAY LOCALIZED
TO THE WOUND BED AREA.

YOU WANT TO KEEP THIS
AREA NICE AND CLEAN.

IF I WAS PACKING THIS
WITH CALCIUM ALGINATE,

I WOULD PROBABLY GET A SKIN PREP

AND PUT A SKIN BARRIER
ALL ALONG HERE

SO THAT IF DRAINAGE COMES ONTO
THE SKIN, IT PROTECTS THE SKIN.

IT ALSO IS GOING TO
SEAL THIS OFF.

AND THEN WHAT HAPPENS
IS SOMETHING CALLED AUTOLYSIS.

THE CLIENT PRODUCES HIS OWN
FLUIDS AND JUICES,

AND THEY ACTUALLY SELF
EAT AWAY THE SLOUGH.

INTERESTING, HUH?

HYDROCOLLOIDS AND CLOSED
DRESSINGS CAN CAUSE
SOME AUTOLYSIS

THAT WILL THE EAT AWAY
SOME OF THIS.

AND THAT WILL BEGIN
TO SHIFT OVER.

SO YOU WANT TO START
WATCHING THAT IN A WEEK OR TWO

AND SEE IS THE SLOUGH COMING
AWAY, IS AUTOLYSIS WORKING?

IF IT'S NOT, THIS WOUND BED
IS AT THE 50%,

SO IT'S KIND OF BORDERLINE
WHETHER WE DO THE MECHANICAL,

WHICH IS THE WET TO DRY,

BUT THERE'S OTHER MECHANICAL
METHODS OF REMOVING SLOUGH.

OKAY? SO WE TALKED
ABOUT AUTOLYSIS

AND WE TALKED
ABOUT THIS WOUND.

LET ME BACK UP BEFORE I GO. I'LL
TALK MORE ABOUT IN DEBRIDEMENT.

BUT, HOW DO YOU GET
THIS OUT OF HERE?

TWEEZERS MIGHT WORK, BUT IT
ACTUALLY SHREDS IT UP, KIND OF.

IT DOES A COUPLE OF THINGS.

THIS IS AN INTERESTING PRODUCT.

LET ME JUST WET
SOME DOWN FOR YOU.

THEN I'LL SEND IT
AROUND HERE.

IT ACTUALLY TURNS KIND OF SLIMY,
KIND OF LIKE SNOT, REALLY.

AND...

PUT IT IN HERE.

AND AFTER IT'S SET WITH --

IT TAKES A FEW MINUTES.
IT KIND OF GELS UP.

IT KIND OF WILL SOMETIMES
COME OUT AS ONE UNIT.

I'VE HAD IT JUST KIND OF COME
OUT ALL AS ONE PLOP, KIND OF.

BUT OTHER TIMES I'VE HAD TO,
LIKE, SCOOP IT OUT,

MAYBE GET SOME APPLICATORS
AND KIND OF SCOOP IT OUT.

OR OTHER TIMES, I'VE JUST SIMPLY
GOTTEN MY IRRIGATION SYRINGE,

FILLED IT UP
AND I IRRIGATED IT OUT.

TILL IT WILL JUST
COME OUT AND LOOSEN UP.

IF A DRESSING IS DRY AND STUCK,
YOU DON'T JUST RIP IT OFF.

YOU'RE GOING TO HAVE TO
SOFTEN IT UP AND WET IT DOWN

SO THAT YOU'RE NOT
MECHANICALLY DEBRIDING A WOUND

THAT YOU DIDN'T WANT TO DEBRIDE.

- SO THAT CAN STICK
TO THE SORE?

- UH-HUH.
IF IT GETS DRIED UP.

WHICH WOULD TELL ME, ONE,
WE'RE NOT CHANGING IT ENOUGH

AND MAYBE IT'S NOT
THE BEST PRODUCT,

THERE'S NOT ENOUGH DRAINAGE
TO KEEP THIS MOIST.

COS MOST OF THE TIMES
IT STAYS MOIST AND IT TURNS
INTO THIS, KIND OF...

THING. IT'S IN THERE.

OKAY, BUT YOU GOT TO GET IT
OUT, AND THAT'S THE WHOLE IDEA.

YOU IRRIGATE IT OUT
AND THEN PUT FRESH IN.

OKAY.

LET'S GO BACK AND TALK
ABOUT DEBRIDEMENTS

THEN I'LL TALK ABOUT IRRIGATING
AND WE'LL BE PRETTY GOOD HERE.

OKAY, MECHANICAL DEBRIDEMENT.
I TALKED ABOUT WET TO DRY.

WHAT ELSE MIGHT
MECHANICALLY DEBRIDE?

- WATER PRESSURE.
- ME. WATER PRESSURE. EXACTLY.

YOU NEED TO KNOW HOW MUCH
PRESSURE YOU'RE EXERTING
BY YOUR SYRINGES.

THIS IS A PISTON SYRINGE
AND IT ACTUALLY HAS A PSI.

POUNDS PER SQUARE INCH
OF FOUR TO FIVE.

IS THAT GOOD OR BAD?

YOU WOULD WANT TO KNOW THAT
AND IT'S IN THE ARTICLES,

AND IT'S IN THE PURPLE BOOK.
SO DON'T BELIEVE ME,

VERIFY EVERYTHING I SAY.

BUT YOU WOULD WANT TO RINSE
THIS OUT WITH SOMETHING

THAT HAS A PSI OF
NOT MORE THAN 15.

BECAUSE 15 DAMAGES THE
FIBROBLAST, THAT GOOD
GRANULATED TISSUE,

AND IT ACTUALLY DRIVES THE
BACTERIA INTO THE GOOD TISSUE.

THE POINT OF IRRIGATING
IS TO CLEAN THE WOUND,
NOT TO MAKE IT WORSE.

SO, WHAT THEY RECOMMEND
IS A PSI OF 4 TO 5,

IF IT'S NICE, BEEFY,
RED GRANULATION TISSUE.

BECAUSE IT'S NOT GOING TO
DAMAGE, BUT IT'S GOING TO
BE ENOUGH PRESSURE

THAT IT REMOVES THE DEBRIS
THAT'S IN THE WOUND.

MAYBE EVEN DEBRIS YOU CAN'T SEE.

BUT NEVERTHELESS, YOU NEED
TO GET IT OUT OF THERE.

IF THERE'S DEBRIS IN THE WOUND

AND THERE'S A LITTLE MORE
SLOUGH AND STUFF GOING ON,

THEN YOU WOULD WANT TO HAVE
A PSI OF ABOUT 15.

HOW DO YOU CREATE A PSI OF 15
WHEN THIS IS THE ONLY
SYRINGE YOU KNOW?

OKAY.

WHAT THEY FOUND IS...

IN THEIR PSI RESEARCH...

IS IF YOU'LL GET A 35CC SYRINGE,

AND YOU'LL PUT AN 18 GAUGE
CATHETER ON THE SYRINGE,

YOU'LL CREATE A PSI
OF ABOUT 8, I THINK.

THAT'S WHAT IT WAS,
EIGHT OR NINE.

- ...ONE MORE TIME?
- I WILL.

WHEN I GET THIS OUT OF HERE,
I'LL SHOW YOU WHAT I MEAN.

YOU'RE GOING TO GET
YOUR 35CC SYRINGE,

AND YOU WANT TO KEEP
YOUR TIP STERILE.

AND WHAT YOU'RE GOING TO DO IS
EITHER GET A BLUNT TIP SYRINGE,

IF THEY HAVE THEM,
AND BLUNT TIP IS REALLY KEY.

OR YOU'RE GOING TO GET YOUR
IV CATHETER, A NUMBER 18.

THE OVER-THE-NEEDLE CATHETER.

TAKE THE NEEDLE OUT.
I'VE LOST MY NEEDLE.

AND THEN CONNECT IT ON.

AND NOW YOU'VE GOT THIS REALLY
SOFT LITTLE CATHETER IN HERE.

DRAW UP YOUR STERILE FLUID.
AND YOU CAN GET DOWN
INTO THIS WOUND,

YOU CAN GET DOWN
INTO THOSE TUNNELS,

AND YOU CAN GET EVERYTHING
ALL CLEANED UP,

NICE AND EASY WITH THIS SYRINGE.

YOU WANT A SYRINGE
THAT'S LARGE ENOUGH,

THAT IT DOESN'T FORCE
PRESSURE.

THAT'S WHY THE 35
IS THE MINIMUM

THAT YOU WOULD WANT
AS FAR AS SYRINGE SIZE.

BECAUSE IF YOU START
GETTING A 10,

YOU START INCREASING THE
PRESSURE LOAD INTO THAT NEEDLE.

AND THEN THE GAUGE DOESN'T --
IT CAN'T BE ANY SMALLER THAN 18,

OR THAT AGAIN INCREASES
THE PRESSURE LOAD.

ALRIGHT. SO, THAT'S
A COOL, LITTLE DEVICE.

THEY HAVE HARD NEEDLES
THAT ARE CALLED BLUNT TIP,

WHEN YOU'RE LOOKING AT NEEDLES.
AND THEY'RE HARD.

AND THEY JUST DON'T
HAVE THAT SHARP NEEDLE

THAT YOU WOULD GIVE
AN INJECTION WITH.

AND THEY'LL PROBE INTO
SOME OF THESE AREAS AS WELL.

YOU JUST HAVE TO BE
A LITTLE MORE CAREFUL

THAT YOU'RE NOT PROBING
AND DAMAGING SKIN WITH
THAT HARD NEEDLE.

OKAY, SO THAT'S
A MECHANICAL METHOD.

YOU CAN ALSO USE WATER PIKS.

INTERESTING, HUH?
GET THE OLD WATER PIK OUT.

LET ME JUST TELL YOU
ON MY LITTLE GRAPH HERE,
ALL THESE PRESSURES.

WATER PIKS.
GETTING THERE.

OKAY.

A SPRAY BOTTLE LIKE THIS
HAS A PRESSURE OF 1.2.

IT DOES HARDLY ANY CLEANING.
IT'S A PURE RINSE.

SO IT'S NOT GOING TO GET
DEBRIS OF THAT'S KIND OF STUCK.

THAT'S WHY YOU WANT TO GO UP
TO YOUR PISTON SYRINGE.

A BULB SYRINGE LIKE THIS...

ONLY HAS A PRESSURE OF 2.

SO IT'S NOT RECOMMENDED
FOR CLEANING WOUNDS EITHER

BECAUSE IT JUST
DRIBBLES ON THEM,

IT DOESN'T KNOCK OFF ANY DEBRIS.

SO YOUR PISTON SYRINGE THEN,

PISTON PLUNGER SYRINGE,

IS GOING TO GET YOU UP TO A 4.

SO THE PISTON CATHETER
TIP SYRINGE, 4.

A SALINE SQUEEZE BOTTLE.

SORRY, TOM. I'M WALKING AL OVER
AND I'M NOT SUPPOSED TO DO THAT.

THAT KEEPS YOU AWAKE AT NIGHT.

THESE LITTLE GUYS DO ABOUT A 4.

THESE LITTLE SALINE
PUSH BOTTLES.

AND SO THEY WILL GIVE YOU
A LITTLE BIT OF PRESSURE.

A WATER PIK AT ITS
LOWEST SETTING IS A 6.

A 35 MM SYRINGE I TOLD YOU --

THIS ONE ACTUALLY IS A 9.
I'M SORRY 8.

OKAY, A WATER PIK NOW
AT ITS MEDIUM SETTING,

ALL OF A SUDDEN WE GO TO 42.

WHOA! THAT'S BIG, HUH?

AND THEN A WATER PIK AT ITS
HIGHEST SETTING IS OVER 50.

SO WATER PIKS ARE ONLY SAFE
IN THEIR LOWEST SETTING.

AND THAT'S AT THE LOW SETTING.

WHAT WAS IT? 6.

ALRIGHT. SO, THIS NICE LITTLE
GRAPH WILL BE ON THE INTERNET

WHEN YOU LOOK UP
YOUR PURPLE BOOKS

AND IT GIVES YOU ALL
THOSE PRESSURE SETTINGS.

ALRIGHT, SO THAT'S
MECHANICAL DEBRIDEMENT.

THERE'S SHARP DEBRIDEMENT,

WHICH IS SIMPLY THAT,
A KNIFE OR A SCISSORS.

AND SOMEONE CUTS AWAY
THE SLOUGH OR THE NECROSIS.

AND THEN THERE'S...

MEDICINE, AND I FORGET
THE WORD FOR IT.

WELL, THEY'RE CALLING IT
ENZYMATIC. OKAY, FINE.

IT'S MEDICINE AND IT WOULD
BE SOMETHING LIKE ELASIS,

THE PRODUCT I HAVE MOST USED.

BUT IT'S A PRODUCT THAT YOU
WOULD PUT ON TO THE SLOUGH AREAS
AND NOT THE BAD AREAS

BECAUSE AGAIN,
IT'S INDISCRIMINATE,

IT JUST WORKS ON TISSUE
AND IT EATS AWAY THE BAD TISSUE.

SO ENZYMATIC OR MEDICINAL
DEBRIDEMENT IS WHAT
YOU WOULD DO.

SO WHAT ARE THE FOUR TYPES?

MECHANICAL.
- WATER, IRRIGATE
WITH WATER.

- THAT'S MECHANICAL.
- SHARP.

- SHARP.

ENZYMATIC.

- AND AUTOLYTIC.
- AUTOLYTIC.

ANOTHER WAY TO DO AUTOLYTIC,

AND THIS IS A VERY
INTERESTING METHOD

IS WHEN A WOUND
IS DRAINING QUITE A BIT

AND THERE'S A LOT OF
SLOUGH IN THE WOUND,

IF YOU WILL TAKE A PLAIN,
OLD TRANSPARENT DRESSING

AND JUST LET IT GATHER UP ALL
OF THOSE JUICES LIKE A BLISTER.

THAT WILL ALSO BE --

IT WILL CAUSE AUTOLYSIS
AND THAT WILL EAT AWAY.

IT'S VERY INTERESTING.

BUT ANY OF THOSE
CLOSED DRESSINGS

LIKE THE HYDROCOLLOIDS
OR THE CALCIUM ALGINATES,

BECAUSE IT'S LEAVING THAT
DRAINAGE IN THERE WILL ALSO
PERFORM, LIKE, AN AUTOLYSIS.

ALRIGHT. I TALKED ABOUT
KEEPING THIS WOUND BED BASE,

BUT WHAT ARE YOU GOING TO DO
ABOUT THIS UNDERMINING,

THIS LIP THAT GOES AROUND
OR THESE TUNNELS?

IF WE DON'T PUT SOMETHING IN
THESE TUNNELS OR SINUS TRACKS,

THEY CAN SEAL UP ON TOP AND THEN
THEY CAN ABSCESS UNDERNEATH.

THEY CAN HEAL AND CLOSE UP.

SO WHAT WE WANT TO DO IS
CREATE A MOIST ENVIRONMENT
INSIDE THE TRACK

SO THAT IT HEALS FROM THE BOTTOM
UP TO THE TOP AND CLOSES IN.

SO WHAT YOU CAN DO
IS GET A PRODUCT LIKE NU GAUZE.

THIS ONE'S GOT AN IODOFORM, IT'S
AN ANTIBACTERIAL COATING ON IT.

AND THEN THIS A PLAIN NU GAUZE.

YOU CAN GET THESE
NU GAUZE STRIPS.

AND IF IT'S A WOUND THAT'S A
LITTLE DRY, YOU CAN PUT...

LIKE A WATER SOLUBLE,

LIKE A KY TYPE
OF A LIQUID ON HERE.

AND THEN YOU CAN PACK IT
INTO THE WOUND.

GET YOURSELF LIKE
A SUTURE REMOVAL KIT,

SO YOUR LITTLE SCISSORS
ARE STERILE.

I WOULDN'T USE MINE
OUT OF MY POCKET.

I DON'T MIND EVEN HOOKING
IT INTO THE THING.

POKE IT IN THERE THERE
AND THEN CUT THE END OUT HERE
SO THAT YOU CAN FIND IT,

AND THEN THAT WILL KEEP
THAT LITTLE TUNNEL MOIST.

DON'T PACK IT IN REAL TIGHT,
JUST PACK IT IN ENOUGH

SO THAT IT'S NOT GOING TO DRY
UP ON ITSELF AND CLOSE OUT.

OKAY. SO NU GAUZES
ARE A FUN LITTLE PRODUCT.

IT COMES IN A LOT
OF DIFFERENT WIDTHS.

IT COMES IN QUARTER INCH,
HALF INCH, ONE INCH,

DEPENDING ON HOW LARGE
YOUR WOUND IS.

OKAY. I THINK I'VE COVERED
JUST ABOUT EVERYTHING
THEORY-WISE I WANTED TO.

YOU CAN READ YOUR
MATERIAL AND SEE

THAT THERE IS A LOT OF
PRODUCTS THAT I DON'T HAVE.

THERE'S POLYURETHANES THAT YOU
CAN USE AS DIFFERENT CHOICES.

ONE OF MY FAVORITES,
AND I DON'T HAVE IT HERE.
IT'S JUST A SAMPLE.

IT'S CALLED BARD ABSORPTIVE GEL.

AND WHAT IT IS ARE
THESE GRANULE BEADS

THAT YOU MIX UP
WITH SOME STERILE WATER.

AND IT TELLS YOU ON THE
PACKAGE HOW MUCH TO HOW MUCH.

BUT YOU JUST MIX UP ENOUGH
TILL IT TURNS LIKE AN
APPLE SAUCE CONSISTENCY.

THEN YOU PUT IT INTO
A STAGE IV WOUND.

A WOUND THAT DRAINS A LOT.

AND IT ACTUALLY ABSORBS FOUR
TIMES ITS WEIGHT IN DRAINAGE.

COVER IT WITH A TELFA
AND MAYBE AN ABD

OR SOMETHING TO CONTAIN IT.

AND THAT GETS RINSED OUT
ABOUT EVERY SHIFT.

BUT IT TAKES ON
A LOT OF DRAINAGE

AND IT STAYS RIGHT
IN THAT WOUND BED.

AND IT'S A NEAT PRODUCT
TO USE AS WELL.

SO THERE'S A LOT OF
PRODUCTS TO USE.

YOU JUST WANT TO KEEP
IN MIND PRINCIPLE.

IS THE WOUND GETTING
BETTER OR IS IT NOT,

WITH ALL OF THE WORK THAT YOU
ARE PUTTING INTO THIS WOUND?

ALRIGHT. ANY QUESTIONS ABOUT --

THERE'S A LOT OF
THIS STUFF HERE.

ALRIGHT.

WHAT YOU ARE GOING TO DO --
OH, DEAR, MORE PROPS.

JUST SO I DON'T FORGET.

I AM GOING TO PUT
ON THE INTERNET.

I FOUND THIS NEW ARTICLE.

AND IT'S ABOUT HOW NUTRITION
AND AGEING AFFECT WOUND CARE.

BUT WHAT WAS MOST INTERESTING TO
ME. THE ARTICLE WAS WONDERFUL.

AND IT TALKS ABOUT
THE PROTEIN GRAMS

THAT ELDERLY NEED SO THAT THEIR
WOUNDS WILL HEAL.

BUT IT HAS A MINI NUTRITIONAL
ASSESSMENT GUIDE

THAT YOU CAN GET
OFF THE INTERNET,

SO YOU COULD MAKE SOME
ASSESSMENTS YOURSELF

AND HAVE THAT GUIDE
AVAILABLE TO YOU.

SO I'LL GIVE YOU A COUPLE
OF INTERNET SITES TO GO ON

SO THAT YOU CAN HAVE
A HANDLE ON WOUND HEALING.

ALRIGHT.
DID CAROL SHOW YOU --

YOU GUYS HAD
CAROL LAST SEMESTER.

DID SHE SHOW YOU THE VAC VIDEO?

OKAY.

GOOD. I KNEW SHE DID IT
AND WE WERE BOTH

KIND OF DUPLICATING
THERE FOR A WHILE.

I KNOW THEY HAVE A NEW TEACHER,
SO I JUST WANT TO MAKE SURE
IT'S GETTING DONE.

OKAY.

ALRIGHT. YOU ARE GOING
TO DO TWO WOUNDS.

AND I EXPLAINED TO YOU
THAT IN THE MIDDLE OF
THIS SECOND WOUND...

THAT I AM GOING TO DO
THAT YOU NEED TO MEASURE.

SO YOU WOULD SAY THIS IS THE
POINT THAT I WOULD MEASURE,

BUT IT'S NOT
WOUND-MEASURING DAY, OKAY?

BUT THEN I'M GOING
TO SEND YOU BACK

AND I'M GOING TO GIVE YOU --

YOU ARE GOING TO
DRAW FROM A STACK.

THERE WILL BE A
WOUND DESCRIPTION.

AND IT SAYS MEASURE THE STAGE
IV WOUND, BUT OMIT THE TUNNELS

OR MEASURE THE STAGE IV WOUND
AND OMIT THE UNDERMINING.

MEASURE THE STAGE III WOUND.

MEASURE THE NECROTIC WOUND.
MEASURE --

WHATEVER IT TELLS YOU
IS WHAT YOU'RE GOING TO MEASURE.

AND WE WANT YOU TO FILL OUT
THIS FORM CORRECTLY FOR
YOUR DOCUMENTATION.

AND SO YOU WILL JUST HAND IT
IN AND I WILL GRADE IT LATER

WHEN I CAN SIT DOWN
AND READ THEM ALL.

AND THIS IS HOW IT WORKS.

LET'S SAY YOU HAD
TO MEASURE THIS WOUND.

I DO IT ON TIME. OH! I GOT
TO GET GOING SO YOU CAN DO
THE TEST.

IF YOU WERE MEASURING
THIS WOUND,

YOU ARE GOING TO TO DRAW
A CIRCLE OF IT AND DATE IT,

SO THAT WE KNOW WHERE THE WOUND
IS THAT YOU ARE TALKING ABOUT.

AND THEN THIS IS YOUR
NUMBER ONE WOUND.

AND YOU ARE GOING TO SAY,
NUMBER ONE, NUMBER ONE,

AND THEN USE THESE DESCRIPTORS

OF TIME AND INITIALS
OF WHAT THE DRESSING IS.

YOU CAN SKIP THAT BECAUSE
YOU DON'T HAVE ONE FOR HERE.

BUT I WANT TO SEE YOUR
MEASUREMENTS IN CENTIMETERS.

DRAINAGE, YOU WON'T HAVE ANY.

ODOR, YOU WON'T HAVE ANY.
SOLUTION USED.

NONE OF THIS
REALLY MATTERS HERE.

WHAT YOU ARE GOING THEN DO
IS COME UP HERE AND DESCRIBE
THIS WOUND

AND TALK TO ME ABOUT THE SLOUGH,
THE GRANULATION AND SO FORTH,

AS ACCORDING TO WHATEVER YOUR
WOUND IS THAT WE TALKED ABOUT.

OKAY? SO YOU WRITE A LITTLE
NARRATIVE NOTE IN INK,

SIGN YOUR NAME,
DON'T LEAVE ANY BLANK SPACES

AND THEN PUT A LINE THROUGH.

ALRIGHT.

DON'T DO ONE LINE, SKIP A
LINE, ONE LINE, SKIP A LINE.

YOU NEVER LEAVE SPACES
IN CHARTING. EVER.

OKAY? AND DON'T LEAVE
ANY BLANK AFTER YOUR CHART,

PUT A LINE AND SIGN
YOUR WHOLE NAME.

- OH, SO YOU DRAW A LINE
IN THE REST OF THE PARAGRAPH.

- JUST FOR YOUR PURPOSES,
OTHER PEOPLE WOULD WRITE.

BUT FOR NOW THIS
IS JUST A ONE TIME SHEET.

OKAY. WE HAVE TWO WOUNDS
THAT YOU ARE GOING TO CHANGE.

ONE IS A WOUND WITH A DRAIN

AND THE OTHER IS AN
OPEN GRANULATING WOUND

IN THE ABDOMEN,
A SURGICAL WOUND.

SO WHAT I WANT YOU DO
IS I WILL GO THROUGH MY SUPPLIES

AND YOU HAVE THESE EXACT
SAME SUPPLIES IN YOUR KITS.

I WANT YOU TO PRACTICE
WITH THEM.

YOU CAN GET THEM WET.
YOU CAN DO WHATEVER.

THEN JUST PACK THEM UP AND THEN
WE JUST PRETEND THEY ARE DRY,

EVEN IF THEY ARE SLOPPY WET.
IT DOESN'T MATTER. OKAY?

IF YOU CHANGE A DRESSING LIKE WE
ARE GOING TO CHANGE THIS ONE

AND THEN YOU PUT YOUR STUFF ON,

THEN JUST TAKE THAT STUFF
AND MAKE IT YOUR STUFF THEN.

YOU DON'T HAVE TO KEEP
CHANGING IT OVER AND OVER.

IT'S ALL THE SAME STUFF.
SO THERE YOU GO.

ALRIGHT. WE CHECKED
OUR DOCTOR'S ORDERS.

THE DOCTOR SAYS CHANGE
THE DRESSING WITH THE DRAIN,

Q DAY, PRN. HOWEVER,
IT NEEDS TO BE CHANGED.

SO WE'RE COMING TO CHANGE IT.

IT'S REALLY NICE
IF THE NURSE BEFORE,

PUTS ON THE CARDEX, WHAT SHE
USED TO CHANGE THE DRESSING,

SO YOU DON'T HAVE TO
SPEND SO MUCH TIME

TRYING TO FIGURE IT ALL OUT.

BUT IF YOU DON'T, THEN I
JUST COME IN AND KIND OF
TAKE A LOOK AND SEE

WHAT THEY'VE GOT
ON TOP AT LEAST,

AND I KNOW I'M GOING TO BE
NEEDING A FEW THINGS MINIMALLY.

THAT IS, I PUT A CHUX UNDER
THEIR ARMS, IN CASE THERE'S
ANY DRAINAGE.

I'M GOING TO NEED A SPLIT --
OR A DRAIN SPLIT GAUZE
OR A DRAIN GAUZE.

A DRAIN'S GOING TO BE COMING
OUT OF THE SKIN OR THE WOUND

AND I'M GOING TO NEED
TO GO AROUND IT

SO THAT I CAN PROTECT THE SKIN.

SO I HAVE MY SPLIT DRAIN.

I'M GOING TO PILE UP A PIECE OF
GAUZE ON TOP OF THE SPLIT DRAIN

TO ABSORB THE DRAINAGE.
SO I'VE GOT THAT.

I'M ALSO GOING TO NEED TO DRY
THE SKIN OFF A LITTLE BIT
AFTER I CLEAN IT,

BECAUSE WE ALWAYS CLEAN SKIN.
SO I HAVE AN EXTRA 4 BY 4.

AND THEN I'M GOING TO USE
MY SUPER SPONGE PACK.

YOU GUYS HAVE A PACK OF TEN.

SO YOU CAN PRETEND IT'S ONE
OR TWO OR WHATEVER.

SO YOU'RE JUST GOING TO
WET IT UP AND USE THEM ON
AND THEN LATER SHUT IT.

OKAY? BUT I'M GOING TO
CLEAN WITH THIS.

I'M GOING TO COVER MY DRESSING
WITH A ABD PAD.

I'VE GOT STERILE GLOVES
FOR DOING THE DRESSING.

I HAVE SOME NON-STERILE
FOR TAKING IT OFF.

THIS IS TO REMIND ME,
INCASE I NEED TO MEASURE IT.

I HAVE TWO-INCH TAPE.

I HAVE A BAG TO PUT
THE OLD DRESSING IN.

SO BRING YOUR BAGGIES
THAT YOU HAVE.

I THINK THERE WAS ONE BAGGY IN
THERE THAT HAD YOUR DRESSINGS.

OR GRAB A BAGGY.
WE HAVE A FEW.

BUT THEY'RE PRETTY
PRECIOUS AROUND HERE.

AND THEN YOU NEED
SOME SODIUM CHLORIDE.

CHECK THE EXPIRATION DATE.
YES, WE'RE EXPIRED.

AND MAKE SURE
IT'S A GOOD PRODUCT.

ONCE THIS HAS BEEN OPENED,
HOW LONG IS IT GOOD?

- 24 HOURS.
- 24 HOURS, OKAY?

SO ONCE YOU OPEN IT,
THEN IT NEEDS TO BE DATE,
TIME AND INITIALED.

WASH MY HANDS,
IDENTIFY MY CLIENT, SAM SPADE.

AND PROVIDE PRIVACY.

SAM, I AM GOING TO CHANGE
THAT DRESSING ON YOUR
UPPER SHOULDER HERE.

AND...

OOPS.

THAT'S NOT WHAT I WANT TO DO.
JUST CAN'T GO UP IN HERE.

WE TRIED A NEW BED METHOD
HERE FOR YOU

SO THAT MAYBE YOU CAN
SEE A LITTLE BETTER.

WE PUT HIM IN
REVERSE TRENDELENBURG'S,
DID YOU NOTICE?

ALRIGHT.

ARE YOU HAVING ANY PAIN,
MR. SPADE?

NO? GOOD.
ALRIGHT.

HAVE YOU HAD THIS
DRESSING CHANGED BEFORE?
WAS THERE ANY PROBLEM?

SOMETIMES DRESSING CHANGES
ARE PAINFUL,

SO YOU MIGHT WANT TO CONSIDER
MEDICATING AN HOUR BEFORE

IF YOU HAVE THE TIME TO DO THAT,

AND THEN CHANGE
THE DRESSING LATER.

THERE'S TWO WAYS THAT YOU CAN
GET READY FOR A DRESSING.

ONE IS YOU CAN SET ALL
YOUR SUPPLIES UP FIRST,

AND THEN TAKE IT OFF
AND CHANGE IT.

OR IF YOU DON'T KNOW WHAT
YOU'VE GOT GOING HERE,

THEN YOU CAN UNDO IT
AND THEN SET UP YOUR SUPPLIES.

IT KIND OF DEPENDS
ON THE CLIENT.

IF YOU THINK THE CLIENT'S
NOT GOING TO BE ABLE
TO TOLERATE THAT MUCH TIME,

THEN DO EVERYTHING AHEAD.

THERE'S REALLY NO
ABSOLUTE ANSWER.

I THINK ON ONE OF YOUR PAPERS,
I HAD YOU SETTING UP FIRST

AND ON THE OTHER ONE,
I HAVE YOU SETTING UP

AFTER YOU TAKE THE DRESSING OFF.

IT'S JUST TO GIVE YOU
TWO DIFFERENT WAYS

TO DO YOUR THING.

DRAINS ARE PUT INTO
SURGICAL INCISIONS

TO LEAVE A PATHWAY SO THAT
THE DRAINAGE CAN GET OUT.

AND SO THAT IT DOESN'T CAUSE
PRESSURE UNDERNEATH THE SUTURES.

SO IT'S KIND OF --
IT LOOKS A LOT LIKE
A TOURNIQUET THAT WE USED.

OTHER THAN --
IT'S KIND OF A TUBING...

THAT'S WITHIN THE SKIN.

ONCE I START TAKING THIS OFF,

I'M PEELING THE TAPE TOWARDS THE
CLIENT INSTEAD OF RIPPING IT.

AND I LIKE TO SUPPORT
MY DRESSINGS HERE

SO THAT I DON'T INADVERTENTLY
PULL IT OUT THE DRAIN.

COS THAT WOULD
NOT BE A HAPPY DAY.

ALRIGHT. LIFT THIS EVER
SO CAREFULLY TO MAKE SURE

THINGS AREN'T STUCK AND THAT
YOU AREN'T PULLING THE DRAIN OUT

AND YOU DON'T HAVE TAPE,
LIKE, STUCK TO THINGS.

THEN I'M PULLING
AND I'M LOOKING TO SEE

WHAT KIND OF DRAINAGE
IS ON THERE.

THE AMOUNT, THE COLOR,
THE QUANTITY...

THE QUALITY, THE ODOR
AND SO FORTH.

PLUCK THAT OFF.

ALRIGHT. THIS IS WHAT
A PENROSE DRAIN LOOKS LIKE.

AND IT JUST COMES OUT
OF THE WOUND.

IT MENTIONS THAT YOU
COULD MEASURE THE WOUND.

WE'VE JUST STUCK INTO
THIS PLATE SO THAT YOU
HAVE SOMETHING TO DO.

SO THERE'S REALLY
NOTHING TO MEASURE.

SO YOU CAN JUST SUFFICE IT
TO SAY THAT YOU WOULD.

ALRIGHT. THEY CAN BE --

THE DRAINAGE DOESN'T COME OUT
OF THE TUBING.

THAT'S NOT THE POINT.
THE DRAIN IS A PASSAGEWAY

TO ALLOW THE FLUID TO ESCAPE
THE WOUND EDGES.

IT'S NOT SUTURED CLOSE.
THEY PUT A DRAIN IN,

SO THAT THE BLEEDING
AND THE SEROSANGUINOUS FLUID

CAN GET OUT OF THERE.

SO IT JUST COMES,
IT FOLLOWS THIS PATHWAY

AND THESE ARE SOPPY
AND THEN THERE'S JUST
DRAINAGE ON THEIR SKIN.

SO WHAT WE WANT TO DO
IS CLEAN THAT SKIN OFF,

AND THEN REDRESS IT.

SO KEEPING A STERILE FIELD
HERE IN MIND,

I WANT TO SET UP MY SUPPLIES
SO THAT I DON'T CROSS OVER.

AND SO THAT MY SUPPLIES ARE,
KIND OF, IN THE ORDER

THAT I'M GOING TO BE USING THEM.

SO THE FIRST THING I'M
GOING TO DO IS CLEAN.

POUR A LITTLE OF THAT ON.

THEN I'M GOING TO --

I'M JUST GOING TO USE MY
PACKAGES AS A STERILE FIELD.

YOU COULD PUT
A STERILE FIELD DOWN

AND THROW EVERYTHING ON IT,
EXCEPT FOR THE WET STUFF.

BUT OPEN YOUR PACKAGES.

THAT ONE I'M GOING TO DRY
THE SKIN WITH.

THEN I'M GOING TO PUT ON
MY DRAIN SPONGE.

THEN I'M GOING TO
DRY THE SKIN.

MY ABD PAD,
I DON'T NEED TO OPEN UP

BECAUSE IT'S GOING TO BE
THE OUTSIDE DRESSING, RIGHT?

AND I KNOW THAT IT'S FOLDED
INSIDE THIS PACKAGE

SO THAT THE OUTSIDE PART
IS ON THE OUTSIDE.

SO I COULD ACTUALLY TOUCH THIS
WITH CONTAMINATED HANDS

AND THEN UNFOLD IT WITH
THE NO-TOUCH TECHNIQUE

AND PUT THE STERILE
SURFACE TOWARDS THE CLIENT.

SO I DON'T WORRY SO MUCH
ABOUT THIS PACKAGE

BEING OPEN OR EXPOSED RIGHT NOW.

I WANT TO GO AHEAD
AND HAVE MY TAPE READY.

IT JUST SAVES A LOT OF TIME
ONCE YOU GET THOSE GLOVES ON.

I KNOW I NEED TWO LONG
AND TWO MEDIUM.

AND THEN I'M GOING TO
GO AHEAD AND DATE, TIME
AND INITIAL THIS GUY.

OKAY. AND NOW I'M GOING TO PUT
MY STERILE GLOVES ON.

SO HOPEFULLY YOU'VE STILL GOT
A PAIR OR TWO OF STERILE GLOVES.

WE HAVE A FEW SPARES,
BUT NOT TOO MANY.

I NEED YOU TO PROBE
THE STERILE GLOVING.

OH, MAN.

THAT'S NOT TOO GOOD.
I RIPPED THEM.

IF I WAS IN SURGERY,
I WOULD WORRY ABOUT IT,

BUT IT'S AT MY WRIST
AND I AM NOT GOING TO WORK
WITH MY WRISTS RIGHT NOW.

SO I'M NOT GOING TO WORRY
ABOUT THAT TOO MUCH.

OKAY.

MOVE YOUR TABLE WITH YOUR
FOOT. DON'T TOUCH ANYTHING.

KEEP YOUR HANDS UP AND OUT.

AND YOU WILL BE GOOD TO GO.

REMEMBER THAT WHEN YOU ARE
CONTAMINATED WITH THE CLIENT,

YOU ARE CONTAMINATED WITH HIM.

BUT GLOVES ARE SO YOU DON'T
INTRODUCE ANYTHING NEW.

SO DON'T THINK OR WORRY ABOUT
THAT YOU'VE TOUCHED HIM

AND NOW EVERYTHING
IS CONTAMINATED.

I AM CLEANING FROM WHAT I WANT
TO BE CLEANEST, OUT.

ONE MORE, IF I NEED IT.
I ALWAYS SQUEEZE
SO IT'S NOT TOO SOPPY.

DON'T PULL THESE OUT.

THE DOCTOR HAS THEM PLACED,
BUT THEY ARE NOT SUTURED IN,

THEY ARE JUST LOOSE.

ALRIGHT. AND THEN MAKE SURE
YOU DRY THE SKIN

BECAUSE IF YOU DON'T WANT
THAT MACERATION SKIN BREAKDOWN

BECAUSE IT'S TOO MOIST.

THEN YOU ARE JUST GOING TO
GET YOUR DRAIN SPONGE

AND PUT IT IN HERE ONE WAY.

AND THEN TAKE YOUR SECOND ONE
AND PUT IT ANOTHER WAY.

OTHERWISE IF YOU LEAVE THAT
OPEN SPLIT, THE DRAINAGE GETS
ON TO THE SKIN.

DID I SAY THAT CLEARLY ENOUGH?

SO GET IT GOING IN
TWO DIRECTIONS.

THEN I JUST WAD IT UP.

BECAUSE AGAIN, IT'S NOT
ABOUT A STRAIGHT LINE.

IT'S NOT COMING OUT
OF THE TUBING.

IT'S THE TUBING PATH
IS ALREADY KEPT.

THEN PUT THOSE THERE.

AND NOW IT DOESN'T MATTER
THAT I'M STERILE OR NOT.

I AM GOING TO HANDLE THIS FROM
THE TOP, NO-TOUCH TECHNIQUE.

AND THEN I AM GOING TO
PLACE IT DOWN LIKE THAT

SO EVERYTHING UNDER
THERE IS STERILE.

GO AHEAD AND PUT
MY DRESSINGS ON.

YOU WANT IT TO BE
IN OCCLUSIVE DRESSING,

SO ALL FOUR EDGES ARE TAPED.

HOW DOES THAT FEEL?

KIND OF, IN YOUR NECK THERE.

YOUR ARMPITS ARE NOT DOING
TOO GOOD EITHER.

I'M NOT REAL PLEASED WITH THAT.

WELL, LET'S SEE
HOW THAT HOLDS UP.

CLEAN UP YOUR AREA.

I AM GOING TO CHECK
THAT IN AN HOUR OR SO

AND SEE IF THAT'S GOING TO
HOLD ON WITH YOUR ARM THERE.

NEVER JUST GET IT
ON THERE AND GO,

"I DON'T LIKE THAT
WOUND SO GOOD."

DEPENDING UPON THE
MOVEMENTS OF THEIR BODY,

YOU MAY JUST NEED
TO FIX IT UP.

ALRIGHT, TIE THEIR GOWNS ON AND
MAKE SURE THEY'RE COMFORTABLE.

MAKE SURE THAT ALL YOUR
DRESSING STUFF IS CLEANED UP
WITH GLOVES ON

BECAUSE THAT'S PART OF SEQUENCE.
IT'S REALLY IMPORTANT.

YOU DON'T WANT TO
BE CONTAMINATED.

PUT YOUR BED DOWN ALL THE WAY.

THEN ALL OF THIS WILL GO
INTO THE TRASH CAN.

I'M SAVING MY PRECIOUS BAG.

TAKE OFF YOUR GLOVES,
WASH YOUR HANDS AND THEN
DOCUMENT YOUR DRESSING CHANGE.

OKAY? YOU'RE JUST GOING TO SAY
YOU'RE GOING TO DOCUMENT.

OUR DOCUMENTATION'S GOING
TO BE ON THAT GUY.

ALRIGHT? ANY QUESTIONS?

NOT TOO BAD.

ALRIGHT, THE NEXT ONE
IS AN IRRIGATION...

OF AN ABDOMINAL WOUND.

YOU NEED LOTS OF SUPPLIES.

YOU NEED TOWELS.
CHUX. LOTS OF THEM.

THIS IS A MOIST
TO DAMP DRESSING.

THE IDEA IS THAT WE'RE GOING
TO PUT IN MOIST GAUZE. MOIST.

AND IT'S GOING TO
ABSORB DRAINAGE

AND IT'S NOT GOING TO
DRY ON TO THE SKIN

BECAUSE WE DON'T WANT
TO DEBRIDE IT.

SO WE'RE GOING TO GET
SOME KERLIX SPONGES.

YOU'RE GOING TO USE
YOUR 4 BY 4'S IN THAT TUB.

YOU NEED --
WHENEVER YOU USE WATER,

YOU NEED TO MAKE SURE THAT IT'S
IN A NON-PERMEABLE CONTAINER.

THAT IT'S NOT GOING TO LEECH
ON TO A CONTAMINATED SURFACE

AND CONTAMINATE YOUR DRESSING.

SO THAT'S WHAT I'M GOING TO --

ACTUALLY, THIS WILL BE OKAY.