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1. Nursing actions performed: Wound care

Client Name: Mrs. L
Medical diagnosis : Post Removal Implant
2. Preparation of Tools and Materials:
• Instrument body
- Anatomical tweezers
- Verband scissors
- Sterile gauze
• Sterile gloves 1 pair
• Clean gloves 1 pair
• NaCl liquid
• Alcohol
• Nierbeken
• Sterile kom
• Plaster
3. The purpose of the nursing action performed:
• Eliminates accumulated secretions and dead tissue in wounds
• Reducing the growth of microorganisms in wounds
• Speed up the wound healing process
4. Steps of nursing actions performed:
a. Pre-Interaction Stage
1) Verify data.
2) Wash hands
b. Orientation Stage
1) Giving greetings as a therapeutic approach
2) Explain the purpose and procedure of action for the family / patient
3) Asking the client's readiness before the activity is carried out
4) Keep privacy
c. Working Stage
1) Wash hands with 6 steps
2) Adjust the position of the patient
3) Bring the necessary tools and materials near the bed / patient
4) Use sampiran to maintain patient privacy
5) Adjust the position of the patient as comfortably as possible and free
the wound area from clothing and blankets
6) Installing equipment
7) Preparing NaCl / insert liquid into a sterile com
8) Inserting sterile gauze into a sterile com containing NaCl liquid
9) Removing gauze / bandages with alcohol cotton using tweezers / clean
gloves (preferably using tweezers) and throwing it into crooked
10) Remove clean gloves replace with sterile ones
11) Use new tweezers to clean the wound, but if you have used sterile
gloves no longer need to wear tweezers, you can immediately clean the
wound with a hand that has been coated with sterile gloves but if you
add tweezers it will be better
12) Use one gauze to clean the wound with NaCl liquid (one-way wound
13) The wound is then covered with sterile gauze and covered with
hypapix tape
d. Termination Stage
1) Evaluating the client's response to the procedure.
2) Farewell to clients
3) Clean up the tools
4) Wash hands
5) Record the date and time of examination.
6) Record client response after the inspection procedure.

Clinical Teacher

(Ahmad Juliadi, Ns., M.Kep)