05.04 Wound Care – Dressing Change

Overview

1. Purpose
   1. Wound care and dressing changes should be performed at least daily or more often depending on orders
      1. SOME dressings (see “Selecting a Dressing” lesson) don’t require daily changes
   2. Dressing changes should be sterile to avoid introducing any new bacteria to the wound and to promote wound healing

Nursing Points

General

1. Supplies needed for Wet-to-Dry Dressing
   1. Sterile Kerlix for packing if available
   2. 2-3 packs of sterile 4×4 gauze
   3. ABD (abdominal) pad dressing
   4. Silk or medipore tape (3 inch-wide)
   5. Wound cleanser
   6. Sterile saline
   7. Sterile forceps/tweezers (can use a suture removal kit)
   8. Sterile gloves

Assessment

1. Should complete wound assessment before applying new dressing.
2. See Wound Care – Assessment lesson

Nursing Concepts

1. Steps and Nursing Considerations
   1. Explain procedure to patient
      1. Consider pre-medicating for pain if needed
   2. Assist patient to appropriate position for dressing change, raise bed to comfortable working height.
   3. Perform hand hygiene
   4. Don clean gloves
   5. Remove old dressing
      1. Do NOT wet it down if stuck, that is the whole point of a wet-to-dry dressing
      2. Allows for debridement
   6. Assess wound
   7. Remove gloves
   8. Perform hand hygiene
   9. Set up dressing supplies
      1. Open 2 packs of sterile gauze, do not touch gauze
      2. Pour sterile saline into one pack
      3. Open ABD dressing pad with sterile technique – do not touch dressing
   10. If available, spray wound cleanser on base of wound
   11. Apply sterile gloves
   12. Use 1-2 pieces of dry gauze to pat the wound dry
   13. Pick up one piece of saline-soaked gauze at a time, open it fully, and wring out excess saline
   14. Using your fingers and sterile forceps if needed, gently pack the wound with the saline-soaked gauze or Kerlix
   15. Do not pack the wound too tightly, but make sure all surfaces are covered with saline-soaked gauze
   16. Cover this with dry gauze
   17. Then cover with an abdominal pad or other large dry dressing
   18. Secure the dressing with 3-inch wide silk or medipore tape
   19. Time, date, and initial your dressing
   20. Discard all supplies
   21. Remove gloves
   22. Perform hand hygiene
   23. Return patient to comfortable position
   24. Document dressing change and wound assessment, as well as patient response / tolerance

Patient Education

1. Signs of infection to report
2. Patients going home with wounds should be taught how to perform wound care using CLEAN technique