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05.04 Wound Care – Dressing Change

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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

Reference Links

Study Tools

Video Transcript

In this video we are going to look at how to do a wet to dry dressing change. Make sure that you have watched the video on wound assessment because that takes place before we actually apply the new dressing.

In this case, our patient has a lower abdominal open wound. We have already removed the old dressing and assess the wound. so now let’s set up our dressing supplies.
First, open both packs of sterile gauze, but don’t touch the gauze yet. Pour some sterile saline into one of the gauze packs. Depending on the size of the wound, you may need more than this.
You also want to open your ABD dressing with sterile technique. Don’t touch the dressing, just lay it open so you have access to it.
If you’re using wound cleanser spray, you’d spray it at this time. Otherwise, go ahead and apply your sterile gloves.
Once you’re sterile, use 1-2 pieces of dry gauze to pat the wound dry, don’t scrub.
Now you’re going to pick up one piece of the saline-soaked gauze at a time, open it fully, and wring out any excess saline. We want it wet but not dripping.
Now, using your fingers and sterile forceps if needed, gently pack the wound with the saline-soaked gauze. You don’t want your sterile gloves to touch any part of the wound bed – just the gauze.
You don’t want to pack the wound too tightly, but you do want to make sure all of the wound surface is covered with the saline-soaked gauze.
Then you’re going to cover this with dry gauze, then cover again with an abdominal pad or other large dry dressing.
Secure that dressing in place with 3-inch wide silk or medipore tape.

That’s it – make sure you time, date, and initial your dressing and document your dressing change AND wound assessment.

We hope this was helpful. Sometimes dressing changes and sterile technique can be very intimidating. But the more you do it, the better you’ll get at it.

We believe in you guys! You’ve got this! Now, go out and be your best selves today. And, as always, happy nursing!

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