Goal: The patient’s skin is free from irritation and injury.
1. Review the medical orders for wound care or the nursing plan of care related to wound care.
2. Gather the necessary supplies and bring to the bedside stand or overbed table.
3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
5. Close curtains around bed and close door to room if possible. Explain what you are going to do and why you are going to do it to the patient.
6. Assess the patient for possible need for nonpharmacologic pain-reducing interventions or analgesic medication before wound care dressing change. Administer appropriate prescribed analgesic. Allow enough time for analgesic to achieve its effectiveness before beginning procedure.
7. Place a waste receptacle at a convenient location for use during the procedure.
8. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8, 2009).
9. Assist the patient to a comfortable position that provides easy access to the wound area. Use a bath blanket to cover any exposed area other than the wound. Place a waterproof pad under the wound site.
10. Perform wound care and a dressing change as outlined in Skills 8-1 through 8-4, as ordered.
11. Put on clean gloves. Clean the skin on either side of the wound with the gauze, moistened with normal saline. Dry the skin.
12. Apply a skin protectant to the skin where the straps will be placed.
13. Remove gloves.
14. Cut the skin barrier to the size of the tape or strap. Apply the skin barrier to the patient’s skin, near the dressing. Apply the sticky side of each tape or strap to the skin barrier sheet, so the openings for the strings are at the edge of the dressing. Repeat for the other side.
15. Thread a separate string through each pair of holes in the straps. Tie one end of the string in the hole. Fasten the other end with the opposing tie, like a shoelace. Do not secure too tightly. Repeat according to the number of straps needed. If commercially prepared straps are used, tie strings like a shoelace. Note date and time of application on strap.
16. After securing the dressing, label dressing with date and time. Remove all remaining equipment; place the patient in a comfortable position, with side rails up and bed in the lowest position.
17. Remove additional PPE, if used. Perform hand hygiene.
18. Check all wound dressings every shift. More frequent checks may be needed if the wound is more complex or dressings become saturated quickly.
19. Replace the ties and straps whenever they are soiled, or every 2 to 3 days. Straps can be reapplied onto skin barrier. Skin barrier can remain in place up to 7 days. Use a silicone-based adhesive remover to help remove the skin barrier.
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