Goal: The procedure is accomplished without contaminating the wound area, without causing trauma to the wound, and without causing the patient to experience pain or discomfort.
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.
7. Place a waste receptacle or bag 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. Position the patient so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end, if being used (see Skill 8-1 for wound cleansing and Skill 8-4 for irrigation techniques). Use the bath blanket to cover any exposed area other than the wound. Place a waterproof pad under the wound site.
10. Put on clean gloves. Carefully and gently remove the soiled dressings. If there is resistance, use a silicone-based adhesive remover to help remove the tape. If any part of the dressing sticks to the underlying skin, use small amounts of sterile saline to help loosen and remove.
11. After removing the dressing, note the presence, amount, type, color, and odor of any drainage on the dressings. Place soiled dressings in the appropriate waste receptacle.
12. Assess the wound for appearance, stage, the presence of eschar, granulation tissue, epithelialization, undermining, tunneling, necrosis, sinus tract, and drainage. Assess the appearance of the surrounding tissue. Measure the wound. Refer to Fundamentals Review 8-3.
13. Remove your gloves and put them in the receptacle.
14. Using sterile technique, open the supplies and dressings. Place the fine-mesh gauze into the basin and pour the ordered solution over the mesh to saturate it.
15. Put on the sterile gloves. Alternately, clean gloves (clean technique) may be used to clean a chronic wound.
16. Clean the wound. Refer to Skill 8-1. Alternately, irrigate the wound, as ordered or required (see Skill 8-4).
17. Dry the surrounding skin with sterile gauze dressings.
18. Apply a skin protectant to the surrounding skin if needed.
19. If not already on, put on sterile gloves. Squeeze excess fluid from the gauze dressing. Unfold and fluff the dressing.
20. Gently press to loosely pack the moistened gauze into the wound. If necessary, use the forceps or cotton-tipped applicators to press the gauze into all wound surfaces.
21. Apply several dry, sterile gauze pads over the wet gauze.
22. Place the ABD pad over the gauze.
23. Remove and discard gloves. Apply tape, Montgomery straps or roller gauze to secure the dressings. Alternately, many commercial wound products are self adhesive and do not require additional tape.
24. 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.
25. Remove PPE, if used. Perform hand hygiene.
26. Check all wound dressings every shift. More frequent checks may be needed if the wound is more complex or dressings become saturated quickly.
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