Sterile Dressing Change

Sterile Dressing Change
■ Wash hands, explain procedure, and position and drape Pt.
■ Open sterile gloves on nearby surface.
■ Using sterile technique, open supplies and set up sterile field.
■ Instruct Pt not to touch incision/wound or sterile supplies.
■ Don clean (nonsterile) gloves and remove old dressing:
♦ Pull tape toward incision, parallel to skin.
♦ Be careful not to dislodge any drainage tubes or sutures.
■ Assess condition and appearance of wound including size, color, and presence of exudate, odor, ecchymosis, or induration.
■ Discard gloves and old dressing per standard precautions.
■ Wash hands and don sterile gloves.
■ Cleanse wound with prescribed solution:
♦ Start from area of least contamination, and cleanse toward the area of most contamination (use a separate swab for each stroke).
♦ Cleanse around drains using a circular motion working outward.
■ Apply medicated/antiseptic ointments as prescribed.
■ Apply prescribed sterile dressing to incision or wound:
♦ Cut dressings to fit around drain if present (use sterile scissors).
♦ Dry dressing: Cover wound with sterile gauze
♦ Wet-to-dry: Cover or pack wound with saline-moist, sterile gauze, and then cover with dry, sterile gauze (2 2, 4 4, etc.), thick ABD, or Surgi- Pad.
♦ Wound packing: Soak sterile gauze in prescribed sterile solution and wring out any excess. Using sterile forceps, gently pack wound until all wound edges are in contact with moist gauze, including any undermined areas. Do not overpack wound (stop at skin level).
■ Reinforce with thick cover dressing (ABD or Surgi-Pad).
■ Secure dressing with tape, rolled gauze, or Montgomery ties.
■ Document: Record dressing change and assessment findings.