CLEANING A WOUND AND APPLYING A STERILE DRESSING:
PURPOSE: To provide oxygen delivery via nasal cannula, nasal catheter or face-mask
PROCEDURE: DONE NOT
DONE
Equipment and materials:
cotton balls soaked with plaster
hydrogen peroxide dressing set
cotton balls soaked with sterile gloves
betadine waste receptacle
sterile gauze or (OS) 4 x4 dry cotton balls
PROCEDURE:
1. Review the physician’s order for wound care of the nursing plan of
care related to wound care.
2. Gather the necessary materials.
3. Identify the patient. Explain the procedure to the patient. Inquire
about any known allergies, specifically related to the products being
used for wound care.
4. Perform hand washing.
5. Close door or curtain. Place the bed at an appropriate and
comfortable working height.
6. Place a waste receptacle or bag at a convenient location for use
during the procedure.
7. Assist patient to comfortable position that provides easy access to
wound care area. Use a bath blanket to cover any exposed area other
than the wound. If necessary, place a waterproof pad under the wound
site.
8. Check the positions of drains, tubes or other adjuncts before
removing the dressing. Put on the clean disposable gloves and loosen
tape on the dressings. If necessary, use an adhesive remover to help get
the tape off.
9. Carefully remove the soiled dressings. If any part of the dressing
sticks to the underlying skin, use small amounts of sterile saline to help
loosen and remove. Do not reach over the wound.
10. After removing the dressing, note the presence, amount, type, color,
and odor of any drainage on the dressings. Place soiled dressing in the
appropriate waste receptacle. Remove your gloves and dispose of in
appropriate waste receptacle.
11. Inspect the wound site for appearance and drainage. Assess if any
pain is present. Check the sutures, steri-strips, staples, and drains or
tubes. Note any problems to include in your documentation.
12. Using sterile technique, prepare a sterile work area and open the
needed supplies.
13. Open the sterile cleaning solution. Depending on the amount of
cleaning needed, the solution might be poured directly over gauze
sponges for small cleaning jobs or in a basin for more complex or lager
cleaning.
14. Put on sterile gloves.
15. Clean the wound. If needed, use sterile forceps to clean the area.
Clean the wound from top to bottom and from center to outside.
Following this pattern, use gauze for each wipe, placing the used gauze
in the waste receptacle. Do not touch any surface with the gloves or
forceps.
16. If a drain is in use, clean around the drain using a circular motion.
Wipe from the center toward the outside. Use the gauze a single time
and then dispose of it.
17. Once the wound is cleansed, dry the area using a gauze sponge in
the same manner. Apply ointment or any other treatments if ordered.
18. Apply the layer of dry sterile over the wound. Forceps may be used
to apply the dressing.
19. Place a second layer of gauze over the wound site.
20. Apply a surgi-pad dressing over the gauze at the site as the
outermost layer of the dressing.
21. Remove and discard sterile gloves. It is often easier to apply the
items used to secure the dressing in place when working without gloves.
Apply tape to secure the dressings.
22. After securing the dressing label dressing with date and time,
remove all remaining equipment, place the patient in a position of
comfort with side rails up and bed in the lowest position, and perform
hand hygiene.
23. Record the procedure, wound assessment, and the patient’s reaction
to the procedure according to institution’s guidelines.
24. Check all wound dressings every shift. More frequent checks may
be needed if the wound is more complex or dressings become saturated
quickly.