20.8 Checklist for Simple Dressing Change
Use this checklist to review the steps for completion of “Simple Dressing Change.”
View an instructor demonstration of Wound Care[1]:
Steps
Disclaimer: Always review and follow agency policy regarding this specific skill.
- Gather supplies: nonsterile gloves, sterile gloves per agency policy, wound cleansing solution or sterile saline, sterile 2″x 2″ gauze for wound cleansing, 4″ x 4″ sterile gauze for wound dressing, scissors, and tape (if needed).
- Use the smallest size of dressing for the wound.
- Take only the dressing supplies needed for the dressing change to the bedside.
- Perform safety steps:
- Perform hand hygiene.
- Check the room for transmission-based precautions.
- Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
- Confirm patient ID using two patient identifiers (e.g., name and date of birth).
- Explain the process to the patient and ask if they have any questions.
- Be organized and systematic.
- Use appropriate listening and questioning skills.
- Listen and attend to patient cues.
- Ensure the patient’s privacy and dignity.
- Assess ABCs.
- Assess wound pain using PQRSTU.
- Prepare the environment, position the patient, adjust the height of the bed, and turn on the lights. Ensure proper lighting to allow for good visibility to assess the wound. Ensure proper body mechanics for yourself and create a comfortable position for the patient. Premedicate, if indicated, to ensure patient’s comfort prior to and during the procedure.
- Perform hand hygiene immediately prior to arranging the supplies at the bedside.
- Place a clean, dry, barrier on the bedside table. Create a sterile field if indicated by agency policy.
- Pour sterile normal saline into opened sterile gauze packaging to moisten the gauze.
- Normal saline containers must be used for only one patient and must be dated and discarded within at least 24 hours of being opened.
- Commercial wound cleanser may also be used.
- Expose the dressing.
- Perform hand hygiene and apply nonsterile gloves.
- Remove the outer dressing.
- Remove the inner dressing. Use transfer forceps, if necessary, to avoid contaminating the wound bed.
- Remove gloves, perform hand hygiene, and put on new gloves.
- Wrap the old inner dressing inside the glove as you remove it, if feasible, to prevent contaminating the environment.
- Assess the wound:
- See “Checklist for Wound Assessment” checklist for details.
- Drape the patient with a water-resistant underpad, if indicated, to protect the patient’s clothing and linen.
- Apply gloves and other PPE as indicated. Goggles, face shield, and/or mask may be indicated.
- Cleanse the wound based on agency policy, using moistened gauze, commercial cleanser, or sterile irrigant. When using moistened gauze, use one moistened 2″ x 2″ sterile gauze per stroke. Work in straight lines, moving away from the wound with each stroke. Strokes should move from a clean area to a dirty area and from top to bottom.
- Note: A suture line is considered the “least contaminated” area and should be cleansed first.
- Cleanse around the drain (if present):
- Clean around the drain site using a circular stroke, starting with the area immediately next to the drain.
- Using a new swab with each stroke, cleanse immediately next to the drain in a circular motion. With the next stroke, move a little farther out from the drain. Continue this process with subsequent circular swabs until the skin surrounding the drain is cleaned.
- Remove gloves, perform hand hygiene, and apply new gloves.
- Apply sterile dressing (4″ x 4″ sterile gauze) using nontouch technique so that the dressing touching the wound remains sterile.
- Apply outer dressing if required. Secure the dressing with tape as needed.
- Remove gloves and perform hand hygiene.
- Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.
- Ensure safety measures when leaving the room:
- CALL LIGHT: Within reach
- BED: Low and locked (in lowest position and brakes on)
- SIDE RAILS: Secured
- TABLE: Within reach
- ROOM: Risk-free for falls (scan room and clear any obstacles)
- Perform hand hygiene.
- Document the procedure and related assessment findings. Compare the wound assessment to previous documentation and analyze healing progress. Report any concerns according to agency policy.
- Open RN Project. (2021, November 11). Wound care [Video]. YouTube. Video licensed under CC-BY-4.0. https://youtu.be/yfcti9Rjtfg ↵