Chapter 4. Wound Care

4.3 Simple Dressing Change

The health care provider chooses the appropriate sterile technique and necessary supplies based on the clinical condition of the patient, the cause of the wound, the type of dressing procedure, the goal of care, and agency policy.

Agency policy will determine the type of wound cleansing solution, but sterile normal saline and sterile water are the solutions of choice for cleansing wounds and should be at room temperature to support wound healing.

For more complex wounds with delayed healing, antiseptic solutions such as povidone iodine or chlorhexidene may be used for cleansing based on agency policy and the recommendation of a wound clinician or physician.

Checklist 33 outlines the steps for performing a simple dressing change.

Checklist 33: Simple Dressing Change
Disclaimer: Always review and follow your hospital policy regarding this specific skill.
Safety considerations: 
  • Perform hand hygiene.
  • Check room for additional precautions.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient; offer analgesia, bathroom, etc.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Assess ABCCS/suction/oxygen/safety.

Steps

 Additional Information
1. Check present dressing with non-sterile gloves. Use non-sterile gloves to protect yourself from contamination.

Apply non-sterile gloves
Apply non-sterile gloves
2. Perform hand hygiene. Hand hygiene prevents spread of microorganisms.

Perform hand hygiene
Perform hand hygiene
3. Gather necessary equipment. Dressing supplies must be for single patient use only.

Use the smallest size of dressing for the wound.

Gather supplies
Gather supplies

Take only the dressing supplies needed for the dressing change to the bedside.
4. Prepare environment, position patient, adjust height of bed, turn on lights. Ensure patient’s comfort prior to and during the procedure.

Proper lighting allows for good visibility to assess wound.
5. Perform hand hygiene. Hand hygiene prevents spread of microorganisms.

Hand hygiene with ABHR
Hand hygiene with ABHR
6. Prepare sterile field.
Prepare sterile field
Prepare sterile field
7. Add necessary sterile supplies.
Add necessary supplies
Add necessary supplies
8. Pour cleansing solution.
Pour sterile cleansing solution into sterile tray
Pour sterile cleansing solution into sterile tray

Normal saline or sterile water containers must be used for only one client and must be dated and discarded within at least 24 hours of being opened.
9. Prepare patient and expose dressed wound.
Prepare patient and expose wound
Prepare patient and expose wound
10. Apply non-sterile gloves. Use non-sterile gloves to protect yourself from contamination.

Apply non-sterile gloves
Apply non-sterile gloves
11. Remove outer dressing with non-sterile gloves and discard as per agency policy.
Removing outer dressing with non-sterile gloves
Remove outer dressing with non-sterile gloves
12. Remove inner dressing with transfer forceps, if necessary.
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Remove inner dressing with transfer forceps
13. Discard transfer forceps and non-sterile gloves according to agency policy.
Discard transfer forceps as per agency policy
Discard transfer forceps as per agency policy
Discard gloves
Discard gloves
14. Assess wound.
Assess wound
Assess wound
15. Drape patient with water-resistant underpad (optional). Water-resistant underpad protects patient’s clothing and linen.

Drape patient with water resistant underpad
Drape patient with water-resistant underpad
16. Apply non-sterile gloves (optional). Use non-sterile gloves to protect yourself from contamination.

Apply non-sterile gloves
Apply non-sterile gloves
17. Cleanse wound using one 2 x 2 gauze per stroke. Strokes should be:

  • From clean to dirty (incision, then outer edges)
  • From top to bottom
 The suture line is considered the “least contaminated” area and is cleansed first.

Using a sterile swab or gauze, clean the suture line by starting at the centre and working toward one end.
1. Using a sterile swab or gauze, clean the suture line by starting at the centre and working toward one end.
With another sterile swab or gauze, start at the centre of the incision and work toward the other end.
2. With another sterile swab or gauze, start at the centre of the incision and work toward the other end.
All other cleansing involves moving from one end to the other on each side of the incision.
3. All other cleansing involves moving from one end to the other on each side of the incision.
Work in straight lines, moving away from the suture line with each successive stroke.
4. Work in straight lines, moving away from the suture line with each successive stroke.
18. Cleanse around drain (if present). If a drain is present, clean the drain site using a circular stroke, starting with the area immediately next to the drain.

Using a new swab, cleanse immediately next to the drain and attempt to clean a little further out from the drain. Continue this process with subsequent swabs until the skin surrounding the drain is cleaned.

DSC_0350
Cleanse around drain
19. Apply inner dressing (4 x 4 gauze) with forceps to incision, then drain site (drain sponges/cut gauze).
DSC_0366
1. Cover incision
DSC_0371
2. Cover drain site
DSC_0372
3. Tape drain tubing to skin
20. Discard non-sterile gloves if they were used. This step prevents the spread of microorganisms.

Discard gloves
Discard gloves
21. Apply outer dressing, keeping the inside of the sterile dressing touching the wound. This step protects wound from contamination.

DSC_0384
Apply outer dressing if required
22. To complete dressing change:

  • Assist patient to comfortable position.
  • Lower patient’s bed.
  • Discard used equipment appropriately.
  • Perform hand hygiene.
 Taking these step ensures the patient’s continued safety.

Hand hygiene with ABHR
Hand hygiene with ABHR
23. Document procedure and findings according to agency policy. Record dressing change as per hospital policy.

Document the wound appearance, if the staples are intact, if the incision is well-approximated.

Chart the time, place of wound, size, drainage and amount, type of cleaning solution, and dressing applied.

State how the patient tolerated the procedure.

Report any unusual findings or concerns to the appropriate health care professional.
24. Compare wound to previous wound assessment and determine healing progress, if any. If there is no movement toward healing, or if there is deterioration, notify the physician or wound care nurse according to agency policy.
Data source: BCIT, 2010a; Perry et al., 2014

Video 4.1

Watch the video Simple Sterile Dressing Change by Renée Anderson and Wendy McKenzie, Thompson Rivers University.

Critical Thinking Exercises

  1. Your patient has a post-operative hip incision. You notice that the wound is slightly inflamed and not approximated, with some yellowish exudate present. What would be your next steps?
  2. As you select your supplies, you notice that the sterile saline container was opened exactly 24 hours ago. What would be your next steps?

License

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Clinical Procedures for Safer Patient Care Copyright © 2015 by Glynda Rees Doyle and Jodie Anita McCutcheon is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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