NARRATOR: Review the clinician’s order and the facility’s protocol for wound care. Assemble the supplies you will need including personal protected equipment for the dressing change. Identify your patient. Explain the procedure and answer all questions. Provide emotional support and pre-medicate if necessary.
Remove the soiled dressing using clean technique, begin at the edges of the dressing and lift towards the center of the wound. Stabilize the skin during the removal and do not contaminate the wound and incision. Verify that all materials used for packing the wound is removed. Inspect and assess the wound for size, appearance, depth, drainage and older.
Measure and stage the wound using your facility’s criteria. If the wound appearance suggests the presence of infection used sterile technique to collect the sample of wound drainage for laboratory testing. Clean the wound bed using sterile normal saline and moistened sterile swabs or 4×4’S by gently wiping the wound from its center towards its outer edge.
Remove the non-sterile gloves, perform hand hygiene and don sterile gloves. Using sterile technique, place sterile normal saline solution and dressings within the sterile field. Apply the dry dressing to the wounded, avoiding contact with the surrounding skin. Gently pack the dressing into open space areas such as tunnels, fistulas and sinus traps.
Apply a secondary dressing to cover and secure the dry dressing. Secure the primary and secondary dressing with a tape as appropriate. Discard the gloves and dressing materials into a bio-hazard bag. Reposition the patient for comfort and reassess for pain. Document the following information in the patient’s medical record: the date and time of dressing change; assessment of the wound, including appearance of the wound bed, amount and type of drainage; the type of procedure performed and the patient’s response to the procedure.
