Sterile Wound Dressing Change

Introduction

• Demonstration by Ellis from Level Up RN
• Steps derived from Clinical Nursing Skills cards
• Pain management is crucial prior to the dressing change:
  • Conduct a pain assessment
  • Administer pain medication

Preparation

• Wash hands and wear gloves
• Obtain a wound care tray (contains necessary sterile items)
• Possibly gather additional items based on facility requirements
• Remove old dressing:
  • Assess drainage (type, color, texture, amount)
  • Inspect wound bed, tissue type, drainage, color, odor

Setting Up Sterile Field

• Open wound care tray correctly
• Use preferred size of sterile gloves if needed
• Use sterile drape:
  • 1-inch border of sterile drape is not sterile
• Put on sterile gloves:
  • Non-dominant hand picks up dominant glove by cuff
  • Dominant hand picks up cuff of non-dominant glove

Sterile Kit Contents

• Saline
• Tape
• Cling roll
• Sterile gauze
• ABD pad
• Label for dressing

Cleaning the Wound

• Open sterile saline and pour into container:
  • Use palm to pour without lowering hand below waist
• Clean wound:
  • Dip gauze in saline
  • Start at center of wound and move outward
  • Use new gauze for each swipe
  • Do not drag bacteria into wound
• Pat wound dry with gauze

Packing the Wound

• Use ordered material (dry gauze for demonstration)
• Apply medication/ointment if ordered
• Pack wound without contaminating it:
  • Avoid dragging gauze over outside skin
  • Carefully place gauze into wound

Covering and Securing the Wound

• Place ABD pad over wound
• Secure with tape on all four sides
• Sterility no longer a concern once wound is covered

Documentation

• Document name, date, and time on label
• Ensure the label is on the wound
• Record the change in the patient’s chart

Conclusion

• Successful completion of a sterile wound dressing change