Changing a Dry, Sterile Dressing

Administering a Tube Feedingn32-2 1701

NURsing Procedure 58-1

Changing a Dry, Sterile Dressing

SUPPLIES AND EQUIPMENT

✓Clean gloves / ✓Pen, paper, and measuring device
✓Marked red biohazard bag / ✓Waterproof marker, if ordered
✓ABD (abdominal) pad or Surgi-Pads, if required / ✓Bath blanket
✓Sterile dressings, as ordered / ✓Sterile gloves, as ordered
✓Sterile saline or water, if required / ✓Tape or Montgomery straps
✓Sterile cotton-tipped applicators or tongue blades / ✓Waterproof pads
✓Medication, as ordered / ✓Sterile forceps optional

RECOMMENDED TECHNIQUE E S NP Comments

Follow LPN WELCOME steps and then
1. Check the orders for type of dressing to apply. Check previous nursing notes to determine the presence or absence of drainage, its character and amount, and size and condition of the wound. Place a waterproof pad under the client, if necessary. /
2. Prepare a marked biohazard bag for soiled dressings. Fold back the cuff and place it within reach of your working area (often, it is handy to tape it to the end of the overbed table). If you are using tape on the new dressing, tear strips of the appropriate size and lightly tape the ends to the overbed table. /
3. Put on clean gloves. Untie the Montgomery straps or gently loosen the tape on the used dressing. Remove the used dressing, being careful not to tear the wound or dislodge any drains. Use sterile saline to moisten the dry dressing, if it is sticking to the wound. Lift the soiled side of the dressing away from the client’s view. /
4. Determine the amount, color, odor, and consistency of any drainage. Observe the condition of the wound and surrounding tissues. Measure and describe the wound. Draw a picture of an irregular wound. If ordered, draw a line around the wound with a waterproof marker and date it. /
5. Remove gloves and place in the biohazard bag. Wash hands. Prepare a sterile field on the bedside or overbed table and open sterile dressings onto it (see In Practice: Nursing Procedure 57–1). Uncap the sterile saline or other prescribed solution and pour it into a sterile receptacle. Place additional sterile dressings or swabs for cleansing onto the sterile field. /
6. Put on sterile gloves (see In Practice: Nursing Procedure 57–2), as ordered. (Gloves are put on after all sterile materials are prepared and in place.) /
7. Moisten sterile dressings or swabs and cleanse the wound, if ordered, moving from top to bottom or from the center of the wound outward (you may use sterile forceps). Use a new swab or gauze pad for each cleansing motion and discard the used materials in the biohazard bag. If necessary, clean the area around the wound as well. Do not use alcohol or soap. /

NURsing Procedure 58-1

Changing a Dry, Sterile Dressing (Continued)

RECOMMENDED TECHNIQUE (Continued) E S NP Comments

8. If necessary, use a gauze pad to dry the wound with the same motions as in step 7. Carefully inspect the wound. Be prepared to describe the wound accurately. /
9. Apply any ointments or medications to the wound, as ordered. Do not touch the wound with your hands. Apply a layer of dry sterile dressings over the incision and wound area, as ordered. Pad with additional dressings and cover with a sterile ABD pad if the wound is large or heavily draining. /
10. If tape is to be used, use the previously torn strips. Apply at least one piece of tape immediately, to hold the dressing in place. In some situations, you may then remove your gloves and complete the taping of the dressing. An alternate method is to tie the dressing with Montgomery straps (see Fig. 53–4), to avoid frequent tape removal. /
11. Remove gloves and wash hands. Reposition and cover the client, while preventing pressure on the wound. Handle only the outside of the biohazard bag, keeping hands inside (under) the cuff on the outside of the bag, and carefully closing it. Dispose of the bag according to agency policy. Wash hands again. /
Follow ENDDD steps.
Special Reminder
• Completely describe the wound and any drainage in your documentation. /

KEY: E = Excels S = Satisfactory NP = Needs Practice

Pass Fail

Student’s Signature: Date:

Instructor’s Signature: Date: