CERRITOS COLLEGE

NURSING PROGRAM

SKILLS CHECKLIST

WOUND CARE-STERILE WET TO MOIST DRESSING

Recommended Technique / S / N.I. / U / Comments
Review the medical order
Enter patient’s room and “IPIE”
Assess for allergies to tape
Assess need for pain medication. Premedicate 15-30” prior to dressing change
Identify dressing change needs (shift report, nurses’ notes) and healing status.
Gather supplies (gloves, gauze, ABD pad, measuring tools, tape, sterile NS)
Set up working area: Clean off over bed table; place supplies in order of use and to facilitate sterile technique; and place trash receptacle within reach. Place over bed table in position to maintain sterile field and reach patient.
Wash hands
Drape patient for privacy
Don clean gloves
Assess external dressing
(clean/dry/ intact/ dated)
Remove old dressing:
-Remove tape by pulling toward the wound
-May need to moisten dressing with NS to loosen from wound
-Monitor pain level
-Inspect old dressing for drainage (type, amt, color, odor)
-Dispose of dressing in trash (in glove if possible to contain smell and contents)
Don clean gloves
Assess wound
Location
Color (red, yellow, black)
Odor (foul, sweet)
Moisture (moist or dry)
Exudates (type, amount, color)
Tissue viability (granulation, epithelialized, necrotic)
Assess peri-wound area (skin, edema, s/s of inflammation, color, temperature)
Measure the wound (length, width, depth)
Presence of undermining, tunneling or sinus tracks
Remove soiled gloves
Perform hand hygiene
Set up materials:
Open packages maintaining sterile technique
-Normal Saline: Check solution, date/time/initials on bottle, decant
-Saturate 4X4 gauze and recap NS bottle
If ordered, irrigate the wound
-Don clean gloves and pad area around wound
-Using sterile NS or lactated ringers solution irrigate wound from top to bottom. (solution is sterile, gloves aren’t)
-Remove clean gloves
Don sterile gloves
To clean wound:
-Using one 4X4 gauze moistened with NS, (make a wonton) clean incision from top to bottom and from inside to out and discard
To dress wound:
Moisten another 4X4 gauze and fluff. Place the gauze into the wound lightly to cover all surface areas. Monitor pain during this portion.
Cover with ABD pad
Remove gloves
-If possibility of blood/body fluid exposure then keep gloves on until dressing secured
Secure dressing (tape, Montgomery straps, stretch mesh)
Place Date/Time/Initials on tape and place on dressing
Clean up work area and assist patient to comfortable position
Wash hands
Document
-Date/Time
-Pain level, medications given and pt response
-Wound assessment
-Type of dressing applied
-Patient’s tolerance