procedure 19 changing a clean dressing procedure 20 ... · pdf filechapter 5 wound care...

Chapter 5 Wound Care

Procedure 19 Changing A Clean Dressing

Procedure 20 Applying A Bandage

Procedure 21 Applying A Sterile Dressing

Procedure 22 Applying A Dressing Around A Drain

Procedure 23 Changing Wet-To-Dry Dressings

Procedure 24 Applying A Transparent Film Dressing

Procedure 25 Applying A Hydrocolloid Dressing

Procedure 26 Pin Care

Procedure 27 Removing Sutures

Procedure 28 Removing Staples

PERFORMANCE REVIEW CHECKLIST

Procedure 19

Changing A Clean Dressing

Name of Patient Care Technician ________________________ Date of Program ______ to ______

Social Security Number or Identification Number _______________________________

Program Code Number (if any) _________________

S=Satisfactory PerformanceU=Unsatisfactory Performance

Place a full signature to correspond with each set of initials appearing below.

Supplies needed:

• 2 pairs clean, disposable exam gloves• Cleansing solution• Plastic bag for used supplies• Clean or sterile gauze pads or other dressing, as ordered, and according to facility policy• Tape or bandage material

Initials Corresponding Signature of Instructor Title

Procedure Guidelines S/U Date Initials S/U Date Initials

1. Perform your beginning procedure actions.

2. Holding gentle traction on the skin, loosen the tape by pulling the ends toward the wound, and then remove the dressing. Discard in the plastic bag.

3. Cleanse and rinse the wound as ordered. If the wound appears abnormal or infected, notify your supervisor.

4. Remove the gloves and discard in the plastic bag.

5. Wash your hands.

6. Set up your dressing supplies and open packages.

7. Apply clean exam gloves.

__________________________________ _______________

Instructor Signature Date

__________________________________ _______________

Student Signature Date

8. Pick up the gauze dressing, holding it only by the corners.

9. Center the dressing over the wound.

10. Tape the dressing securely in place, or cover with a bandage (Procedure 20), as instructed.

11. Perform your procedure completion actions.



Procedure 20

Applying A Bandage








1. After applying the dressing, apply the bandage. Most bandaging materials are conforming, self-adhering gauze. Brand name products, such as Kling

®

and Kerlix

®

, or generic products, such as conforming gauze, are commonly used in health care facilities.

2. The bandage must cover the dressing completely. Begin by holding the bandage in your dominant hand. Hold the bandage against the skin with your nondominant thumb, approximately one inch below the dressing.

3. Wrap the bandage around the extremity two or three times to hold it securely in place.

4. Wrap the bandage from distal to proximal, in overlapping spiral turns. Each turn should overlap 1⁄2 to 3⁄4 of the previous turn. The bandage should be snug so it does not fall off. However, it must not be so tight that it restricts blood flow.

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5. Wrap the bandage at least one inch above the top of the dressing. Wrap it completely around the extremity twice, then cut the end. Tape the end to the bandage, not the skin.

6. Assess the circulation distal to the bandage to ensure that the circulation is adequate.




Procedure 21

Applying A Sterile Dressing






Supplies needed:

• 1 pair disposable exam gloves• 1 pair sterile gloves• Cleansing solution• Plastic bag for used supplies• Sterile gauze pads or other dressing• Tape or bandage material




2. Holding gentle traction on the skin, loosen the tape by pulling the ends toward the wound, and then remove the dressing. Discard it in the plastic bag.

3. Cleanse and rinse the wound as ordered. If the wound appears abnormal or infected, notify your supervisor.


5. Wash your hands.

__________________________________ _______________


__________________________________ _______________


6. Set up your sterile field and prepare sterile dressing supplies. Arrange the field so that you do not have to cross over it when reaching for supplies.

7. Cut the tape, if used. Place on the edge of the overbed table, if permitted by your facility policy.

8. Apply sterile gloves.

9. Pick up sterile dressings, holding them only by the corners. Center them over the wound.

10. Tape the dressing securely in place, or cover with a bandage (Procedure 20). You may remove your gloves to apply the tape or bandage, if desired.




Procedure 22

Applying A Dressing Around A Drain






Supplies needed:

• 1 pair disposable exam gloves• 2 pairs sterile gloves• Gown, mask, and eye protection if copious drainage or splashing of blood or body fluids is

anticipated • Plastic bag for used supplies• Cleansing solution• Small sterile bowl (optional)• Sterile forceps (optional)• Sterile towel or drape• Sterile cotton applicators (optional)• Sterile gauze pads or other dressings• Sterile pre-cut drain gauze• Tape or bandage material




2. Holding gentle traction on the skin, loosen the tape by pulling the ends toward the wound, and then remove the dressing.

3. Cleanse and rinse the skin surrounding the incision, as ordered. If the wound appears abnormal or infected, notify your supervisor. Visually check the drain to ensure that it is attached to the skin securely. Avoid disturbing the drain at this time. Cleanse only the wound.


5. Wash your hands.

6. Set up your sterile field and prepare sterile dressing supplies. Pour liquid solution into the sterile basin, if necessary. Arrange the field so that you do not have to cross over it when reaching for supplies.



9. Cleanse the incision itself, as ordered. Use a sterile applicator or gauze sponge. Wipe from cleanest to less clean, in a single downward stroke. Discard the applicator or gauze sponge. If another is needed, use a second applicator. Avoid contaminating the solution with a used applicator.

10. Rinse the skin.

11. Pat dry with a gauze sponge, if necessary.

12. Cleanse the area surrounding the drain. Use a circular motion, beginning at the center and working outward. Handle the drain as little as possible. Lift it using a sterile applicator or your finger.

13. Apply at least two layers of pre-cut drain gauze, or as ordered. Cover with two layers of uncut gauze.

14. If your gloves are visibly contaminated with drainage, remove them, wash your hands, and reapply new sterile gloves before proceeding.


__________________________________ _______________


__________________________________ _______________


15. Pick up the sterile cover dressings by holding them only by the corners. Center them over the wound and drain, or dress each area separately, according to location and physician’s orders.

16. Tape the dressing securely in place.




Procedure 23

Changing Wet-To-Dry Dressings






Supplies needed:

• 1 pair disposable exam gloves• 1 pair sterile gloves• Gown, mask, and eye protection if copious drainage or splashing of blood or body fluids is

anticipated • Plastic bag for used supplies• Cleansing solution• Sterile normal saline• Small sterile bowl• Sterile towel or drape• Sterile gauze pads or other dressings• Tape or bandage material




2. Holding gentle traction on the skin, loosen the tape by pulling the ends toward the wound, and then remove the dressing. The purpose of a wet-to-dry dressing is to debride the skin. The dressing will stick slightly. Remove it gently, but do not moisten the dressing with saline to facilitate removal, if you can avoid it. Discard the used dressing in the plastic bag.

3. Cleanse and rinse the area, as ordered. If the wound appears abnormal or infected, notify your supervisor.


5. Wash your hands.

6. Set up your sterile field and prepare sterile dressing supplies. Pour liquid solution into the sterile basin, if necessary. Arrange the field so that you do not have to cross over it when reaching for supplies.

7. Place sterile gauze sponges in the basin and pour sterile normal saline over them. The gauze may be packaged in a plastic tray. The inside of the tray is sterile, and saline may be poured into this container, if desired.



10. Cleanse the incision itself, as ordered. Use a sterile applicator or gauze sponge. Wipe from cleanest to less clean, in a single downward stroke. Discard the applicator or gauze sponge. If another is needed, use a second applicator. Avoid contaminating the solution with a used applicator.

11. Pick up the moist gauze sponges, one at a time. Squeeze them so they are damp and not dripping. Open and unfold the dressings. Avoid touching other surfaces or the patient’s skin when opening the gauze sponges. Place the dressings over the wound. Cover the wound completely.

12. Pick up the sterile cover dressings, holding them only by the corners. Cover the damp dressings and wound completely.

13. Tape the dressing securely in place.



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__________________________________ _______________



Procedure 24

Applying A Transparent Film Dressing






Supplies needed:

• 2 pairs disposable exam gloves• Normal saline or cleansing solution• Sterile gauze sponges• Transparent dressing• Plastic bag for used supplies




2. If placing the dressing for the first time, shaving the hair may be necessary. Check with your supervisor. Remove oil from skin surrounding the wound, if present, with alcohol. Avoid contacting an open wound with alcohol. Allow to dry.

3. Apply disposable exam gloves.

__________________________________ _______________


__________________________________ _______________


4. Holding gentle traction on the skin, press down on the skin, then loosen the adhesive in one corner, and remove the dressing by peeling it back. Stretch the dressing horizontally, gently lifting it over the open area. The stretching helps to break the adhesive bond. Always remove the dressing by pulling in the direction of hair growth. If the skin is not hairy, the corners on opposite sides of the dressing can be lifted. Stretch the dressing from the edges toward the center and lift off. Discard in plastic bag.

5. Cleanse the wound with normal saline or skin cleansing solution, as ordered. Rinse.

6. Pat the skin dry with sterile gauze sponges.

7. Remove gloves and discard in plastic bag.

8. Wash your hands.

9. Open the package by peeling the tabs back, and remove the dressing.

10. Grasp the tabs on the underside of the dressing, and peel them back approximately one inch.

11. Center the dressing over the wound, then gently lower it, smoothing the center portion in place.

12. Peel away the backing paper slowly from one side at a time, while gently smoothing the film in place. Gently smooth out wrinkles as you go.

13. Perform your procedure completion actions



Procedure 25

Applying A Hydrocolloid Dressing






Supplies needed:

• 2 pairs disposable exam gloves• Normal saline or cleansing solution• Sterile gauze sponges• Hydrocolloid dressing• Adhesive or other bandage tape• Plastic bag for used supplies




2. If placing the dressing for the first time, shaving the hair may be necessary. Check with your supervisor. Remove oil from skin surrounding the wound, if present, with alcohol. Avoid contacting an open wound with alcohol. Allow to dry.

3. Apply disposable exam gloves.

__________________________________ _______________


__________________________________ _______________


4. Holding gentle traction on the skin, press down on the skin, loosening the adhesive in one corner. Continue pressing and lifting around the edges of the dressing until all are loose. Carefully peel back the remainder of the dressing, in the direction of hair growth. Discard in plastic bag.

5. Cleanse the wound with normal saline or skin cleansing solution, as ordered. Rinse.

6. Pat the skin dry with sterile gauze sponges.

7. Remove gloves and discard in plastic bag.

8. Wash your hands.

9. Open the package by peeling the tabs back, and remove the dressing.

10. Separate the backing paper on the back side of the dressing. Peel back approximately one inch.

11. Center the dressing over the wound, then gently lower it, smoothing the center portion in place.

12. Peel away the backing paper slowly from one side at a time, while gently smoothing the dressing in place. Gently smooth out wrinkles as you go.

13. Place the palm of your hand over the dressing and hold for 30 to 45 seconds. This warms the dressing, promoting adherence.

14. Tape the edges, if necessary.

15. Perform your procedure completion actions



Procedure 26

Pin Care






Supplies needed:

• Sterile gloves• Sterile normal saline or prescribed cleansing solution• Sterile applicators• Sterile gauze dressings, if ordered• Plastic bag for used supplies




2. Moisten an applicator with normal saline or prescribed cleansing solution.

3. Beginning with the skin closest to the insertion site, wipe the skin in a circle around the pin. Discard the applicator.

4. With a second moistened applicator, wipe the skin around the pin in a second circle, working outward from the pin insertion site. Discard the applicator.

5. Continue wiping outward, using one applicator for each circle, until you have cleansed a 11⁄2-inch area surrounding the insertion site. Use each applicator for one circle only. Avoid contaminating the cleansing solution with used applicators.

__________________________________ _______________


__________________________________ _______________


6. Apply sterile dressings as ordered. A healed pin insertion site may be left open to the air.




Procedure 27

Removing Sutures






Supplies needed:

• Suture removal kit or sterile suture removal scissors and sterile forceps• Sterile normal saline solution or other cleansing agent• Sterile gauze for wound cleansing and removing sutures from forceps• Sterile dressings as necessary for covering the wound after suture removal• Disposable exam gloves• Sterile gloves• Butterfly® bandage, steri-strips®, or other skin adhesive, as needed• Plastic bag for used supplies




2. Open the suture removal kit and set up dressing supplies.

3. Apply exam gloves.

4. Remove the dressing and discard in plastic bag.

5. Remove the gloves and discard in plastic bag.

6. Wash your hands.


__________________________________ _______________


__________________________________ _______________


8. Cleanse the incision line with normal saline or prescribed cleansing solution.

9. Remove every other suture by lifting the suture up, away from the skin, with the tweezers. Cut the suture close to the skin.

10. With the tweezers, lift the suture up by the knot, and pull it through the skin in one piece.

11. Discard used sutures on a gauze pad. Then discard all the sutures and the pad in plastic bag after all sutures are removed.

12. Remove every other suture. Evaluate the skin to determine if the edges are separating. If so, notify the nurse before proceeding. If the skin separates at any time during the procedure, notify the nurse.

13. Cleanse the skin with the skin cleanser, allowing it to dry.

14. Apply a butterfly® or steri-strip® to the skin where each suture was removed.

15. Remove remaining sutures.

16. Apply a butterfly® or steri-strip® to the skin where each suture was removed.

17. Dress the wound as ordered.




Procedure 28

Removing Staples






Supplies needed:

• Staple removal kit or sterile staple extractor• Sterile normal saline solution or other cleansing agent• Sterile gauze for wound cleansing and removing sutures from forceps• Sterile dressings as necessary for covering the wound after suture removal• Disposable exam gloves• Sterile gloves• Butterfly® bandage, steri-strips® or other skin adhesive, as needed• Plastic bag for used supplies




2. Open the staple removal kit and set up dressing supplies.

3. Apply exam gloves.

4. Remove the dressing and discard in plastic bag.

5. Remove the gloves and discard in plastic bag.

6. Wash your hands.


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__________________________________ _______________


8. Cleanse the incision line with normal saline or prescribed cleansing solution.

9. Slide the staple remover under the staple. Squeeze the handles. Gently lift the staple out.

10. Discard used staples on a gauze pad, then discard all the staples and the pad in plastic bag after all staples are removed.

11. Remove every other staple. Evaluate the skin to determine if the edges are separating. If so, notify the nurse before proceeding. If the skin separates at any time during the procedure, notify the nurse.

12. Cleanse the skin with the skin cleanser, allowing it to dry.

13. Apply a butterfly® or steri-strip® to the skin where each staple was removed.

14. Remove remaining staples.

15. Apply a butterfly® or steri-strip® to the skin where the remaining staples were removed.

16. Dress the wound as ordered.



procedure 19 changing a clean dressing procedure 20 ... · pdf filechapter 5 wound care...

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