clinical patient care
Wound Care and Dressing Change
A simple dressing change replaces the covering on a wound and gives you a chance to look at it.
16 steps5 criticalLimit 8 minAlways tested
Steps
- 1Critical stepCheck the order and gather only the supplies you need: gloves, cleansing solution or sterile saline, sterile gauze, dressing, and tape
- 2Perform hand hygiene, confirm the patient's identity with two identifiers, and explain the procedure
- 3Position the patient with good lighting and the wound exposed, protecting privacy and dignity
- 4Perform hand hygiene, set a clean dry barrier on the table, and set out supplies; moisten sterile gauze with sterile normal saline if you are using gauze to cleanse
- 5Critical stepPut on nonsterile gloves and remove the outer dressing, then the inner dressing; wrap the old inner dressing inside the glove if feasible
- 6Critical stepRemove your gloves, perform hand hygiene, and put on new gloves
- 7Critical stepAssess the wound: location, wound base, size, drainage amount and color, odor, and the skin around it, and compare with the last assessment
- 8Cleanse the wound as ordered or per policy; if using moistened sterile gauze, use one gauze per stroke, working in straight lines away from the wound, from clean to dirty and top to bottom, and put on any other PPE the policy calls for
- 9If irrigation is used instead of gauze (per order or policy), hold the syringe about 1 inch above the wound and flush gently with continuous pressure until the returned fluid is clear, draining into a basin
- 10If you irrigated, dry the wound edges with sterile gauze
- 11Critical stepRemove your gloves, perform hand hygiene, and put on new gloves
- 12Apply the new sterile dressing using a nontouch technique so that the part touching the wound stays sterile
- 13Apply an outer dressing if required and secure the dressing with tape as needed
- 14Remove your gloves, dispose of used supplies per policy, and perform hand hygiene
- 15Help the patient into a comfortable position and leave the call light and table within reach and the bed low and locked
- 16Document the procedure and your assessment findings, compare with the previous record, and report concerns per policy
What graders are watching for
Tips
- Clean from the cleanest area to the dirtiest, working away from the wound and from top to bottom; a suture line is cleansed first.
- New purulent drainage (thick and opaque; tan, yellow, green or brown) or other new signs of infection should be reported to the provider.
- Change gloves and perform hand hygiene between removing the old dressing and cleaning, and between cleaning and applying the new dressing.
Common mistakes
- Using the same gloves for dirty and clean parts of the procedure.
- Wiping back and forth across the wound.
- Touching the wound-side of the dressing.
- Not looking at the wound before covering it.
Practice this skill
Practise the sequence with critical-step highlighting and a rationale for each step.
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Sources and how we check them: How we verify.