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NNA E5 AF 5.

NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIA ELEMENT 5: CONTINUUM OF CARE

5.3 ASEPTIC WOUND DRESSING


1. INTRODUCTION Wound dressing is one of the major nursing responsibilities. Aseptic technique is mandatory to minimize complications. Effective wound dressing promotes wound healing and lead to early discharge and thus save cost.

2.

OBJECTIVES : 1. To ensure nurses perform wound dressing using aseptic technique

2. 3.

To assess the caring component during dressing To document wound findings after the procedure in the appropriate patients records. 3. STANDARD : 1. Nurses perform wound dressing using aseptic technique 2. Nurses exhibit the caring component during dressing 3. Nurses document wound findings in the appropriate patients records.

National Nursing Audit, Ministry of Health Malaysia: Revised June 2008 Nursing Division, Ministry of Health Malaysia

NNA E5 AF 5.3

4.

CRITERIA

Structure
1. Screen / Procedure Room. 2. Dressing trolley. 3. Hand-washing facilities/ hand rub. 4. Relevant protective personal equipment (PPE). 5. Kidney Dish lined with yellow plastic bag at bottom of dressing trolley. 6.Clinical waste bin in procedure room. 7. Domestic waste bin. 8. Protective cover. 9. Sterile dressing set. 10. Sterile soft dressings. 11. Cleansing agent. 12. Adhesive tapes. 13. Nursing Operating Procedure (N.O.P.) / Manual of wound dressing. 14. Copy of Standard Precautions by Ministry of Health is available. 15. The nurse is competent in performing aseptic wound dressing.

Process
1. Greet patient and introduce self. 2. Identify right patient. 3. Verify right dressing. 4. 5. 6. 7. 8. 9.

Outcome
1. Correct dressing perform on right patient.

2. Dressing performed adhering to principles Perform pain assessment . of aseptic technique. Administer analgesic (if 3. Patient is informed indicated). of the progress of Place sterile dressing set his/her wound. on clean dry trolley. 4. Respect and Inform patient and comfort explain procedure. of patient is Provide privacy to the maintained. patient. 5. Wound findings and Place patient in its progress are documented.

comfortable position. 10. Perform hand hygiene. 11. Wear mask. 12. Perform hand hygiene. 13. Open outer layer of dressing set. 14. Discard soiled dressing. 14. Perform hand hygiene. 15. Open inner layer of dressing set. 16. Pour cleansing agent.

National Nursing Audit, Ministry of Health Malaysia: Revised June 2008 Nursing Division, Ministry of Health Malaysia

NNA E5 AF 5.3 Add soft dressings /

Structure

Process
supplementary. 17. Perform hand hygiene. 18. Wear sterile gloves (optional). 19. Perform dressing 20. Make patient comfortable after procedure. 21. Discard used dressing set 22. Perform hand hygiene. 23. Document findings.

Outcome

5. 5.1.

AUDIT GUIDE FOR ASEPTIC WOUND DRESSING INCLUSION CRITERIA All adult patients in surgical, Orthopedic , Medical, Post Natal Obstetrics and Gynecology Wards. 5.2. EXCLUSION CRITERIA Patients with burn dressings. 5.3. INSTRUMENT Check list (E5-AF 5.3) one check list for one observation. 5.4. Methodology 5.4.1. Direct observation of wound dressing being performed. 5.4.2. Sample Frame: All in-patients 5.4.3. Setting : All adult Surgical / Orthopedic / Medical / Post Natal Obstetric /Gynecology Wards 5.4.4. Population : Staff Nurses Sample Design
National Nursing Audit, Ministry of Health Malaysia: Revised June 2008 Nursing Division, Ministry of Health Malaysia
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5.5.

NNA E5 AF 5.3 5.6. Simple random sampling of nurses

Sample Size 50% of staff nurses of each discipline

6. -

DEFINITION OF OPERATIONAL TERMS : Hand hygiene - include both hands washing with either plain or antisepticcontaining soap and water, or use of alcohol-base hand rub. [WHO, 2007] Sterile soft dressings refer to sterile swab / gauze / gamgee Cleansing agent - refers to any lotion used to clean the wound Sterile field refers to the area within the sterile packaging, i.e. 1 inch around the working area be kept free of instruments. ensure body / any part of uniform of nurse does not touch sterile field. assessment of pain should be done prior to procedure and should include administration of analgesic if indicated. - aseptic technique includes: - discard soiled forceps after use. - keep forceps facing downwards and above waist line. - no contact of forceps when transferring soft dressing from one hand to another. - correct technique of pouring of cleansing agent (no touching and spillage) and topping up of supplementary. - body / any part of uniform of nurse must not touch sterile field. - does not cross sterile field at all times. - clean the skin area around wound thoroughly. - cover wound appropriately. - pain assessment use pain score format from KKM to assess pain. Discard soiled dressing involves loosening dressing, removing soiled dressing, discard soiled dressing forceps and observing condition of wound.

National Nursing Audit, Ministry of Health Malaysia: Revised June 2008 Nursing Division, Ministry of Health Malaysia

NNA E5 AF 5.3 * Failure to comply with any of the above will be considered non-conformance to aseptic technique. documentation of wound finding includes wound size and depth, nature of wound-swelling, dirty, clean, slough, gangrene, healing process and nature of discharge - smell, color, serous, bloody, pus 7. Compliance of Aseptic Wound Dressing Audit. Every step in the process must be performed. a) Technical - Perform hand hygiene. - Wear mask. - Perform hand hygiene. - Open outer layer of dressing set. - Perform hand hygiene. - Open inner layer of dressing set. - Pour cleansing agent. - Add soft dressings / supplementary. - Assess patients pain threshold (observe / ask). - Perform hand hygiene. - Wear sterile gloves (optional). - Remove soiled dressing with forceps. - Discard used forceps into receiver. - Perform dressing. - Cover the wound with appropriate dressing. - Discard used dressing set. - Perform hand hygiene. b) Essence of care (soft skills) - Greet patient and introduce self. - Perform pain assessment. - Administer analgesic (if indicated).
National Nursing Audit, Ministry of Health Malaysia: Revised June 2008 Nursing Division, Ministry of Health Malaysia
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NNA E5 AF 5.3 - Inform patient and explain procedure. - Provide privacy to the patient. - Place patient in a comfortable position before procedure. - Make patient comfortable after procedure involves placing patient in a comfortable position and reassess pain. c) Documentation Documentation of wound finding includes: wound size and depth, healing process nature of wound-swelling, dirty, clean, slough, gangrene, nature of discharge - smell, color, serous, bloody, pus

National Nursing Audit, Ministry of Health Malaysia: Revised June 2008 Nursing Division, Ministry of Health Malaysia

NNA E5 AF 5.3 8. Audit Form

NATIONAL NURSING AUDIT, MINISTRY OF HEALTH MALAYSIA.


ELEMENT 5 : CONTINUUM OF CARE TOPIC : 5.3 ASEPTIC WOUND DRESSING DOCUMENT NO : E5 AF 5.3

VERSION 1/08

DATE: 1.11.08

PAGE NO 1/3

STANDARD : 1. Nurses perform wound dressing using aseptic technique 2. Nurses exhibit the caring component during dressing 3. Nurses document wound findings in the appropriate patients records. OBJECTIVES : 1. 2. 3. To ensure nurses perform wound dressing using aseptic technique To assess the caring component during dressing To document wound findings after the procedure in the appropriate patients records. Date of Audit: Locality : . Auditors: 1............................................... 2...............................................

NB. Instruction for Auditors


1. To tick [] at the appropriate column.

National Nursing Audit, Ministry of Health Malaysia: Revised June 2008 Nursing Division, Ministry of Health Malaysia

NNA E5 AF 5.3
S/N O

ITEM Greet patient and introduce self. Identify right patient.

SOURCE OF INFORMATION Listen / Observe nurse. Listen / Observe nurse.

YES

NO

N/A

1. 2.

National Nursing Audit, Ministry of Health Malaysia: Revised June 2008 Nursing Division, Ministry of Health Malaysia

NNA E5 AF 5.3 3. 4. 5. 6. 7. 8. 9. 10. 11 12. 13. 14. 15. 16. 17. 18. 19.
S/N O

Verify right dressing. Perform pain assessment. Administer analgesic (if indicated). Place sterile dressing set on clean dry trolley. Inform patient and explain procedure. Provide privacy to the patient. Place patient in comfortable position. Place protective cover. Perform hand hygiene. Wear mask. Perform hand hygiene. Open outer layer of dressing set. Discard soiled dressing (*using forcep) Perform hand hygiene. Open inner layer of dressing set. Pour cleansing agent and add soft dressings / supplementary. Perform hand hygiene. ITEM Wear sterile gloves (optional). Perform dressing : 21.1 Swab from clean area to dirty area.

Observe nurse. Observe nurse Observe nurse Observe nurse Observe nurse. Observe nurse. Observe nurse. Observe nurse Observe nurse. Observe nurse. Observe nurse. Observe nurse. Observe nurse. Observe nurse Observe nurse Observe nurse Observe nurse. SOURCE OF INFORMATION Observe nurse.
YES NO N/A

20. 21.

Observe nurse.

National Nursing Audit, Ministry of Health Malaysia: Revised June 2008 Nursing Division, Ministry of Health Malaysia

NNA E5 AF 5.3 21.2 21.3 21.4 21.5 21.6 21.7 21.8 22. 23. 24. 25. Keep forceps facing downwards and above waist line. Maintain sterile field. Avoid contamination of equipments. Use one swab for each stroke. Clean skin area around wound. Apply appropriate dressing for wound. Secure wound dressing. Observe nurse. Observe nurse. Observe nurse. Observe nurse. Observe nurse. Observe nurse. Observe nurse. Observe nurse. Observe nurse. Observe nurse. Observe nurse. 25.1 25.2 wound size and depth. nature of wound-swelling, dirty, clean, slough, gangrene, healing process. nature of discharge - smell, colour, serous, bloody, pus.

Make patient comfortable. Clear dressing set. Perform hand hygiene. Document findings:

25.3

AUDIT REPORT
(please [] the appropriate box)

National Nursing Audit, Ministry of Health Malaysia: Revised June 2008 Nursing Division, Ministry of Health Malaysia

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NNA E5 AF 5.3

Conformance

Non- Conformance

REMARKS

Auditor 1 (name and signature):. .. Auditor 2 (name and signature):. .

National Nursing Audit, Ministry of Health Malaysia: Revised June 2008 Nursing Division, Ministry of Health Malaysia

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