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NNA E5 AF 5.

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

5.3 ASEPTIC WOUND DRESSING
1. INTRODUCTION Aseptic technique is employed to maximize and maintain asepsis and is applicable in any clinical setting. According to S. Rowley (UCLH, 2003) states:…”research shows one of the most effective way of containing hospital acquired infection is through the application of a standardized aseptic technique for clinical procedures”. “Asepsis is a method by which we prevent microbial contamination during invasive procedure or care of breaches in the skin’s integrity” (ICNA, 2003). Two types of asepsis can be classified: medical and surgical asepsis ( Ayliffe, 2000). Medical asepsis (clean technique) aims to reduce the number of organisms reducing their spread. This is mainly observed in clinical areas during non invasive procedures. Surgical asepsis is a strict process and includes procedures to eliminate micro organisms from an area and is practiced by nurses and other healthcare workers in operating theatres. It is appropriate for invasive procedures. Wound dressing is a core nursing responsibilities and utilizes aseptic technique. The goal of aseptic technique is to protect the patient from infection.

National Nursing Audit, Ministry of Health Malaysia : Version 4/June 2011, Bahagian Kejururawatan , Kementerian Kesihatan Malaysia Page 1

2 3.1 3.3 2. Ministry of Health Malaysia : Version 4/June 2011. OBJECTIVES : 3. Bahagian Kejururawatan . To assess the caring component during dressing To document findings accurately and completely in patient’s medical record. STANDARD : The nurses observe principles of medical asepsis during wound dressing to minimize introduction of potential infection and or its spread. National Nursing Audit. 3.3 To ensure nurses perform wound dressing using principles of aseptic technique. Kementerian Kesihatan Malaysia Page 2 .NNA E5 AF 5.

Prepare trolley for dressing 4. 15. Standard Operating Procedure (S. Place patient in comfortable position. 9. Provide privacy to the patient 5. 6. Bahagian Kejururawatan .) / Manual of wound dressing. 3. 11. 3. . Open inner layer of dressing and add necessary items using non touch technique 12. Process Outcome adhering to principles of aseptic technique.3 4 CRITERIA Structure 1.P.O. Perform hand hygiene 11. 4. Protective cover. Patient is informed of the progress of his/ her wound. 13. 12. Explain the procedure. Wear mask 8. Sterile soft dressings. 4. 6. Relevant protective personal equipment (PPE). 1. 14. Cleansing agent. 2. 10. Sterile dressing set. Dressing performed 2. 5. Kementerian Kesihatan Malaysia Page 3 . Perform hand hygiene 7. Dressing trolley. Discard soiled dressing 10. 1. 7. Open outer layer of dressing set. 8. Hand-washing facilities/ hand rub. Greet/ Acknowledge patient. Ministry of Health Malaysia : Version 4/June 2011. 2. Adhesive tapes.NNA E5 AF 5. Domestic waste bin. Clinical waste bin. Perform hand hygiene Wear glove Perform dressing Perform hand hygiene Document findings National Nursing Audit. Respect and comfort of patient is maintained. 9. Screen / Procedure Room. Wound findings and its progress are documented. 16. 3.

Ministry of Health Malaysia : Version 4/June 2011. Copy of Standard Precautions by Ministry of Health is available 14. National Nursing Audit. Kementerian Kesihatan Malaysia Page 4 .3 13. The nurse is competent in performing aseptic wound dressing.NNA E5 AF 5. Bahagian Kejururawatan .

DEFINITION OF OPERATIONAL TERMS : 6. 6. 6. 5. INCLUSION CRITERIA All inpatients and outpatients 5.NNA E5 AF 5. [WHO.4 METHODOLOGY Direct observation of Registered Nurses performing wound dressing 5. Bahagian Kejururawatan .2 MAINTAINING STERILE FIELD: This includes the following: Sterile field refers to the area within the sterile packaging.1. Kementerian Kesihatan Malaysia Page 5 . i. or use of alcohol-base hand rub.3 INSTRUMENT Check list (E5-AF 5.1 Ensure body / any part of uniform of nurse does not touch sterile field.3 5.2.3) – one check list for one observation.2 Hands do not cross sterile field at all times.2. 6. 2007] 6. 1 inch around the working area be kept free of instruments.2 EXCLUSION CRITERIA Patients with burn dressings.e. 5.include both hands washing with either plain or antiseptic .5 SAMPLE SIZE .30% of Registered Nurses . AUDIT GUIDE FOR ASEPTIC WOUND DRESSING 5.1 HAND HYGIENE . National Nursing Audit. Ministry of Health Malaysia : Version 4/June 2011.containing soap and water.

3. National Nursing Audit. discard soiled dressing forceps and observing wound condition 6.3 6.3. Bahagian Kejururawatan .3.1 Open the pack : unwrap folded layers of wrapping material away from the center of the pack. Ministry of Health Malaysia : Version 4/June 2011. and then unwrap the left and right side follow by near side 6.3. touching only the outside edges of the wrapping material. Discard soiled dressing involves loosening dressing .3 CORRECT ASEPTIC TECHNIQUE: This includes the following: 6.1.6 6.3.5 6.1 Apply correct technique when opening sterile set ie.NNA E5 AF 5.4 6.8 Soiled forceps should be discarded.3.9 Cover wound appropriately. Swab from clean area to dirty area Use one swab for each stroke Clean the skin area around wound thoroughly.3.3. Kementerian Kesihatan Malaysia Page 6 .7.4. Removing soiled dressing. Always pull edges toward your body keeping the pack at arms’ length away.3 Keep forceps facing downwards and above waist line No contact of forceps when transferring soft dressing from one hand to another.2 6. 6. 6.3. 6. Unwrapped the far side by reaching your arm around the pack.

bloody. National Nursing Audit.6. Bahagian Kejururawatan . serous. slough. 6. ASSEMBLE NECESSARY ITEMS USING NON TOUCH TECHNIQUE : 6. Add soft dressings / supplementary. *FAILURE TO COMPLY WITH ANY OF THE ABOVE WILL BE CONSIDERED NON-CONFORMANCE TO ASEPTIC TECHNIQUE.NNA E5 AF 5.* 6. Every step in the process must be performed.5. Perform hand hygiene. the pouring container should not touch the receiving container. Wear mask. COMPLIANCE OF ASEPTIC WOUND DRESSING AUDIT.2 Nature of the wound includes -swelling. Perform hand hygiene.3 6. Open inner layer of dressing set.smell. Wear sterile gloves (optional).2 When pouring cleansing agent.6.6. ACCURATE AND COMPLETE DOCUMENTATION This includes the following : 6. A) TECHNICAL Perform hand hygiene. pus 7.5.1 Wound size and depth. Ministry of Health Malaysia : Version 4/June 2011.5. Open outer layer of dressing set. Kementerian Kesihatan Malaysia Page 7 . clean.1 The right quantity of soft dressing (cotton/ gauze/ gamgee) is added into sterile field without contamination 6. gangrene. Pour cleansing agent. color. dirty. Avoid plashing and spillage. healing process and nature of discharge .

3 B) Remove soiled dressing with forceps. . . gangrene. . Perform dressing.Administer analgesic (if indicated). Ministry of Health Malaysia : Version 4/June 2011. Perform hand hygiene. .Inform patient and explain procedure.Perform pain assessment .Make patient comfortable after procedure – involves placing patient in a comfortable position and reassess pain. slough. nature of wound-swelling. Discard used forceps into receiver. serous. pussy National Nursing Audit.smell. Kementerian Kesihatan Malaysia Page 8 . color. Cover the wound with appropriate dressing.Provide privacy to the patient. Bahagian Kejururawatan . . bloody.Greet / Acknowldge patient . dirty. wound size and depth. nature of discharge .NNA E5 AF 5. .Place patient in a comfortable position before procedure. clean. Discard used dressing set. C) DOCUMENTATION Documentation of wound findings include: i. iii. ESSENCE OF CARE (SOFT SKILLS) . healing process ii.

.. 2.................... OBJECTIVES : 2.3 8....NNA E5 AF 5.... Ministry of Health Malaysia : Version 4/June 2011..2011 1.2...6..... STANDARD : The nurses adhere to the principles of medical asepsis during wound dressing to minimize introduction of potential infection and or its spread.. 2. ELEMENT 5 : CONTINUUM OF CARE TOPIC : 5.............. To assess the caring component during dressing To document findings accurately and completely in patient’s medical record... 2.................3 VERSION 4/2011 DATE: 21.... Bahagian Kejururawatan . Auditors: 1.. Date of Audit:……………………………………… Locality : …………………………………………….3 To ensure nurses perform wound dressing using principles of aseptic technique... AUDIT FORM NATIONAL NURSING AUDIT... Kementerian Kesihatan Malaysia Page 9 ........ National Nursing Audit.. MINISTRY OF HEALTH MALAYSIA..3 ASEPTIC WOUND DRESSING PAGE NO 1/3 DOCUMENT NO : E5 AF 5.........1 2..

T9. Observe nurse. To tick [√] at appropriate column. Instructions for Auditors 1. 14 ITEM Greet / Acknowledge patient Inform patient and explain procedure Prepare trolley for dressing Provide privacy to the patient. YES NO N/A National Nursing Audit. T6 T7 T8.2 Correct aseptic technique while performing dressing Observe nurse. Ministry of Health Malaysia : Version 4/June 2011. Wear mask. 2. Kementerian Kesihatan Malaysia Page 10 . S/NO S1.NNA E5 AF 5.B. Listen/Observe nurse. Perform hand hygiene. Bahagian Kejururawatan .3 N. Perform hand hygiene Wear glove Perform dressing : T14. Discard soiled dressing. S2. Perform hand hygiene Open inner layer of dressing and add necessary items using non touch technique. Observe nurse. T14.1 Maintain sterile field. S / T/ D indicate soft skill / technical skill / documentation respectively. T10 T11. Observe nurse Observe nurse Observe nurse. T3 S4. Observe nurse Observe nurse Observe nurse. S5. Place patient in confortable position. Observe nurse SOURCE OF INFORMATION Listen/Observe nurse. T12 T13. Observe nurse. Observe nurse. Open outer layer of dressing set.

NNA E5 AF 5. color. pus. Document findings: SOURCE OF INFORMATION Observe nurse.3 S/NO ITEM T14. T15 D16 Perform hand hygiene.3 Apply and secure appropriate wound dressing properly. Bahagian Kejururawatan . National Nursing Audit. …………………………………………. serous.1 16. nature of discharge . Check document 16. gangrene. Ministry of Health Malaysia : Version 4/June 2011. clean.smell. slough.3 AUDIT REPORT (please [√] the appropriate box) RATING : CONFORMANCE NON CONFORMANCE Conformance Technical Documentation Soft skill Non conformance REMARKS: Auditor 1 (name and signature): …………………………………………. nature of wound-swelling. dirty. Observe nurse.2 wound size and depth. healing process. Kementerian Kesihatan Malaysia Page 11 . YES NO N/A 16. bloody.

Kementerian Kesihatan Malaysia Page 12 . Ministry of Health Malaysia : Version 4/June 2011. National Nursing Audit. Bahagian Kejururawatan .NNA E5 AF 5.3 Auditor 2 (name and signature): ………………………………………….