Sterile Dressing (Wet to Moist/Dry) Criteria

1. Check written order, patients name, allergies, and gather necessary

equipment.
2. Perform hand hygiene. Identify patient by two methods and verify
allergies. Provide privacy. Explain procedure.
3. Assess need for pain medication and state appropriate course of action
if patient complains of pain.
4. Raise bed side table to waist height and position over bed. Adjust bed
height.
5. Have trash receptacle and biohazard bag within reach.
6. Don non-sterile gloves. Remove old dressing. Assess old dressing for
type and amount of drainage and odor.
7. Assess the wound characteristics:
a. Location: Midline abdominal, sacral, right ischial
b. Size: Closed Incision Line: length. Open Wound: LxWxD
c. Color: Wound bed
d. Surrounding area: Erythema and/or Edema
e. Drainage: any further drainage in wound
f. Odor: No odor, foul, pungent, offensive
g. Wound edges: Approximated or not approximated
8. Perform hand hygiene.
9. Open sterile kit/set-up sterile field. Maintain sterile technique.
10. Check for correct solution ordered by physician. Check for clarity,
expiration date, date and time when opened. Lip when needed. Pour.
11. Don sterile gloves.
12. Follow physicians order to clean the wound. Clean from least
contaminated to most contaminated.
13. Lightly pack wound with saline soaked gauze, covering the wound bed
surfaces. Use sterile cotton-tip applicator or forceps to assist with
packing.
Revised/Reviewed: 6/2015 - JM
14. Cover wound with sterile 4x4s and dry ABD pad.
15. Remove gloves if contaminated. Don non-sterile gloves.
16. Secure dressing. (Tape in a picture frame or use Montgomery straps.)
Label dressing with date, time and initials.
17. Assist patient to a safe and comfortable position. Assess for pain.
Assure bed is in lowest position, side rails up and call bell within reach.
18. Perform hand hygiene.
19. Document procedure including:
a. Pain assessment before and after procedure (#3 and #17).
b. Assessment of old dressings (#6).
c. Assessment of wound (#7).
d. Action performed on the wound (#12, #13, #14, and #16).
e. Patient response and any difficulties encountered.

Revised/Reviewed: 6/2015 - JM