Name : Noviani Dwi Wahyuningsih

NIM : P07120216048
Courses : English Lesson II

NUSING Lecturer : Ns. Nurun Laasara, S.Kep

PROCEDURE

OBSERVATION SHEET OF WOUND DRESSING

Competence : Implementing nursing care for patients with impaired skin

integrity

No Element Competency Assessment Criteria

Conduct patient Impaired skin integrity data : patients with wound

1
needs assessment problems.

Prepare the tool to 1. Tools are prepared:

be used
- Tray
- Receiver
- Gloves
- Gauze pieces
- Bowl
2 - Rubber mat
- Dissecting forceps
- Lister Bandage scissors
- Bandages
- Sterile water/ saline
- Sofratulle

2. The tools are placed in a clean place

Make 3. Therapeutic greetings

preparations
4. The procedures and objectives of the action are
delivered in clear language

3 5. The environment is prepared to maintain patient

privacy

6. The position of the patient's implant is set

 Name : Noviani Dwi Wahyuningsih
NIM : P07120216048
Courses : English Lesson II
Lecturer : Ns. Nurun Laasara, S.Kep

Take action 7. Wash hands with water and soap

8. Put the rubber mat under the wound section.

9. Remove bandages and other dressing with finger or
with forceps.
10. Pour the Natrium Chlorida into bowl.
11. Use gloves and put the gauze pieces into Natrium
Chlorida solution
4
12. Clean the wound using sterile water or saline and use a
rotating motion from the closest to the furthest from the
wound.
13. After cleaning, dry the wound using gauze.
14. Put Sofratulle above the wound.
15. Wound cover using gausi then cover with plaster.
16. Apply sterile dressing and fasten it with a bandage.

Conduct 17. Ask patient response

5 evaluation and
18. Therapeutic greetings
follow-up

Take notes in 19. Actions, results and patient responses when and after
6 nursing the action are recorded clearly and concisely
documentation
20. Time, initial, and name included in the patient's record