Name: ___________________________________________________________________ Date: ______________

Evaluator/Signature: ________________________________________________________ Grade: _____________

CHANGING A DRY STERILE DRESSING

Definition:

Purposes:

1.

2.

Considerations:

1.

2.

3.
Equipment:

1. A sterile dressing set that includes

- A drape or towel
- Cotton balls or gauze squares to clean the wound
- A container for the cleaning solution
- An antimicrobial solution
- Two pairs of forceps (thumb or artery)
- Gauze dressings and surgical pads
- Applicators or tongue blades to apply ointments.

2. If a set is not available, gather these items from a central supply cart.
- Additional supplies required for the particular dressing
- Disposable gloves.
- Sterile gloves
- A mask
- A moisture-proof bag for disposal of the old dressings and the used cleaning gauzes.
- Tape or tie tapes to secure the dressing.
- A bath blanket, if necessary , to cover the client and prevent undue exposure.
- Acetone or another solution to loosen adhesive, if necessary.
 PERFORMED
ACTION RATIONALE REMARKS
YES NO
1. Check MD orders for type of dressing and
frequency. Determine last change. Obtain
supplies
2. Assess patient’s comfort/anxiety level.
Administer pain medicine as ordered 30
minutes prior to change if needed.
3. Explain procedure to patient and provide
privacy.
Preparing the client
4. Acquire assistance for changing a dressing
on a restless or confused adult.
5. Assist the client to a comfortable position, in
which the wound can be readily exposed.
Expose only the wound area, using a bath
blanket to cover the client, if necessary.
6. Make a cuff on the moisture-proof bag for
disposal of the soiled dressing, and place the
bag within reach. It can be taped to the
bedclothes or bedside table.
7. Don a face mask.

Removing the Soiled Dressing

8. Removable binders, if used, and place them
aside. Untie tie tapes, if used.
9. If adhesive tape was used, remove it by
holding down the skin and pulling the tape
gently but firmly toward the wound. Use a
solvent to loosen the tape, if required.
10. Don gloves and remove the outer abdominal
dressing or surgipad by hand if the dressing
 is dry, or using disposable glove if the
dressing is moist. Lift the dressing so that the
underside is away from the client’s face.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
11. Place the soiled dressing in the waterproof
bag without touching the outside of the bag.

12. Remove gloves, dispose of them in the

waterproof bag, and wash your hands.

13. Open the sterile dressing set by using the

technique described for opening sterile
packages.

14. Place the sterile drape beside the wound and

don sterile gloves (optional).

15. Remove the under dressings with tissue

forceps or sterile gloves , taking care not to
dislodge any drains If the gauze sticks to the
drain , use two pairs of forceps, one to
remove the gauze and one to hold the drain ,
or secure the drain with one hand.

16. Assess the location, type (color,

consistency), and odor of wound drainage,
and the number of gauzes saturated or the
diameter of drainage collected on the
dressings.

17. Discard the soiled dressings in the bag. To

avoid contaminating the forceps tips on the
edge of the paper bag, hold the dressings 10-
 15 cm (4-6 in) above the bag, and drop the
dressings into it. After the dressings are
removed, discard the forceps or set them
aside from the sterile field.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
18. Clean the wound, using the second pair of
artery or forceps and gauze swabs moistened
with antiseptic solution. Keep the forceps
tips lower than the handles at all the times.
Use a separate swab for each stroke, cleaning
from the top of the incision downward.
Discard each swab after use.
a. Clean with strokes from the top to the
bottom, starting at the center and
continuing to the outside. Or clean with
strokes outward from the incision on one
side and then outward on the other side.
b. If drain is present, clean it after the
incision.
c. For irregular wounds, such as decubitus
ulcer, clean from the center of the wound
outward using circular strokes.
19. Repeat the cleaning process until all drainage
is removed.

20. Dry the wound with dry gauze swabs, using

the strokes described in step 15.

21. Assess the overall appearance of the

wound.

22. Apply powder or ointment if required. Shake

powder directly onto the wound or; use
sterile applicators or tongue blades to apply
 ointment.

23. Apply sterile dressings one at a time over the

wound, using sterile forceps.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
24. Remove gloves if worn and discard.

25. Secure the dressings with tape, tie tapes, or a

binder.

26. Document the dressing change and all

nursing assessments.

Learner’s Reflection: (What did you learn most of the activity? What is its Instructor’s Comments:
impact to you?)