NAME: _____________________________________ DATE PERFORMED:

YEAR & SECTION: ______________

WOUND DRESSING

Performed Performed
Unable to
Independently with
PROCEDURE Perform Remarks
Assistance
4-5 0-1
2-3

PREPARATION

1. Assess:

Client allergies to wound- cleaning agents

The appearance and size of the wound

The amount and character of exudate

Client’s complaints of discomfort

The time of the last pain medication

Signs of systemic infection

2.  Determine any specific order about the

wound or dressing

3. Assemble equipment:

 Bath Blanket (if necessary)

 Moisture-proof bag

 Mask

 Acetone or other solution to loosen adhesive

 Clean gloves

 Sterile gloves

 Sterile dressing set or pack. If none is

available, gather the following items:

 Drape or towel

 Gauze squares
  Container for the cleaning solution

 Sterile forceps

 Gauze dressing and surgical pad

 Applicator or tongue blades to apply

ointment or cream

 Additional supplies as ordered

 Tape, tie tapes, plaster or binder

4. Prepare the client:

 Ask for assistance in changing dressing on a

restless or confused client.

 Assist the client to a comfortable position in

which the wound can be readily exposed.
Expose only the wound area.

 Make a cuff on the moisture-proof bag for

disposal of the soiled dressing, placing the
bag within reach.

1. Introduce yourself, and verify the client’s identity.

Explain to the client what you are going to do, why it is
necessary and how the client can cooperate.

2. Perform hand hygiene and observe other appropriate

infection control procedures.

3. Provide client privacy

4. Remove blinders and tape, if used, and put them aside;

untie tapes.

5. If adhesive tape was used, remove it by holding down

the skin and pulling the tape gently but firmly towards the
wound. Use acetone to loosen the tape, ir necessary.

6. Remove and dispose of soiled dressing appropriately.

7. Put on clean disposable gloves and remove the outer

abdominal dressing and surgical pad. Lift the outer
dressing such that the underside is away from the client’s
face.

8. Place the soiled dressing in the moisture-proof bag

without it touching the outside of the bag.

9. When removing the outer dressing, be careful not to

dislodge any drains. If the gauze sticks to the drain,
support the drain with one hand, and remove the gauze
with the other hand.

10. Assess the location, type, odor of the wound drainage

and the number of gauze saturated with drainage.

11. Dispose soiled dressing in the bag as before. Remove

gloves and dispose them in the moisture-proof bag. Wash
hands.

12. Open the sterile pack using aseptic technique and set
up the sterile supplies.

13. Open the sterile cleaning solution and pour it on the

gauze sponges in the plastic container. Put on sterile
gloves.

14. Clean the wound with the moistened gauze.

15. When using forceps, keep the tips lower than the
handles at all times.

16. Use a separate swab for each stroke. Dispose swab in

the moisture –proof bag.

17. If a drain is present, clean it taking care to avoid

reaching across the incision. Clean the skin around the
drain by swabbing in half or full circle from around the
drain site outward using separate swab for each stroke.

18. Support and hold the drain erect while cleaning

around it. Clean as many time as necessary.

19. Dry the surrounding skin with gauze swab. Do not dry
the incision or wound itself because moisture facilitates
healing.

20. Apply sterile dressing one at a time to the drain site

and incision. Place the bulk of the dressing over the drain
area.

21. Remove gloves and dispose them. Secure the dressing

with tape or ties.

22. Document the procedure and assessment findings.

______________________________________________

Clinical Instructor