COLLEGE OF NURSING

Visca, Baybay City, Leyte, Philippine

Telephone: (053) 565-0600, local 1012
Email: nursing@vsu.edu.ph
Website: www.vsu.edu.ph

Name of Student: Date:

Section:

WOUND CARE: REMOVING AND APPLYING DRY DRESSING

Scale of Achievement:

Performed the step with no prompting or

4 Exemplary (95 -100%)
3 Proficient (89 - 94%)
2 Developing (82- 88%)
Emerging (75-81% )
1
input from the faculty.
Performed the step with minimal (1 or less)
prompting from the faculty
Performed the step with multiple (2 or
more) prompts from the faculty
Did not perform the step. Faculty guided
the student to demonstrate the step.

Purpose :
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Articles Needed:

Commen
STEPS RATIONALE 4 3 2 1
ts/
Remar
ks
PREPROCEDURAL STEPS

-Provide privacy as needed.

-Introduce yourself to the client.
-Perform hand hygiene and put
on appropriate PPE if indicated.

Assessment:
 Assess client for pain
and provide non
pharmacological and
pharmacological
interventions.

Gather supplies and clear

working area at bedside. Place
a waste receptacle or red bag

Vision: A globally competitive university for science, technology, and environmental conservation.
Mission: Development of a highly competitive human resource, cutting-edge scientific knowledge
and innovative technologies for sustainable communities and environment.
 COLLEGE OF NURSING
Visca, Baybay City, Leyte, Philippine
Telephone: (053) 565-0600, local 1012
Email: nursing@vsu.edu.ph
Website: www.vsu.edu.ph

close to work area.

Adjust the bed to comfortable

working height

Assist the client into a

comfortable position, using a
bath blanket provide cover to
expose areas other than the
wound. Place an absorbent pad
beneath the client.
Apply clean gloves

Remove the old dressing

Loosen the tape or adhesive

edges by removing in the
direction of hair growth.
Lift a corner of the dressing
away from the skin with
dominant hand, while gently
pushing the skin away from the
dressing with nondominant
hand.
Apply small amounts of sterile
water to loosen the dressing if
sticks to wound.
Note the presence, amount,
color, and odor of any drainage.
Place old dressing in
appropriate receptacle
Assess the wound for size,
appearance, and drainage.
Note the presence of any
sutures and drains.
Remove soiled gloves and
perform hand hygiene.
Use sterile technique. Prepare
a sterile work area and open
supplies
Open sterile cleaning solution
and pour directly over gauze
pack or into a sterile basin.

Vision: A globally competitive university for science, technology, and environmental conservation.
Mission: Development of a highly competitive human resource, cutting-edge scientific knowledge
and innovative technologies for sustainable communities and environment.
 COLLEGE OF NURSING
Visca, Baybay City, Leyte, Philippine
Telephone: (053) 565-0600, local 1012
Email: nursing@vsu.edu.ph
Website: www.vsu.edu.ph

Put on sterile gloves.

Clean wound from top to bottom

or from center to the outside.
Select a new gauze or sterile
swab for each wipe. Dispose
used gauze or swab in
appropriate receptacle.
Remove and dispose of gloves.
Perform hand hygiene.
Apply sterile gloves unless it is
a chronic wound or pressure
injury. Once the wound is
cleaned and dry, apply a skin
protectant on healthy skin
around the wound.
Place a layer of sterile gauze
dressing over wound or as
prescribed by the provider.
Extend at least 1 inch past the
wound edges. This dressing
can be applied with forceps if
desired.
Apply a surgical or abdominal
pad over the gauze if needed.
Apply tape to dressing edges
Remove gloves and discard.
Perform hand hygiene
Position client, and cover client
with bed linens. Lower the
height of the bed.
Ensure that the client is in a
safe position prior to leaving the
room and has the call light
within reach.
Perform hand hygiene after
removing all PPE.

Document the procedure with

time, date and remarks if any like
condition of the skin and client’s
response.

Vision: A globally competitive university for science, technology, and environmental conservation.
Mission: Development of a highly competitive human resource, cutting-edge scientific knowledge
and innovative technologies for sustainable communities and environment.
 COLLEGE OF NURSING
Visca, Baybay City, Leyte, Philippine
Telephone: (053) 565-0600, local 1012
Email: nursing@vsu.edu.ph
Website: www.vsu.edu.ph

Knowledge (30%) ___________ Skills (50%) ___________ Attitude (20%) __________

General Comments/ Suggestions:

__________________ ______________________
Clinical Instructor Student’s Signature

Vision: A globally competitive university for science, technology, and environmental conservation.
Mission: Development of a highly competitive human resource, cutting-edge scientific knowledge
and innovative technologies for sustainable communities and environment.