EMILIO AGUINALDO COLLEGE

Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph
ISO 9001:2015 CERTIFIED

SCHOOL OF NURSING QUALITY MANAGEMENT SYSTEM

WOUND DRESSING CHECKLIST

NAME: ______________________________________________ SCORE: _____________________

YR/SEC/GRP: _________________________________________ DATE: ______________________

PERFORMED
PLANNING MASTERED COMMENTS
YES NO
Check the doctor’s order for any special
orders or medications to be used. Pain
medications should be administered 30
minutes before wound dressing procedure.
EQUIPMENT
Dressing pack (contains 2x2 gauzes, plastic
pick up forceps, receptacle for used
dressings)
Normal saline solution
Antiseptic solution
Clean gloves
Sterile gloves
4x4 gauze bandage
plasters
When surgical wound dressing is done,
always replace clean gloves to a sterile glove
after removal of the old dressing and after
handwashing.
PERFORMANCE
1. Introduce self and verify the client’s
identity using agency protocol. Explain
to the client what you are going to do,
why it is necessary and how the client
can participate. Discuss how the
results will be used in planning further
care or treatments.
2. Provide for client Privacy
3. Check the room for additional
precautions (like the use of PPE if
indicated).
4. Prepare environment, position patient,
adjust height of bed, turn on lights.
Procedure
5. Perform hand hygiene and observe other
appropriate infection prevention
procedures
6. Prepare a sterile field, add necessary
sterile supplies, pour cleansing solution
into sterile tray
7. Expose dressed wound
8. Wear a clean glove to remove the old
outer dressing
 Removal of soiled dressing should be
positioned away from client’s vision.
 Inspect and palpate the area for
swelling.
 Inspect for the presence of and status
of wounds (open wounds will require a
dressing before a bandage is applied).
 Note the presence of drainage
(amount, color, odor, viscosity).
 Inspect and palpate for adequacy of
circulation (skin temperature, color,

• VIRTUE • EXCELLENCE • SERVICE

 and sensation). Rationale: Pale or
cyanotic skin, cool temperature,
tingling, and numbness can indicate
impaired circulation.
 Ask the client about any pain
experienced (location, intensity, onset,
quality).
9. Remove gloves and discard it in the
receptacle or according to hospital policy.
10. Perform hand hygiene
11. Wear a sterile glove (if wound is
considered sterile or surgical in nature) or
clean gloves for contaminated or non-
surgical wounds.
12. Using a forceps, soak 2x2 gauze in an
antiseptic solution mixed with saline
solution, clean the wound from the least
contaminated (starting at the center to the
sides and rear end of wound) to the most
contaminated using 1 gauze per stroke,
from top to bottom.
13. If drain is present, clean drain site using a
circular stroke, starting with the area
immediately next to the drain. Continue
this process with subsequent new swabs
until the skin surrounding the drain is
cleaned.
14. Apply inner dressing 4x4 gauze to cover
drain and wound.
15. Apply outer dressing and secure with a
tape.
16. Remove gloves and discard in the
receptacle.
17. Dispose off receptable according to
hospital policy.
18. Assist client to a comfortable position,
19. Perform hand hygiene
20. Document procedure done and client’s
response in the nurses’ notes, or
according to hospital policy.
TOTAL SCORE

EVALUATED BY: CONFORME:

_____________________________ ____________________________________
Signature over Printed Name of the Faculty Signature over Printed Name of the Student