San Sebastian College Recoletos de Cavite

Nursing Department

Performance Checklist
WOUND CARE

Name of Student: Date:

Year & Section: Instructor/Evaluator:

Score:

MAIN OBJECTIVE:
1. To clean and prevent infection of the wound.
2. To provide material for absorption of secretions.
3. To protect are from trauma.
4. To restrict motion that tends to disrupt the edge of the wound.

5 4 3 2 1 Procedure Comments
1. Assess size and location of the wound to be dressed.
Helps nurse to plan for proper type and amount of
supplies needed.
2. Ask client to rate pain using a scale of 0-10 (0 for no
pain while 10 for severe pain). also ask for any known
allergies, especially related to the products to be used
on wound care.
To assess client’s pain tolerance using pain scale,
removal of dry dressing can be painful; client may
require pain medication.
3. Assess client’s knowledge of the purpose of changing
wound dressing.
To assess client’s understanding why dressing of
wound is necessary or needed. To clean and prevent
infection of the wound.
4. Determine the need of the client or family member to
participate in wound dressing.
To gain client or family cooperation on wound care.
5. Review physician’s order for wound care.
To indicate the type of dressing or application use.
6. Gather all necessary equipment and bring to bedside
table.
For easy access of the materials needed and to save
time and effort.
7. Explain the procedure to the client. Provide privacy.
Place the bed at an appropriate and comfortable
working height.
Explaining tactfully what you have to do so that they
will be more cooperative and it will decrease their
anxiety.
8. Perform hand hygiene.
To reduce transfer of microorganisms.

Revised 2022
9. Position client comfortably and according to the site of
the wound. Drape to expose only the wound site. If
necessary, place a waterproof and under area to be
clean (for not to wet the bed linens). Instruct client not
to touch wound or sterile supplies.
Providing privacy and reduces airborne
microorganisms. Sudden unexpected movement on
client’s part could result contamination of wound and
supplies.
10. Place waste receptable or disposable waterproof
waste bag within reach.
For easy access on disposing soiled and infectious
waste.
11. Wear clean gloves. Remove and pull tape parallel to
the skin toward the dressing. If it is on hairy area,
remove it in the direction of hair growth.
Prevents transmission of infectious organisms from
soiled dressings to nurse’s hands. Pulling tape toward
dressing reduces stress on suture line or wound
edges.
12. Still with clean gloves, remove wound dressing one
layer at a time, observing appearance and drainage on
dressing. Use caution to avoid tension on any drains
that are present.
Removal of one layer at a time reduces the chance of
accidental removal of underlying drains.
13. Inspect the expose wound for appearance, size, depth,
drainage, and integrity. Note any problem to include in
documentation and if referral is needed.
Provides estimate of drainage amount and
assessment of wound’s condition.
14. Fold soiled dressing with contained drainage inside
and remove glove inside out. Dispose gloves and soiled
dressing in waste receptacle or disposable waterproof
waste bag. Wash hands.
To reduce risk of transferring harmful
microorganisms.
15. Using sterile technique prepare a sterile work area and
open needed supplies.
Sterile dressings remain sterile while on or within
sterile surface.
16. Put on sterile gloves.
Allows handling of sterile supplies without
contamination.
17. Cleanse wound with antiseptic solution by:
a. Using separate swab for each cleansing stroke.
b. Clean from least contaminated area to most
contaminated.
c. Cleansing around drain (if present), using a circular
stroke starting near the drain and moving outward.
Always remember to clean from the inner to outer or
from cleanness to the dirtiest part.
18. Dry area using gauze sponge in the same manner.
Apply ointment if ordered.
Reduces excess moisture, which could eventually
harbor microorganisms.

Revised 2022
 19. Applying dressing:
a. Apply loose, wove gauze as contact layer to
promote proper absorption of drainage.
b. Cut 4x4 gauze (or precut gauze is also available) flat
to fit around drain, if present.
c. Apply second layer.
d. Apply thicker woven gauze or pad.
To provide material for absorption of secretions if
present.
20. Secure dressing:
a. Apply adhesive tape.
b. If would is on extremity, dressing is secured with
rolled gauze or elastic bandage.
To restrict motion that tends to disrupt the edge of
the wound.
21. Remove sterile gloves inside out and dispose them in
waste receptacle or waterproof bag. Wash hands.
Reduces transmission of infection.
22. Place client in a comfortable position. Pull side rails up
and bed on the lowest level.
Promote client’s sense of well-being.
23. Clean and return all instruments used.
To provide neatness and order to client’s bedside or
room.
24. Record the procedure, wound assessment, and client’s
reaction to the procedure according to institution’s
guidelines.
25. Check wound dressing every shift or as necessary.
More frequent checking and wound dressing maybe
needed if the wound is more complex or dressings
become soaked quickly.

Remarks:

Instructor’s Signature / Date:

Revised 2022