Perform hand hygiene Verbalize

to Insure Privacy Verbalize

Introduce yourself Hi Mr (name) my name is …….

am a student nurse from Sheridan college, am
going to be your student nurse today. And am
here to change your wound dressing. Is that
okay with you?

Verify your patient Can you please verify your name and date of
birth please

Explain the procedure During the procedure first I will remove the
old dressing, clean your wound, and also I
will apply for a new dressing

Gather your material Verbalize

Position the patient in comfortable position Verbalize

Asses for pain On a scale 0 to 10 zero means no pain 10 is

the worst pain can you rate your pain

Medication before the dressing Verbalize I will give my patient pain

medication 30 min before the procedure.

Use your sterile bag.

Garbage bag

Remove the dressing Remove the dressing toward the patient so he

is not going to see it

Observe for character and amount of drainage I see 20% serosanguinous drainage with red
on the dressing and the appearance and size of color and no odor..
the wound using ( REEDA) No redness
No edema
No ecchymosis
No drainage in the wound
And the edges of the wound is well
approximated

Remove gloves Next, I will fold dressings with drainage

contained inside and
remove my gloves inside out and then dispose
of them. Then perform Hand Hygiene.
Perform hand hygiene
Prepare sterile dressing tray
Check the expiry date of Saline water
Put on sterile gloves
Clean the wound
Remove sutures or staples
Cover the wound as per the doctor's order
Remove gloves
IV ADMINISTRATION
Verify the doctor's order against MAR
Do the first and second checks
Verbalize
1. I will open the sterile dressing tray with
clean hands touching only the one-inch sterile
border.
2. I will add any necessary individually
wrapped sterile supplies, opening the
packages away from yourself onto the sterile
field.
It's not expired, the expiry date is….
Next, I’m gonna leap some saline water into
the garbage bag and then pour some into the
sterile tray to soak the gauze using the same
side of the bottle that I leaped.
I will clean the wound from the least
contaminated to the most contaminated. Next,
I’ll dry the area in the same manner with dry
gauze, then, I’ll apply sterile, and dry dressing
to cover the wound. I’ll apply the dressing and
secure it with tape.
Remove in the order of 2 - 4-6 then 1-3-5
Using gauze or Abdo pad
I’ll remove my gloves and dispose of all the
materials that I used.
I will lower the bed, ensure the patient is
comfortable, and document.
Check the patient name, MRN number
allergy, and diagnosis, and compare all the
medication transcription on MAR against the
doctor's order.
Do your six rights which are (the right patient,
 right medication, right dose, right route, right
time and frequency, and right reason )

Right patient I verify the patient and date of birth, check

allergy and expiry date of IV

Right Medication I’ll confirm the name of the IV e.g Normal

saline, ringers lactate

Right dosage I have e.g 1000ml IV bag on hand, then I have

an order of 100ml per hour. I’m gonna
calculate the drip rate.

Right route The order says IV and this is IV , so I have the

right route

Right Frequency and time The says 0800 and it's 8am in the morning, so
I have the right time

Right reason The patient is/has…., and I am giving …., so

that’s the right reason

Right education Mr…I’m giving you this …because….and

it’s gonna help you….

Right to refuse So, Mr…are you ok to take this medication?

Right documentation I’m gonna document

the Right evaluation And come back after 15 mins to evaluate and
be sure that you’re doing well and that the
needed action of the drug has set in.