NURS2101 NURSING 3 BASIC WOUND DRESSING 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Introduces her/himself to the patient.

Explains that they have been assigned to care for them today and asked them for permission to do the dressing on the pt’s wound Asks pt how the wound has been feeling Ask if the pt normally requires any pain relief before the dressing is done – administers it as necessary Waits an appropriate time for analgesia to be effective before commencing dressing Asks the patient if they need to go to the toilet Reads the pt bed notes and Nursing Care Plan (NCP) to find dressing requirements Responds to client’s anxiety by communicating patiently, simply and clearly Explains process to the client Places the patient in comfortable position with easy access to wound Adjusts the bed height for comfortable access to wound, checks brakes are on Cleans dressing trolley and collects equipment as per NCP(May consult the procedure manual) 1. Places dressing pack on top of trolley 2. Places extra equipment on bottom of trolley i.e. solution, waste bag, dressings, tapes or hyperfix and disposable gloves Takes trolley to bedside positioning it next to patient Position waste bag so aseptic field is not compromised Uncovers pt and loosens the tapes on the dressing – if dressing has strikethrough – disposable gloves must be worn when touching the dressing Washes hands 60 secs. Dons disposable gloves Removes dressing from wound and places it in waste bag (if dressing sticks to wound – leave it as dressing may remove soaking) Removes gloves Maintaining Aseptic principles throughout, opens dressing pack and puts dressing pack on top of dressing trolley Provides rationale for wearing/not wearing clean gloves when doing dressing (i.e. may have cut on hands) Maintaining Aseptic principles throughout, opens dressing pack and assembles equipment • Uses top forcep to set out equipment • Sorts swabs for moistening and drying • Opens dressings and places on aseptic field • Opens solution and pours into appropriate container • Opens other equipment that may be necessary Soaks dressing if required and removes with forcep If any contamination occurs and asepsis is broken, the student self corrects and begins again. Discards forcep Assesses wound Maintaining Aseptic principles, uses 2 remaining forceps to perform dressing Maintaining Aseptic principles throughout cleans area moving from dry area to moist Maintaining Aseptic principles cleans area moving from clean to dirty area Maintaining Aseptic principles dries area Covers with dressings as per NCP and fixes with tape or hyperfix Removes gloves if worn Repositions pt in bed and adjusts bedclothes. Ensures bell is within reach Assess pt’s reaction to dressing verbally Ask pt to inform you if any strikethrough occurs Concludes interaction with pt suitably Cleans and tidy work area. Washes hands Documents findings in progress notes



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12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

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22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39.

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