SURGICAL DRESSING

PURPOSE
 To promote wound healing by primary intention
 To prevent infection
 To assess the healing process
 To protect the wound from mechanical trauma

EQUIPMENT/SUPPLIES
 Sterile dressing pack
o Sterile drape
o Sterile gauze
o Container for cleaning solution
o Kidney dish
o Two forceps (3 optional)
 Water-proof pad
 Cleaning solution
 Mask
 Clean gloves
 Sterile gloves
 Tape, ties, or other form of securing dressing
 Tongue depressors or cotton tipped applicators for ointment application
 Dirty receptacle with appropriate color coded bag for contaminated articles

ASSESSMENT RATIONALE

1. Check physician's orders for the dressing
change frequency and type of dressing
2. Assess the size and location of wound, and
for the presence of drains and suture
material under dressing.
3. Assess for the presence of drainage on
dressing, including amount, color,
consistency, odor, location.
4. Assess for allergies to tape or to cleaning
solutions.
5. Assess for intrinsic factors affecting wound
healing, such as nutritional status, shock,
acidosis, hepatic or renal failure.
6. Extrinsic factors that affect wound healing,
such as steroid therapy, chemotherapy, and
irradiation.
7. Assess pain scale and the time of last dose
of analgesic or for PRN analgesic order.
1. To insure proper wound care is carried
out.
2. To determine type of dressing and
extra supplies needed to dress around
drains, i.e. equipment to monitor
drainage.
3. For documentation purposes and to
assess for signs of infection to report,
and any blood lose
4. To prevent allergic reactions
5. To be able to ascertain if wound
healing process may be hampered and
intervention necessary
6. To be able to ascertain if wound
healing process may be hampered and
interventions made necessary
7. May need to administer analgesic prior
to procedure
8. Assess for patient’s level of cooperation. 8. A confused patient may move and
contaminate sterile field/wound

PLANNING RATIONALE

1. Prepare dressing room (sweep, mop floor) 1. To ensure room is clean to prevent wound
contamination and nosocomial infections.
2. Carbolize the surfaces 2. To insure work surfaces are aseptic and to
reduce risk of microorganisms that may lead to
nosocomial infections.
3. Ensure that windows and door are closed. 3. To prevent air movements that may carry
microorganisms.
4. Turn off fans. 4. To prevent blowing microorganisms on open
wounds or sterile equipment
5. Gather equipment 5. To allow for smooth work flow and to prevent
cross contamination from clean vs sterile items.
6. Cut tape 6. To allow for smooth work flow.
7. Place disposal bag within reach away from 7. To prevent cross contamination with
wound care. preparation

IMPLEMENTATION RATIONALE

1. Review documentation for dressing order. 1. To ensure that appropriate dressing is carried
out as per orders.
2. Identify patient, introduce self, and explain 2. To put patient at ease and to ensure right patient
procedure. right procedure.
3. Closing curtains/doors. 3. To provide patient privacy and to put patient at
ease.
4. Assist patient to comfortable position. Assist 4. If dressing will be done in dressing room assist
to treatment room if dressing will not be done patient to room. Do not allow patient with
at the bedside. diabetic ulcers, for example, to walk unassisted.
Assist patient to position of accessibility to
wound.
5. Evaluate pain status, if pre-procedure 5. Plan effect time of any ordered medications and
analgesics are ordered. administer all analgesics prior to initiating
procedure so that they will adequately have
taken effect.
6. Wash hands and don a clean glove 6. Adhere to all standard precautions.
7. Elevate bed to working level, lower bed rails, 7. To allow for proper body mechanics, and safety
and expose area of wound to self and patient.
8. Remove tape slowly by pulling towards the 8. To reduce pain and disrupting new tissue
wound while applying counter pressure on the growth and to avoid stressing the sutures and
skin surface. tissues.
9. Remove all but innermost dressing in direction 9. Remove away from the patient’s face to avoid
that is away from the patient’s face. Support distressing patient. Leave the innermost layer to
drains when removing adhesives.

10. Discard old dressing material in bag.
11. Remove and discard gloves.
12. Wash hands using technique for sterile
procedure and dry hands.
13. Open dressing tray using sterile technique, and
drop supplies on to sterile field.
14. Pour antiseptic into receptacle on the field
while holding the container 3 inches above
sterile field
15. Don sterile gloves.
16. Prepare swabs.
17. Identify clean and dirty hands and
corresponding forceps.
18. Drape sterile sheets or towels over area being
treated
19. Discard remaining soiled dressing with a sterile
forceps and discard forceps from sterile field
into receiving dish without contaminating
clean hand.
20. Select a method of cleaning - never return to an
area you have previously cleaned. Work from
the wound outward for an area of three inches,
holding forceps pointed downwards.
21. Clean the drain holding it erect. Use a new
swab for each stroke.
22. Pat dry surrounding skin but not the incision
23. Place clean forceps onto dressing tray and lace
dirty forceps/gloves into receiver on bottom
shelf
24. Apply any ordered ointments with swabs if
indicated
25. Apply dressings one at a time to incision or
drain site. Once dressing is placed it must not
be moved or readjusted.
keep the wound open as little as possible to
avoid contamination from airborne particles.
10. Maintain proper waste disposal with
appropriate red bag.
11. Adhere to all standard precautions.
12. Adhere to all standard precautions.
13. Adhere to principles of sterility to avoid
contamination
14. Avoid contaminating sterile area with antiseptic
container. Keep container at edge of sterility
and do not pass over sterile field.
15. Maintain standard precautions.
16. Prepare sterile swabs as needed prior to
contaminating your dirty hand for ease of work
flow.
17. The hand identifies as being dirty will be your
dominant hand. Your non-dominant hand will
be your clean hand for ease of maneuvering.
18. Do not allow sterile gloved hands to become
contaminated while doing this.
19. The hand identified as dirty will remove the
remaining dressing from the wound. This is
your dirty hand for the remaining of the
procedure, and is not to return into the sterile
field.
20. Either clean in longitudinal rows working inner
to outer along the length of the incision, or
work outwards from the incision, right and
then left, or in a circular pattern, inner to outer,
for circular wounds.
21. Avoid contaminating drain or touching it to
skin while cleaning to avoid cross
contamination.
22. Moistness aid the healing process of the
incision itself. Pat dry skin to avoid chaffing.
23. Maintain clean and dirty areas even when
cleaning area.
24. Avoid contaminating ointment. Use tongue
depressors or cotton tipped applicators.
25. If a dressing is moved after placement it will
contaminate wound from the previous area that
it came in contact with.
26. Apply gauze around drain. The bulk of the
dressing must be placed over the drainage site
to prevent leakage.
27. Secure gauze dressing with tape or bandage.
Tape middle of dressing first then work
outward.
28. Assist patient back to a comfortable position in
bed.
29. Care for equipment and clean up surrounding
area
26. Either place pre-cut gauze square around drain
or wrap drain with a folded piece of gauze.
Drain must be completely surrounded and
supported by dressing to avoid skin irritation.
Avoid cutting a gauze square – this causing
loose threads which can enter the wound and
cause inflammation.
27. Secure middle of the dressing first to avoid
movement. Various types of tapes and ties and
bandage holders exist, but always begin in the
middle.
28. To provide patient comfort.
29. To maintain clean work area, to reduce risk
infection, and to have area prepared for
subsequent use.

EVALUATION
 Evaluate patient’s tolerance of procedure.
 Evaluate effects of analgesics.
 Conduct follow up such as amount of drainage, granulation tissues, odor, presence of
inflammation, and drain site.
 Report deviations from normal or unexpected finding with primary physician,

RECORDING AND REPORTING

 Patient’s tolerance of procedure and pain level
 Solution used
 Position of incision and appearance, redness, etc.
 Number of sutures intact
 Presence of drains and location
 Amount of drainage
 Legal signature
 Patient’s current status

REFERENCE
 Berman, A., & Snyder, S. (2016). Kozier & Erb's: Fundamentals of nursing - Concepts,
process, and practice (10th ed.). Upper Saddle River, NJ: Pearson Education Incorporated.
 SKILLS CHECKLISTS

UNIVERSITY OF BELIZE
FACULTY OF NURSING, ALLIED HEALTH & SOCIAL WORK
DEPARTMENT OF NURSING

Code and Name of Course: NURS 3101 L Venue: - Nursing Laboratory

Student’s NAME/ ID #: __________________________ Date: ______________________

Time allotted: 25 minutes Time Start: ___________ Time End: __________________

Total Points: ______/ ____ Pass_________ Fail: ___________

INSTRUCTIONS TO CANDIDATES:
Steps done correctly =1 point is allotted
Steps done incompletely = 0.5 point is allotted
Steps done incorrectly = 0 points are allotted

SKILLS CHECKLIST FOR SURGICAL DRESSING

PROCEDURE POINTS COMMENTS

ASSESSMENT
1. Check physician's orders for the dressing change and type

2. Presence of drains and suture material under dressing

3. Presence of drainage on dressing, including amount,
color, consistency, odor, location
4. Allergies to tape and solution
5. Intrinsic factors affecting wound healing, such as
nutritional status, shock, acidosis, hepatic or renal failure
6. Extrinsic factors that affect wound healing, such as
steroid therapy, chemotherapy, and irradiation
7. Ability of patient to cooperate

PLANNING
1. Prepare dressing room
2. Carbolize the surfaces
3. Ensure that windows and door are closed
4. Turn off fans
5. Gather equipment
6. Cut tape
7. Place disposal bag within reach away from wound care
IMPLEMENTATION
1. Identifies patient
2. Introduces self to the patient, explains and educates
3. Gains verbal consent.
4. Provides for client privacy
5. Assists patient to comfortable position
6. Washes hands and dons a clean glove
7. Elevates bed to working level and exposes area of wound
8. Removes tape slowly by pulling toward the wound
supporting any drains as applicable.
9. Removes all dressing in direction that is away from the
patients face.
10. Assesses wound
11. Innermost dressing is replaced on wound, rest is
discarded in waterproof bag.
12. Removes and discards gloves
13. Washes hands
14. Opens dressing tray using sterile techniques
15. Drops sterile items on to sterile field.
16. Pours antiseptic into receptacle on the field
17. Dons a sterile glove
18. Prepares swabs
19. Identifies dirty and clean forceps
20. Drapes sterile sheets over area being treated
21. Removes remaining dressing with forceps and discards
from sterile field
22. Selects a methods of cleaning and works outward from
incision site
23. Forceps held in a downward position at all times
24. Cleans drain holding erect
25. Dries surrounding skin but not the incision
26. Applies any ordered ointments with swabs
27. Applies dressings one at a time to incision site. Once
dressing is applied it is not moved nor re-adjusted
28. Applies gauze around drain
29. Places clean forceps in dressing dray, places dirty forceps
in receiving receptacle.
30. Secures gauze dressing with tape or bandage. Tape
middle of dressing first the work outward
31. Assists patient back to a comfortable position in bed
32. Lowers bed and raise bedrails if indicated.
33. Cares for equipment and clean up surrounding area

EVALUATION
1. Evaluates degree of healing and granulation tissues.
2. Evaluates amount of drainage, color, consistency, odor
and presence of inflammation.
3. Evaluates pain

DOCUMENTATION
1. Date and time
2. Location and size of wound
3. Presence of sutures, drains, packs, clips, Steri-strips
4. Dressing done and type of dressing placed
5. Description of drainage, color, amount, odor,

Student’s Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________

Student Signature: __________________________ Date: _____________________________

Evaluator Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________

Evaluator Signature/s: ________________________ Date: ____________________________________________