Central Mindanao University

College of Nursing
FUNDAMENTALS OF NURSING PRACTICE, RLE
Procedure Checklist

Name of Student:
Clinical Instructor:

Cleaning a Sutured Wound and Changing a Dressing on a Wound with a Drain

A. Direction: Write your answers on the space provided.

Assessments:

Possible Nursing Diagnoses:

1.
2.

Materials:

B. Directions: Provide your assessment findings/rationale on the box. You are rated based on the
performance rubrics.

PROCEDURE RATIONALE
PREPARATION
Prepare the client and assemble the equipment.
1. Obtain assistance for changing a
dressing on a restless or confused adult.
2. Assist the client to a comfortable
position in which the wound can be
readily exposed. Expose only the wound
area, using a bath blanket to cover the
client, if necessary.
3. Make a cuff on the moisture-proof bag
for disposal of the soiled dressings, and
place the bag within reach.
4. Apply a face mask, if required.

PERFORMANCE
Removing soiled dressing
5. Prior to performing the procedure,
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 he or she
can participate. Discuss how the results
will be used in planning further care or
treatments.
6. Perform hand hygiene.

7. Provide for client privacy.

8. Remove adhesive tape by holding down

the skin and pulling the tape gently but
firmly toward the wound. Acetone may
be used to loosen the adhesive.
9. Remove and dispose of soiled dressings
appropriately.

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ASEPSIS
 Central Mindanao University
College of Nursing
FUNDAMENTALS OF NURSING PRACTICE, RLE
Procedure Checklist
PROCEDURE RATIONALE
10. Apply clean gloves and remove the
outer abdominal dressing or surgipad.

11. Lift the outer dressing so that the

underside is away from the client’s
face.

12. Place the soiled dressing in the

moisture-proof bag without touching
the outside of the bag.

13. Remove the underdressing, taking care

not to dislodge any drains. If a drain is
present and the gauze sticks with it,
support the drain with one hand and
remove the gauze with the other.

14. Assess the location, type (color,

consistency), and odor of wound
drainage, and the number of gauzes
saturated or the diameter of drainage
collected on the dressings.
15. Discard the soiled dressings in the
bag as before.

16. Remove and discard gloves in the

moisture-proof bag.

17. Perform hand hygiene.

Setting up a sterile field

18. Open the sterile dressing set, using
surgical aseptic technique or prepare
all sterile materials in a sterile field if
a sterile dressing set is not available
19. Place the sterile drape beside the
wound.

20. Open the sterile cleaning solution

(normal saline) and pour it over the
gauze sponges in the plastic container
(kidney basin).
21. Apply sterile gloves.

Cleaning the wound

22. Clean the wound, using your gloved
hands or forceps with gauze swabs
moistened with cleaning solution
(normal saline). Methods of cleaning
surgical wounds: A, cleaning the
wound from top to bottom, starting at
the center; B, cleaning a wound
outward from the incision; C, if a
Penrose drain is present, clean the
site in a circular motion beginning in
the center then outward. For all
methods, a clean sterile swab is used
for each stroke.

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ASEPSIS
 Central Mindanao University
College of Nursing
FUNDAMENTALS OF NURSING PRACTICE, RLE
Procedure Checklist
PROCEDURE RATIONALE
23. If using forceps, keep the forceps tips
lower than the handles at all times.

24. Dry the surrounding skin with dry

gauze swabs as required. Do not dry
the incision or wound itself.

25. Apply ointment using a cotton

applicator or tongue blade in the same
direction mentioned above.

Applying a sterile dressing

26. If a drain is present, place a precut
4×4 gauze snugly around the drain.

27. Apply the sterile dressings one at a

time over the drain and the incision.
Place the bulk of the dressings over
the drain area and below the drain,
depending on the client’s usual
position.
28. Apply the final surgipad. Remove and
discard gloves. Secure the dressing
with tape or ties.

29. Perform hand hygiene.

30. Document the nursing procedure

done in the nurse’s notes or checklist
depending upon the hospital protocol.

Reference:
(Berman, Snyder, & Frandsen, Kozier and Erb's Fundmentals of Nursing Concepts, Process and
Practice, 2016)

C. Write medical terms and abbreviations related to this procedure. Provide meaning for each.

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ASEPSIS