1.

Review the physician’s order for wound care or the nursing plan of care
CLINICAL
related to INSTRUCTOR
3. Identify wound care.Explain the procedure to the patient. Inquire about
the patient.
Rationale:
CLEANING
any allergies, Reviewing
A WOUND therelated
and
specifically order
APPLYING and plan
to the of care being
Aproducts
STERILE validate
DRESSING usedtheforcorrect
wound patient
and
2.
care. correct
5. Gather
Close the
the procedure.
Rationale: necessary
room Patient
door or supplies.
identification
curtains. Rationale: the Preparation
validates
Place bedtheatcorrect promotes
patient and
an appropriate and
efficient
correct time
procedure.
comfortable management
Discussion and organized
and explanationapproach
help to the
allay task.
anxiety,
7.
8. Check theworking
Assist the patient
positiontoheight.
ofa drains,
comfortabletubes,position
or otherthat provides
adjuncts easyremoving
before access to
encourage
4.
6.
the Perform
Rationale:
Place
wound the
dressing. patient
hand
Closing
waste
area.
PutUse cooperation,
hygiene.
the door
receptacle
onthe the
clean, bath and
Rationale:
or curtain
or bag
blanket
disposable prepare
Hand
promotes
at
to a the patient
hygiene
convenient
cover
gloves any for
prevents
privacy.
location
exposed what
Proper for
area to
the
bed
useexpect.
spread
on other than
9.
10.Carefully
After remove
removing the soiled
dressing, dressings.
note the If anyand
presence,partloosen
of thetape
amount, dressing
type, the old
sticks
color,
of
themicroorganisms.
positioning
during the
wound.
dressings. helps
procedure.
If reduce
necessary, back
place strain
the while
waterproof you are
pad performing
under the the
wound site.
to
andthe ofIfany
underlying
odor necessary,
skin, use
drainage use
on an
theadhesive
small amountsremover
dressings. ofPlace tosaline
sterilesoiledhelpdressings
get the loosen
to help tape
in theoff.
procedure.
Rationale: Having
Patient
Checking
and remove.waste
appropriate Do not a waste
positioning
ensures container
reach overRemove
receptacle. and
that a usehandy
drain
the wound. of a
is means
bath
not the
blanket
removed soiled
provide dressing
for
accidentally
your gloves and dispose of them if may
one
in
be
is discarded
comfort
Rationale:and
present.
an appropriate
11. easily,
warmth.
Gloves
Cautious
Inspect the waste without
Waterproof
protect
removal
woundreceptacle.the the spread
pad
nurse
of the from of
dressing microorganisms.
protects underlying
contaminated
is more surfaces.
dressings
comfortable
site for size, appearance, and drainage. Assess if and
for the
prevent
patient
Rationale:the
and spread
ensures
The of
presence
any pain is present. Check microorganisms.
that anyof
thedrain
drainage present
sutures, Adhesive
shouldis not tape
removed.remover
be documented.
Steri-strips, staples, helps
Sterile
and salineor
Proper
drains
reduce
provides
disposal
tubes. patient
forsoiled
of
Note any discomfort
easier removaltoof
dressings
problems during
and removal
theused
include dressing of
yourand
ingloves dressing.
prevents
prevents
documentation. tissueofdamage.
spread
microorganisms.
Rationale:
12. Using sterileWound healingprepare
technique, or the presence
a sterile of irritation
work area and or infection
open theshould
documented.
needed materials. Rationale: Supplies are within easy reach and sterility is
maintained.

13. Open the sterile cleaning solution. Depending on the amount of

cleaning needed, the solution might be poured directly over gauze sponges
for small cleaning jobs or into a basin for more complex or larger cleaning.
Rationale: Sterility of dressings and solution is maintained.

14. Put on sterile gloves

Rationale: Use of sterile gloves maintains surgical asepsis and sterile
technique and reduces the risk of spreading microorganisms.

15. Clean the wound. If needed, use sterile forceps to clean the area.
Clean the wound from top to bottom and from the center to the outside.
Following this pattern, use gauze for its wipe, placing the used gauze in the
waste receptacle. Do not touch any surface with the gloves or forceps.
Rationale: Cleaning occurs from the least to most contaminated area.
Using a single gauze for each wipe ensures that the previously cleaned
area is not contaminated again.
16. If a drain is in use, clean around the drain using a circular motion. Wipe
from the center toward the outside. Use the gauze a single time and then
dispose of it.
Rationale: Cleaning occurs from the least to most contaminated area.
17. Once the wound is cleansed, dry the area using the gauze sponge in
the same manner. Apply ointment or any other treatments if ordered.
Rationale: Moisture provides a medium for growth of microorganisms.
The growth of microorganisms may be retarded and the healing process
improved with use of ordered ointments or other applications.

18. Apply a layer of dry sterile dressing over the wound. Forceps maybe
used to apply the dressing.
Rationale: Primary dressing serves a wick for drainage. Use of forceps
helps ensure that sterile technique is maintained.

19. Place a second layer of gauze over the wound site.

Rationale: A second layer provides for increased absorption of drainage.

20. Apply a Surgi-pad or ABD dressing over the gauze at the site as the
outermost layer of the dressing.
Rationale: The dressing acts as additional protection for the wound
against microorganisms in the environment.

21. Remove and discard sterile gloves. Apply tape or tie tapes to secure
the dressings. Rationale: Tape is easier to apply after gloves have been
removed. Proper disposal of gloves prevents the spread of
microorganisms.

22. After securing the dressing, label dressing with date and time. Remove
all remaining equipment, place the patient in a position of comfort with side
rails up and bed in the lowest position, and perform hand hygiene.
Rationale: Recording date and time provides communication and
demonstrates adherence to plan of care. Proper patient and bed positioning
promotes safety. Hand hygiene prevents spread of microorganisms.

23. Record the procedure, wound assessment, and the patient’s reaction to
the procedure according to institution’s guidelines.
Rationale: Documentation promotes continuity of care and
communication.
RHA 101 RETURN DEMONSTRATION
JENNIE J. PAUYA, RN