WOUND CARE

PROCEDURE PRINCIPLES
1. Assemble equipment and bring to the bedside To save time and effort
2. Explain the procedure to the patient To gain trust and rapport
3. Wash hand To reduce microorganisms in hand
4. Position client comfortably Maintaining client comfort assists
in completing skills smoothly
5. Place waste receptable within reach of work This facilitates safe disposal of the
soiled dressings.
6. Remove tape: pull parallel to the skin, toward dressing. If over hairy This reduces stress on the suture
areas, remove in the direction of hair growth. line or wound edges
7. With clean gloves, remove dressing one layer at a time, observing the This is to determine the dressings
appearance and drainage on the dressing. needed for replacement
8. Inspect the wound for appearance, size, depth, drainage and To monitor the status of healing
approximation.
9. Fold dressings with drainage contained inside and remove gloves This provides containment of soiled
inside out. dressings
10. Apply sterile gloves or use the no-touch technique with the sterile To prevent contamination
forceps.
11. Clean wound with hydrogen peroxide. This prevents the transfer of
 Use a separate swab for each cleaning stroke. organisms from the previously
 Clean from the least contaminated area to the most cleaned area
contaminated.
12. Apply antiseptic solution using the same technique as for cleansing. To kill microorganisms
13. Apply dry dressing. To promote proper absorption of
drainage
14. Apply tape To secure dressing
15. Do hand washing To reduce the number of
microorganisms
16. Ask the client to rate pain. Inspect the status of dressing at least every This helps determine the frequency
8hours. of applying dressings.
17. Do charting Proper documentation.

REFERENCES:
Kozier and Erb’s fundamentals of nursing: Concepts, process, & practice (10th ed.). New York, NY: Pearson.
 PERFORMANCE EVALUATION CHECKLIST FOR WOUND CARE
NCM 109 RLE- Care of Mother, Child at Risk or with Problems
Name: Score:
Year/Block: Group:

DEFINITION:
Refer to specific part types of treatment for pressure sores, skin ulcers, and other wounds that break the skin.
Dry Dressing:
Protect the wound from injury, prevent the introduction and spread of bacteria, reduce discomfort, and speed healing.
PURPOSES:
 Promote haemostasis by direct pressure and absorption of drainage.
 Support or immobilize a body part.
ASSESSMENT:
 Assess the size and location of the wound to be dressed. Assist in planning for the proper type and amount of supplies
needed.
 Ask the client to rate pain using a scale of 0 to 10. The client may require pain medication before the dressing change.
EQUIPMENT:
1. Clean disposable gloves 5. Cotton balls
2. Sterile gloves or sterile forceps 6. Hydrogen peroxide
3. Gauze 7. Antiseptic solution
4. Plaster (hypoallergenic) 8. Waste receptacle
CRITERIA FOR RATING:
3 – Skill performed with mastery using the recommended technique.
2– Skill performed using the recommended technique but without mastery.
1– Skill performed using some but not all of the recommended technique.
0 – Skill not performed or missed
DIRECTIONS: Mark each step of the procedure following the rubric below denoting the skill performance of the student. Total the
scores and look for the equivalent grade on the transmutation table. The Remark section is for suggestions that will help improve the
skills of students.
SCORE
STEPS Remarks
3 2 1 0
1. Assemble equipment and bring to the bedside
2. Explain the procedure to the patient
3. Wash hand
4. Position client comfortably
5. Place waste receptable within reach of work
6. Remove tape: pull parallel to the skin, toward dressing. If over hairy areas,
remove in the direction of hair growth.
7. With clean gloves, remove dressing one layer at a time, observing the
appearance and drainage on the dressing.
8. Inspect the wound for appearance, size, depth, drainage and
approximation.
9. Fold dressings with drainage contained inside and remove gloves inside
out.
10. Apply sterile gloves or use the no-touch technique with the sterile forceps.
11. Clean wound with hydrogen peroxide.
 Use a separate swab for each cleaning stroke.
 Clean from the least contaminated area to the most contaminated.
12. Apply antiseptic solution using the same technique as for cleansing.
13. Apply dry dressing.
14. Apply tape
15. Do hand washing
16. Ask the client to rate pain. Inspect the status of dressing at least every
8hours.
17. Do charting
Total
Equivalent Grade

___________________ _______________________________
Student’s Signature Name & Signature of Clinical Instructor