EMILIO AGUINALDO COLLEGE

Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph
`
SCHOOL OF NURSING

SKIN INTEGRITY AND WOUND CARE

CLEANING and IRRIGATING A WOUND
NAME: _Flora May A. Abarracoo________________________________SCORE: _____________________
YR/SEC/GRP: _1st Year/ BSN 1-5 C/ 2______________________ DATE: __July 19, 2021____________________

PERFORMED
PLANNING MASTERED COMMENTS
YES NO

Check the doctor’s order about the area to be

bandaged.
3
The nurse needs to know the purpose of
bandaging and assess the area requiring
support.
EQUIPMENT
Bandage of appropriate size
Plaster or bandage clips 3
Clean gloves
When bandages are used to secure dressings,
the nurse wears gloves to prevent contact 3
with body fluids.
PERFORMANCE
1. 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 the client 3
can participate. Discuss how the results
will be used in planning further care or
treatments.
2. Provide for client Privacy 3

3. Perform hand hygiene and observe other

appropriate infection prevention 3
procedures
Note: All identified bandaging techniques are featured here.
4. Inspect and palpate the area for
swelling.
 Inspect for the presence of and status of
wounds (open wounds will require a 3
dressing before a bandage is applied).
 Note the presence of drainage (amount,
color, odor, viscosity). 3
 Inspect and palpate for adequacy of
circulation (skin temperature, color, and
sensation). Rationale: Pale or cyanotic 3
skin, cool temperature, tingling, and
numbness can indicate impaired
circulation.
 Ask the client about any pain
3
experienced (location, intensity, onset,
quality).
Circular bandage

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5. Hold the bandage in your dominant hand,
keeping the roll uppermost, and unroll
the bandage about 8 cm (3 in.). This 3
length of unrolled bandage allows good
control for placement and tension.
6. Apply the end of the bandage to the part
of the body to be bandaged. Hold the end 3
down with the thumb of the other hand
7. Encircle the body part a few times or as
often as needed, making sure that each
layer overlaps one half to two thirds of
the previous layer. This provides even 3
support to the area.
The bandage should be firm, but not too
tight. Ask the client if the bandage feels
comfortable. A tight bandage can 3
interfere with blood circulation, whereas
a loose bandage does not provide
adequate
protection
8. Secure the end of the bandage with tape
3
or clips if there is no Velcro fastener.
Spiral Turns
9. Make two circular turns. Two circular
turns anchor the bandage.
Continue spiral turns at about a 30° angle, 3
each turn overlapping the preceding one
by two thirds the width of the bandage

10. Terminate the bandage with two circular

turns, and secure the end as described for 3
circular turns.
Spiral Reverse Turns
11. Anchor the bandage with two circular
turns and bring the bandage upward at 3
about a 30° angle.
12. Place the thumb of your free hand on the
upper edge of the bandage. The thumb 3
will hold the bandage while it is folded on
itself.
13. Unroll the bandage about 15 cm (6 in.),
and then turn your hand so that the
bandage falls over itself.
Continue wrapping the bandage around
the limb, overlapping each previous turn 3
by two thirds the width of the bandage.
Make each bandage turn at the same
position on the limb so that the turns of
the bandage will be aligned
14. Terminate the bandage with two circular
turns, and secure the end as described for 3
circular turns.

• VIRTUE • EXCELLENCE • SERVICE

 EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph
`
SCHOOL OF NURSING
Recurrent Turns
15. Anchor the bandage with two circular
turns. Fold the bandage back on itself, 3
and bring it centrally over the distal end
to be bandaged
16. Bring the bandage back over the end to
the right of the center bandage but 3
overlapping it by two thirds the width of
the bandage
17. Bring the bandage back on the left side,
also overlapping the first turn by two
thirds the width of the bandage. Continue
this pattern of alternating right and left 3
until the area is covered. Overlap the
preceding turn by two thirds the bandage
width each time.
18. Terminate the bandage with two circular 3
turns. Secure the end appropriately
Figure of 8 Turns
19. Anchor the bandage with two circular
turns. Carry the bandage above the joint, 3
around it, and then below it, making a
figure-eight.
20. Continue above and below the joint,
overlapping the previous turn by two
thirds the width of the bandage. 3
Terminate the bandage above the joint
with two circular turns, and then secure
the end appropriately.
Shoulder Spica Wrap
21. Stand facing the clients, let client anchor 3
his arm into his hips “arms akimbo”
22. Wrap elastic bandage around top of the
bicep twice, creating an anchor then pull 3
moderately tight but do not take the
stretch out of the bandage.
23. Wrap underneath the armpit, over the
top of the shoulder and across the chest,
pulling tightly. Follow the wrap
underneath the unaffected armpit and 3
across the back and pull tightly over the
shoulder, loop underneath the affected
armpit and over the shoulder again, back
across the chest.
24. Overlap the bandage at least one-half
width of the previous pattern. Repeat the 3
pattern until the elastic bandage runs out.
25. Tape the finished end of the elastic wrap
and follow the pattern back. Tape around
the anchor on the arm for an extra 3
support wrap. The spica should resemble
a figure-8 pattern.

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 26. Remove and discard gloves, perform
hand hygiene and document procedure 3
done and client’s response in the nurses’
notes.
/99
TOTAL SCORE

EVALUATED BY: CONFORME:

_____________________________ _FLORA MAY A. ABARRACOSO______________

Signature over Printed Name of the Faculty Signature over Printed Name of the Student

• VIRTUE • EXCELLENCE • SERVICE