Wound and Pressure Ulcer Care
Changing a Dressing
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Take the Review Test:
Safety
- When a dry dressing inadvertently adheres to a wound, minimize trauma by moistening the gauze with sterile normal saline or sterile water before removing the dressing.
- In a moist-to-dry dressing, allow the inner primary dressing to dry and adhere to underlying tissues; moistening the dressing is a common error in technique that reduces the amount of debris the dressing removes.
- Discard solutions 24 to 48 hours after opening, and replace them with fresh solutions that are clearly labeled with the date and time of opening.
- Use sterile scissors to cut the amount of dressing needed to pack a wound. Pour the prescribed solution over the packing gauze or strip to moisten it. Do not let the strip touch the bottle. To avoid trauma during dressing removal, do not overpack the wound.
- If the wound appears inflamed and tender, begins draining, or has an odor, monitor the patient for signs of infection, notify the health care provider, and obtain a culture.
- If the wound bleeds during a dressing change, observe the color and amount of drainage. If it is excessive, apply a pressure dressing. Obtain vital signs as needed, and notify the health care provider.
- Use paper or nonallergenic tape, wraps, or mesh instead of adhesive tape in older adults. Adhesive can irritate their skin or cause it to tear.
Equipment
(Roll cursor over items to see labels)
Clean gloves
Sterile normal saline
Sterile dressing kit
2 gauze pads
Sterile gloves
Cotton balls
Forceps
Sterile drape
Sterile basin (base of kit)
ABD dressing
Metapore tape
Wound drain (if needed)
Waterproof pad
Biohazard bag
PrintableDelegation
As the nurse, you are responsible for wound assessment and may not delegate this skill to nursing assistive personnel (NAP). In addition, you may not delegate the skill of caring for acute new wounds or any skills that require sterile technique or a moist-to-dry dressing change. You may, however, delegate the application of a dry dressing or a change of the top dressing. Be sure to inform NAP of the following:
- Review the signs of infection and poor wound healing. Instruct the NAP to report such findings to you immediately for further assessment.
- Explain any unique modifications, such as the need to use a special tape or taping technique to secure the dressing.
Preparation
- Assess the size and location of the wound.
- Determine the patient’s comfort level using a scale of 0 to 10.
- Assess the patient’s knowledge of the purpose of the dressing change.
- Assess whether the patient or a family member wishes to and is ready to participate in the dressing change.
- Review the medical orders for the dressing change procedure.
- Identify any risk factors for wound healing problems, including the following:
- Advanced age
- Prematurity
- Obesity
- Diabetes
- Compromised circulation
- Poor nutritional state
- Immunosuppressive drugs
- Irradiation of wound area
- High stress level
- Use of steroid medications
- Explain the procedure to the patient.
- When indicated, premedicate the patient 30 minutes before the dressing change with an ordered analgesic.
Follow-up
- Observe the appearance of the wound as it heals, including its size and the amount, color, and type of drainage. Note any erythema or swelling around the wound.
- Immediately report to the physician any problems or complications, such as drainage, an unexpected change in the appearance of the wound, accidental drain removal, bright-red bleeding, or signs of dehiscence or evisceration.
- Ask the patient to rate his or her pain using a scale of 0 to 10.
- Inspect the condition of the dressing at least once each shift.
- Ask the patient or a family member to describe the steps required for a proper dressing change.
Documentation
- Document the following:
- Appearance of the wound, including its color and the presence and characteristics of any exudate
- Any change in wound characteristics, especially a change in the amount of drainage
- Type and amount of dressings applied
- Patient’s tolerance of the dressing change
- Write the date and time of the dressing change in ink on a piece of tape, initial it, and affix the tape to the dressing. Do not use a marker.
- Report drainage, unexpected changes in the appearance of the wound, accidental drain removal, bright-red bleeding, or evidence of wound dehiscence or evisceration.
Review Questions
1. A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient’s pain?
Premedicate the patient with a prescribed analgesic 30 minutes before the intervention.
Use a distraction technique to divert the patient’s attention during the procedure.- Position the patient comfortably before the intervention.
- Thoroughly explain the procedure to the patient.
CORRECT. Administration of a prescribed analgesic would directly control the patient's pain level during the dressing change. This intervention is more likely to be effective than the other options listed.
INCORRECT. Using distraction in combination with analgesics is an appropriate intervention for this patient, but distraction alone would not be effective.
INCORRECT. Positioning the patient comfortably is appropriate, but does not directly address the patient’s complaint of pain.
INCORRECT. Thoroughly explaining the procedure is appropriate, but doing so is not a pain reduction intervention.
2. Which action reduces the nurse’s risk for infection when changing the dressing of an infected abdominal wound?
- Begin antibiotic therapy before the dressing change.
- Use appropriate personal protective equipment (PPE).
- Adhere to sterile technique during the intervention.
- Complete the dressing change in an effective, timely way.
INCORRECT. Beginning antibiotic therapy before the dressing change would not protect the nurse from infection and would expose him or her to other risks.
CORRECT. Using appropriate PPE minimizes the nurse’s contact with body fluids and contaminated items during the dressing change, thereby reducing the risk for infection.
INCORRECT. Adhering to sterile technique during the intervention would reduce the patient’s risk for infection but would not protect the nurse.
INCORRECT. The nurse would strive to complete all dressing changes in an effective, timely way, but doing so would have no bearing on his or her risk for infection.
3. What is the nurse’s best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago?
- Notify the surgeon of the bleeding.
- Remove the dressing, and assess the wound.
- Assess the patient for signs of shock.
- Further assess the patient and the wound.
INCORRECT. It is unnecessary to notify the surgeon, since such drainage is unlikely to indicate a surgical complication this late in the patient’s recovery.
INCORRECT. The nurse would not remove the initial surgical dressing without an order to do so.
INCORRECT. Assessing the patient for shock is probably unnecessary this late in the patient’s recovery.
CORRECT. Completing a further wound assessment and gathering more detailed information about the patient and his or her wound, such as pain level and amount of blood, would be the most appropriate action for the nurse to take.
4. When changing a patient’s surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves?
- After performing hand hygiene at the start of the procedure
- Before removing the inner dressing
- After removing the original dressing materials and performing hand hygiene a second time
- Just before cleansing the wound with sterile water
INCORRECT. Applying sterile gloves at the start of the procedure would compromise the sterility of the gloves.
INCORRECT. Applying sterile gloves before removing the inner dressing would compromise the sterility of the gloves.
CORRECT. The nurse would wear clean gloves to remove the contaminated original dressing, and he or she would then perform hand hygiene again. Only then would the nurse apply sterile gloves.
INCORRECT. The nurse would apply sterile gloves before performing any step that requires sterile technique, rather than wait until it is time to cleanse the wound with sterile water.
5. Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound?
- Cleansing the wound with sterile water
- Blotting the incision with dry gauze
- Wearing sterile gloves to cleanse the wound
- Using a new gauze pad for each stroke while cleansing the wound
INCORRECT. Using sterile water does not minimize the risk for cross-contamination.
INCORRECT. Drying a wound after cleansing it does not minimize the risk for cross-contamination.
INCORRECT. Wearing sterile gloves minimizes the introduction of pathogens to the wound, not the cross-contamination of pathogens already found within the wound.
CORRECT. Using a new gauze pad for each stroke minimizes the risk for cross-contamination by preventing contaminated gauze from introducing microorganisms into other areas of the wound.
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