{"id":219,"date":"2018-06-05T11:35:31","date_gmt":"2018-06-05T15:35:31","guid":{"rendered":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/4-3-simple-dressing-change\/"},"modified":"2019-10-01T11:32:53","modified_gmt":"2019-10-01T15:32:53","slug":"4-5-simple-dressing-change","status":"publish","type":"chapter","link":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/4-5-simple-dressing-change\/","title":{"raw":"4.5 Simple Dressing Change","rendered":"4.5 Simple Dressing Change"},"content":{"raw":"The healthcare provider\u00a0chooses the appropriate sterile\u00a0technique and necessary supplies based on the clinical condition of the patient, the cause\u00a0of the wound, the type of\u00a0dressing procedure, the goal of care, and agency policy.\r\n\r\nAgency policy will determine the type of wound cleansing solution, but sterile normal saline and sterile water are the solutions of choice for cleansing wounds and should be at room temperature to support wound healing.\u00a0The ideal cleansing agent and the optimal method of wound cleansing has not been\u00a0established conclusively (International Wound Infection Institute, 2016). Some wound cleansing solutions include sterile water, sterile saline, tap water, chlorhexidine, and povidone\/iodine. Each cleansing solution has characteristics that make it a good or poor choice in certain situations. The nurse should use the wound cleansing solution as directed by agency policy and\/or wound specialists.\r\n\r\nSurgical dressings should remain in place for at least 48 hours and should be reinforced if soiled. At the 48 hour point, the wound may be exposed to air, but this is dependent on a number of factors such as type of surgery, wound healing (wound edges must be approximated and the wound not leaking), comfort of the client with an exposed incision, and agency policy (BC Provincial Skin and Wound Committee, 2011).\r\n\r\nChecklist 35 outlines the steps for performing a simple dressing change.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
\r\n

<\/a>Checklist 35:\u00a0Simple Dressing Change<\/h3>\r\n
Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/h5>\r\n<\/td>\r\n<\/tr>\r\n

\r\n
Safety considerations:\u00a0<\/span><\/h5>\r\n
\r\n

Steps<\/h4>\r\n<\/td>\r\n

\r\n

\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n

1. Assess current dressing.<\/td>\r\nIf you plan to touch the dressing, donne non-sterile gloves to protect yourself from exposure to BBF. Assess dressing for signs of shadowing \/ bleeding, type and size of dressing used.\r\n\r\n[caption id=\"attachment_5561\" align=\"aligncenter\" width=\"150\"]\"Apply<\/a> Apply non-sterile gloves[\/caption]<\/td>\r\n<\/tr>\r\n
2. Perform hand hygiene.<\/td>\r\nHand hygiene reduces risk of spread of microorganisms.\r\n\r\n[caption id=\"attachment_6220\" align=\"aligncenter\" width=\"150\"]\"Perform<\/a> Perform hand hygiene[\/caption]<\/td>\r\n<\/tr>\r\n
3. Gather necessary equipment.<\/td>\r\nDressing supplies must be for single patient\u00a0use only. Use the smallest size of dressing for\u00a0the wound.\r\n\r\n[caption id=\"attachment_6225\" align=\"aligncenter\" width=\"150\"]\"Gather<\/a> Gather supplies[\/caption]\r\n\r\nTake only the dressing supplies needed for the dressing change to the bedside. Equipment that is contaminated at the bedside cannot return to general circulation to be used with other patients.<\/td>\r\n<\/tr>\r\n
4. Prepare environment; position patient; adjust height of bed; and turn on lights.<\/td>\r\nEnsure patient's comfort prior to and during the procedure.\u00a0Proper lighting allows for good visibility to assess wound.<\/td>\r\n<\/tr>\r\n
5. Perform hand hygiene.<\/td>\r\nHand hygiene prevents spread of microorganisms.\r\n\r\n[caption id=\"attachment_5972\" align=\"aligncenter\" width=\"150\"]\"Hand<\/a> Hand hygiene with ABHR[\/caption]<\/td>\r\n<\/tr>\r\n
6. Prepare sterile field.<\/td>\r\n\r\n\r\n[caption id=\"attachment_6219\" align=\"aligncenter\" width=\"150\"]\"Prepare<\/a> Prepare sterile field[\/caption]<\/td>\r\n<\/tr>\r\n
7. Add necessary sterile supplies.<\/td>\r\n\r\n\r\n[caption id=\"attachment_6221\" align=\"aligncenter\" width=\"150\"]\"Add<\/a> Add necessary supplies[\/caption]<\/td>\r\n<\/tr>\r\n
8. Pour cleansing solution.<\/td>\r\n\r\n\r\n[caption id=\"attachment_4751\" align=\"aligncenter\" width=\"150\"]\"Pour<\/a> Pour sterile cleansing solution into sterile tray[\/caption]\r\n\r\nNormal saline or sterile water containers must be used for only one client, and they must be dated and discarded within at least 24 hours of being opened.<\/td>\r\n<\/tr>\r\n
9. Prepare patient and expose dressed wound.<\/td>\r\n\r\n\r\n[caption id=\"attachment_4744\" align=\"aligncenter\" width=\"150\"]\"Prepare<\/a> Prepare patient and expose wound[\/caption]<\/td>\r\n<\/tr>\r\n
10. Apply non-sterile gloves.<\/td>\r\nUse non-sterile gloves to protect yourself from contamination.\r\n\r\n[caption id=\"attachment_5561\" align=\"aligncenter\" width=\"150\"]\"Apply<\/a> Apply non-sterile gloves[\/caption]<\/td>\r\n<\/tr>\r\n
11. Remove outer dressing with non-sterile gloves and discard as per agency policy.<\/td>\r\n\r\n\r\n[caption id=\"attachment_4701\" align=\"aligncenter\" width=\"150\"]\"Removing<\/a> Remove outer dressing with non-sterile gloves[\/caption]\r\n\r\nThe rationale for non sterile gloves is to protect you from exposure to BBF.<\/td>\r\n<\/tr>\r\n
12. If necessary, remove inner dressing with transfer forceps.<\/td>\r\n\r\n\r\n[caption id=\"attachment_4899\" align=\"aligncenter\" width=\"150\"]\"DSC_0328\"<\/a> Remove inner dressing with transfer forceps[\/caption]<\/td>\r\n<\/tr>\r\n
13. Discard transfer forceps & gloves<\/td>\r\n\r\n
<\/div>\r\n\r\n[caption id=\"attachment_413\" align=\"alignleft\" width=\"147\"]\"\" Discard transfer forceps[\/caption]\r\n\r\n[caption id=\"attachment_414\" align=\"aligncenter\" width=\"117\"]\"\" discard gloves[\/caption]<\/td>\r\n<\/tr>\r\n
14. Assess wound<\/td>\r\nAre the wound edges approximated? Are the staples \/ sutures intact? Is there evidence of complications?<\/td>\r\n<\/tr>\r\n
14. Cleanse wound remembering principles of asepsis<\/a><\/td>\r\nClean to dirty; one wipe one way discard; fluids flow in the direction of gravity.\r\n\r\n\"\"\r\n\r\n <\/td>\r\n<\/tr>\r\n
15. Cleanse around the drain if present<\/td>\r\nUsing a circular motion, clean the area immediately next to the drain and work outward\u00a0 still following principles of asepsis\r\n\r\n\"\"<\/td>\r\n<\/tr>\r\n
16. Apply new sterile dressing.<\/td>\r\nThe type of dressing applied will depend on the needs of the wound and the supplies available in the agency.\r\n\r\nSecure dressings and drains with tape.\r\n\r\nWrite the date and time on the outside of the dressing as a way to inform others.<\/td>\r\n<\/tr>\r\n
17. Ensure the patient is comfortable before leaving the bedside.\r\n\r\nPerform hand hygiene.\r\n\r\n <\/td>\r\nDiscard used equipment according to agency policy.<\/td>\r\n<\/tr>\r\n
18. Document according to agency policy.\r\n\r\n \r\n\r\nConsider the progression of wound healing. If concerned notify the prescriber.<\/td>\r\nDocumentation example:\r\n\r\ndate \/ time: abdominal dressing changed. Moderate sanguinous drainage from distal end of incision. Wound well approximated. Staples intact. Cleansed with 0.9% NS. Dressed with medipore dressing. Patient tolerated well. ------- B. Dage RN<\/em>\r\n\r\n \r\n\r\n <\/td>\r\n<\/tr>\r\n
Data source: BCIT, 2010a; Perry et al., 2018<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n
\r\n
If necessary review Principles of Asepsis<\/a><\/em> developed by Ren\u00e9e Anderson & Wendy McKenzie Thompson Rivers University.<\/div>\r\n
Watch the video Simple Sterile Dressing Change<\/em><\/a> developed by Ren\u00e9e Anderson and Wendy McKenzie Thompson Rivers University School of Nursing (2014).<\/div>\r\n<\/div>","rendered":"

The healthcare provider\u00a0chooses the appropriate sterile\u00a0technique and necessary supplies based on the clinical condition of the patient, the cause\u00a0of the wound, the type of\u00a0dressing procedure, the goal of care, and agency policy.<\/p>\n

Agency policy will determine the type of wound cleansing solution, but sterile normal saline and sterile water are the solutions of choice for cleansing wounds and should be at room temperature to support wound healing.\u00a0The ideal cleansing agent and the optimal method of wound cleansing has not been\u00a0established conclusively (International Wound Infection Institute, 2016). Some wound cleansing solutions include sterile water, sterile saline, tap water, chlorhexidine, and povidone\/iodine. Each cleansing solution has characteristics that make it a good or poor choice in certain situations. The nurse should use the wound cleansing solution as directed by agency policy and\/or wound specialists.<\/p>\n

Surgical dressings should remain in place for at least 48 hours and should be reinforced if soiled. At the 48 hour point, the wound may be exposed to air, but this is dependent on a number of factors such as type of surgery, wound healing (wound edges must be approximated and the wound not leaking), comfort of the client with an exposed incision, and agency policy (BC Provincial Skin and Wound Committee, 2011).<\/p>\n

Checklist 35 outlines the steps for performing a simple dressing change.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

<\/a>Checklist 35:\u00a0Simple Dressing Change<\/h3>\n
Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/h5>\n<\/td>\n<\/tr>\n

\n
Safety considerations:\u00a0<\/span><\/h5>\n
\n

Steps<\/h4>\n<\/td>\n

\n

\u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n

1. Assess current dressing.<\/td>\nIf you plan to touch the dressing, donne non-sterile gloves to protect yourself from exposure to BBF. Assess dressing for signs of shadowing \/ bleeding, type and size of dressing used.<\/p>\n
\"Apply<\/a>
Apply non-sterile gloves<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
2. Perform hand hygiene.<\/td>\nHand hygiene reduces risk of spread of microorganisms.<\/p>\n
\"Perform<\/a>
Perform hand hygiene<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
3. Gather necessary equipment.<\/td>\nDressing supplies must be for single patient\u00a0use only. Use the smallest size of dressing for\u00a0the wound.<\/p>\n
\"Gather<\/a>
Gather supplies<\/figcaption><\/figure>\n

Take only the dressing supplies needed for the dressing change to the bedside. Equipment that is contaminated at the bedside cannot return to general circulation to be used with other patients.<\/td>\n<\/tr>\n

4. Prepare environment; position patient; adjust height of bed; and turn on lights.<\/td>\nEnsure patient’s comfort prior to and during the procedure.\u00a0Proper lighting allows for good visibility to assess wound.<\/td>\n<\/tr>\n
5. Perform hand hygiene.<\/td>\nHand hygiene prevents spread of microorganisms.<\/p>\n
\"Hand<\/a>
Hand hygiene with ABHR<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
6. Prepare sterile field.<\/td>\n\n
\"Prepare<\/a>
Prepare sterile field<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
7. Add necessary sterile supplies.<\/td>\n\n
\"Add<\/a>
Add necessary supplies<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
8. Pour cleansing solution.<\/td>\n\n
\"Pour<\/a>
Pour sterile cleansing solution into sterile tray<\/figcaption><\/figure>\n

Normal saline or sterile water containers must be used for only one client, and they must be dated and discarded within at least 24 hours of being opened.<\/td>\n<\/tr>\n

9. Prepare patient and expose dressed wound.<\/td>\n\n
\"Prepare<\/a>
Prepare patient and expose wound<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
10. Apply non-sterile gloves.<\/td>\nUse non-sterile gloves to protect yourself from contamination.<\/p>\n
\"Apply<\/a>
Apply non-sterile gloves<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
11. Remove outer dressing with non-sterile gloves and discard as per agency policy.<\/td>\n\n
\"Removing<\/a>
Remove outer dressing with non-sterile gloves<\/figcaption><\/figure>\n

The rationale for non sterile gloves is to protect you from exposure to BBF.<\/td>\n<\/tr>\n

12. If necessary, remove inner dressing with transfer forceps.<\/td>\n\n
\"DSC_0328\"<\/a>
Remove inner dressing with transfer forceps<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
13. Discard transfer forceps & gloves<\/td>\n\n
<\/div>\n
\"\"
Discard transfer forceps<\/figcaption><\/figure>\n
\"\"
discard gloves<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
14. Assess wound<\/td>\nAre the wound edges approximated? Are the staples \/ sutures intact? Is there evidence of complications?<\/td>\n<\/tr>\n
14. Cleanse wound remembering principles of asepsis<\/a><\/td>\nClean to dirty; one wipe one way discard; fluids flow in the direction of gravity.<\/p>\n

\"\"<\/p>\n

 <\/td>\n<\/tr>\n

15. Cleanse around the drain if present<\/td>\nUsing a circular motion, clean the area immediately next to the drain and work outward\u00a0 still following principles of asepsis<\/p>\n

\"\"<\/td>\n<\/tr>\n

16. Apply new sterile dressing.<\/td>\nThe type of dressing applied will depend on the needs of the wound and the supplies available in the agency.<\/p>\n

Secure dressings and drains with tape.<\/p>\n

Write the date and time on the outside of the dressing as a way to inform others.<\/td>\n<\/tr>\n

17. Ensure the patient is comfortable before leaving the bedside.<\/p>\n

Perform hand hygiene.<\/p>\n

 <\/td>\n

Discard used equipment according to agency policy.<\/td>\n<\/tr>\n
18. Document according to agency policy.<\/p>\n

 <\/p>\n

Consider the progression of wound healing. If concerned notify the prescriber.<\/td>\n

Documentation example:<\/p>\n

date \/ time: abdominal dressing changed. Moderate sanguinous drainage from distal end of incision. Wound well approximated. Staples intact. Cleansed with 0.9% NS. Dressed with medipore dressing. Patient tolerated well. ——- B. Dage RN<\/em><\/p>\n

 <\/p>\n

 <\/td>\n<\/tr>\n

Data source: BCIT, 2010a; Perry et al., 2018<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n
\n
If necessary review Principles of Asepsis<\/a><\/em> developed by Ren\u00e9e Anderson & Wendy McKenzie Thompson Rivers University.<\/div>\n
Watch the video Simple Sterile Dressing Change<\/em><\/a> developed by Ren\u00e9e Anderson and Wendy McKenzie Thompson Rivers University School of Nursing (2014).<\/div>\n<\/div>\n","protected":false},"author":397,"menu_order":5,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-219","chapter","type-chapter","status-publish","hentry"],"part":195,"_links":{"self":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/219","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/users\/397"}],"version-history":[{"count":25,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/219\/revisions"}],"predecessor-version":[{"id":5166,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/219\/revisions\/5166"}],"part":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/parts\/195"}],"metadata":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/219\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/media?parent=219"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapter-type?post=219"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/contributor?post=219"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/license?post=219"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}