Bicol University Tabaco Campus
NURSING DEPARTMENT
Tabaco City
RLE EVALUATION SHEET
(SKILLS LABORATORY)
Name: __________________________________ Rating: __________________
Group No.: ______________________________ Date: ___________________
Legend:
5 – Excellent – Carries out the procedures efficiently, systematically and independently.
4 – Very Satisfactory – Carries out the procedures efficiently and systematically but requires
minimal guidance and supervision.
3 – Satisfactory – Carries out the procedures efficiently and systematically but requires
moderate guidance and supervision.
2 – Fair – Carries out the procedures efficiently and systematically but requires close guidance
and supervision.
1 – Needs Improvement – Carries out the procedure inefficiently and unsystematically and
requires close guidance and supervision.
CLEANING A WOUND AND APPLYING A DRY, STERILE DRESSING
5 4 3 2 1 CI’s Remarks
The goal of wound care is to promote tissue repair and
regeneration to restore skin integrity. Wound cleansing is
performed to remove debris, contaminants, and excess
exudate.
Equipment/Supplies:
Sterile gloves
Clean disposable gloves
Sterile gauze dressings
Sterile gauze pad or cotton balls
Sterile dressing set (for the sterile scissors and
forceps)
Sterile cleaning solution as ordered (Povidone
iodine, or a commercially prepared wound
cleanser)
Sterile basin (may be optional)
Sterile drape (may be optional)
Plastic bag or other appropriate waste container
for soiled dressings
Waterproof pad and bath blanket (if available)
Adhesive Tape (Micropore / Leukoplast)
Bath blanket or other linens for draping patient
1. Review the medical orders for wound care or the
nursing plan of care related to wound care.
2. Gather the necessary supplies and bring to the
bedside stand or over-bed table
3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
5. Provide privacy. Explain what you are going to do and
why you are going to do it to the patient.
6. Place a waste receptacle or bag at a convenient
location for use during the procedure.
7. Adjust bed to comfortable working height, usually
elbow height of the caregiver
8. Assist the patient to a comfortable position that
provides easy access to the wound area. Use the
bath blanket to cover any exposed area other than
the wound. Place a waterproof pad under the
wound site.
9. Put on clean, disposable gloves and loosen tape on
the old dressings.
10. Carefully remove the soiled dressings. If any part of
the dressing sticks to the underlying skin, use small
amounts of sterile saline to help loosen and remove.
11. After removing the dressing, note the presence,
amount, type, color, and odor of any drainage on
the dressings. Place soiled dressings in the
appropriate waste receptacle. Remove your gloves
and dispose of them in an appropriate waste
receptacle.
12. Inspect the wound site for size, appearance, and
drainage. Assess if any pain is present. Check the
status of sutures, adhesive closure strips, staples,
and drains or tubes, if present. Note any problems
to include in your documentation.
13. Using sterile technique, prepare a sterile work area
and open the needed supplies.
14. Open the sterile cleaning solution. Depending on the
amount of cleaning needed, the solution might be
poured directly over gauze sponges over a container
for small cleaning jobs, or into a basin for more
complex or larger cleaning.
15. Put on sterile gloves.
16. Clean the wound. Clean the wound from top to
bottom (for incised/lacerated wound; beginning
from the center to the sides by doing 5
strokes/wipes) and / or from the center to the
outside (for abrasion/penetrated/punctured wound;
in circular motion). Following this pattern, use new
gauze pad/cotton ball for each wipe, placing the
used gauze in the waste receptacle. Alternately,
spray the wound from top to bottom with a
commercially prepared wound cleanser, if being
used.
17. Once the wound is cleaned, dry the area using a
gauze sponge in the same manner. Apply ointment
or perform other treatments, as ordered.
18. Apply a layer of dry, sterile dressing over the wound.
Forceps may be used to apply the dressing.
19. Remove and discard gloves. Apply tape.
20. Remove all remaining equipment; place the patient
in a comfortable position, with side rails up and bed
in the lowest position.
21. Remove PPE, if used. Perform hand hygiene.
22. Document the location of the wound and that the
dressing was removed. Record your assessment of
the wound including approximation of wound edges,
presence of sutures, staples or adhesive closure strips
(if any), and the condition of the surrounding skin.
Note if redness, edema, or drainage is observed.
Record the type of dressing that was reapplied. Note
pertinent patient and family education and any
patient reaction to this procedure, including patient’s
pain level and effectiveness of non-pharmacologic
interventions or analgesia if administered.
