Cleaning a Wound and Applying a Dry, Sterile Dressing

Goal: The wound is cleaned and protected with a dressing without contaminating the wound area, without causing
trauma to the wound, and without causing the patient to experience pain or discomfort.
Procedure
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 overbed table.
3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
5. Close curtains around bed and close door to room if possible. Explain what you are going to do and why you
are going to do it to the patient.
6. Assess the patient for possible need for nonpharmacologic pain-reducing interventions or analgesic
medication before wound care dressing change. Administer appropriate prescribed analgesic. Allow enough
time for analgesic to achieve its effectiveness.
7. Place a waste receptacle or bag at a convenient location for use during the procedure.
8. Adjust bed to comfortable working height, usually elbow height of the caregiver.
9. 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.
10. Check the position of drains, tubes, or other adjuncts before removing the dressing. Put on clean, disposable
gloves and loosen tape on the old dressings. If necessary, use an adhesive remover to help get the tape off.
11. Carefully remove the soiled dressings. If there is resistance, use a silicone-based adhesive remover to help
remove the tape. If any part of the dressing sticks to the underlying skin, use small amounts of sterile saline to
help loosen and remove.
12. 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.
13. 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.
14. Using sterile technique, prepare a sterile work area and open the needed supplies.
15. 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.
16. Put on sterile gloves.
17. Clean the wound. Clean the wound from top to bottom and from the center to the outside. Following this
pattern, use new gauze 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.
18. Once the wound is cleaned, dry the area using a gauze sponge in the same manner. Apply ointment or
perform other treatments, as ordered.
19. If a drain is in use at the wound location, clean around the drain.
20. Apply a layer of dry, sterile dressing over the wound. Forceps may be used to apply the dressing.
21. Place a second layer of gauze over the wound site.
22. Apply a surgical or abdominal pad (ABD) over the gauze at the site as the outermost layer of the dressing.
23. Remove and discard gloves. Apply tape, Montgomery straps or roller gauze to secure the dressings.
Alternately, many commercial wound products are self-adhesive and do not require additional tape.
24. After securing the dressing, label dressing with date and time. Remove all remaining equipment; place the
patient in a comfortable position, with side rails up and bed in the lowest position.
25. Remove PPE, if used. Perform hand hygiene.
26. Check all wound dressings every shift. More frequent checks may be needed if the wound is more complex or
dressings become saturated quickly
Performing Irrigation of a Wound

Goal: The wound is cleaned without contamination or trauma and without causing the patient to experience pain or
discomfort.
Procedure
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 overbed table.
3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
5. Close curtains around bed and close door to room if possible. Explain what you are going to do and why you
are going to do it to the patient.
6. Assess the patient for possible need for nonpharmacologic pain-reducing interventions or analgesic
medication before wound care and/or dressing change. Administer appropriate prescribed analgesic. Allow
enough time for analgesic to achieve its effectiveness before beginning procedure.
7. Place a waste receptacle or bag at a convenient location for use during the procedure.
8. Adjust bed to comfortable working height, usually elbow height of the caregiver.
9. Assist the patient to a comfortable position that provides easy access to the wound area. Position the patient
so the irrigation solution will flow from the clean end of the wound toward the dirtier end. Use the bath
blanket to cover any exposed area other than the wound. Place a waterproof pad under the wound site.
10. Put on a gown, mask, and eye protection.
11. Put on clean gloves. Carefully and gently remove the soiled dressings. If there is resistance, use a silicone-
based adhesive remover to help remove the tape. If any part of the dressing sticks to the underlying skin, use
small amounts of sterile saline to help loosen and remove.
12. 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.
13. Assess the wound for appearance, stage, the presence of eschar, granulation tissue, epithelialization,
undermining, tunneling, necrosis, sinus tract, and drainage. Assess the appearance of the surrounding tissue.
Measure the wound.
14. Remove your gloves and put them in the receptacle.
15. Set up a sterile field, if indicated, and wound cleaning supplies. Pour warmed sterile irrigating solution into the
sterile container. Put on the sterile gloves. Alternately, clean gloves (clean technique) may be used when
irrigating a chronic wound.
16. Position the sterile basin below the wound to collect the irrigation fluid.
17. Fill the irrigation syringe with solution. Using your nondominant hand, gently apply pressure to the basin
against the skin below the wound to form a seal with the skin.
18. Gently direct a stream of solution into the wound. Keep the tip of the syringe at least 1 above the upper tip of
the wound. When using a catheter tip, insert it gently into the wound until it meets resistance. Gently flush all
wound areas.
19. Watch for the solution to flow smoothly and evenly. When the solution from the wound flows out clear,
discontinue irrigation.
20. Dry the surrounding skin with gauze dressings.
21. Apply a skin protectant to the surrounding skin.
22. Apply a new dressing to the wound
23. Remove and discard gloves. Apply tape, Montgomery straps, or roller gauze to secure the dressings.
Alternately, many commercial wound products are self-adhesive and do not require additional tape.
24. After securing the dressing, label dressing with date and time. Remove all remaining equipment; place the
patient in a comfortable position, with side rails up and bed in the lowest position.
25. Remove remaining PPE. Perform hand hygiene.
26. Check all wound dressings every shift. More frequent checks may be needed if the wound is more complex or
dressings become saturated quickly.
Caring for a Jackson-Pratt Drain
Goal: The drain is patent and intact
Procedure
1. Review the medical orders for wound care or the nursing plan of care related to wound/drain care.
2. Gather the necessary supplies and bring to the bedside stand or overbed table.
3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
5. Close curtains around bed and close door to room if possible. Explain what you are going to do and why you
are going to do it to the patient.
6. Assess the patient for possible need for nonpharmacologic pain-reducing interventions or analgesic
medication before wound care dressing change. Administer appropriate prescribed analgesic. Allow enough
time for analgesic to achieve its effectiveness before beginning procedure.
7. Place a waste receptacle at a convenient location for use during the procedure.
8. Adjust bed to comfortable working height, usually elbow height of the caregiver.
9. Assist the patient to a comfortable position that provides easy access to the drain and/or wound area. Use a
bath blanket to cover any exposed area other than the wound. Place a waterproof pad under the wound site.
10. Put on clean gloves; put on mask or face shield if indicated.
11. Place the graduated collection container under the outlet of the drain. Without contaminating the outlet
valve, pull the cap off. The chamber will expand completely as it draws in air. Empty the chamber’s contents
completely into the container. Use the gauze pad to clean the outlet. Fully compress the chamber with one
hand and replace the cap with your other hand.
12. Check the patency of the equipment. Make sure the tubing is free from twists and kinks.
13. Secure the Jackson-Pratt drain to the patient’s gown below the wound with a safety pin, making sure that
there is no tension on the tubing.
14. Carefully measure and record the character, color, and amount of the drainage. Discard the drainage
according to facility policy. Remove gloves.
15. Put on clean gloves. If the drain site has a dressing, include cleaning of the sutures with the gauze pad
moistened with normal saline. Dry sutures with gauze before applying new dressing.
16. If the drain site is open to air, observe the sutures that secure the drain to the skin. Look for signs of pulling,
tearing, swelling, or infection of the surrounding skin. Gently clean the sutures with the gauze pad moistened
with normal saline. Dry with a new gauze pad. Apply skin protectant to the surrounding skin if needed.
17. Remove and discard gloves. Remove all remaining equipment; place the patient in a comfortable position,
with side rails up and bed in the lowest position.
18. Remove additional PPE, if used. Perform hand hygiene.
19. Check drain status at least every four hours. Check all wound dressings every shift. More frequent checks may
be needed if the wound is more complex or dressings become saturated quickly