simple wound dressing

Question 1

What is the PPE to be worn (if there is existing wound dressing)?

Answer 1

surgical mask + white plastic apron + non sterile gloves

Question 2

How do you don your PPE (if there is existing wound dressing)?

Answer 2

6. For wound dressing, you cannot gather equipment from the bottom of trolley and put it on the top of trolley because the top of trolley is presumed to be the disinfected working space. Hence, in the subsequent steps, you should grab the equipment one at a time from the bottom of the trolley and wear them.
7. “I will check the expiry date of each personal protective equipment before I wear them.” Look for the expiry date on the equipment packaging OR the boxes for some equipment (eg. for gloves, the expiry date is on the box). Some equipment may not have expiry dates, but just show that you are looking for the expiry date on both the equipment and their boxes, even if there turns out to be no expiry date in the end. You will have a lot of time anyway!
8. Don surgical mask first, then white plastic apron, then non-sterile gloves. (M > A > G)
   a. Don surgical mask – blue surface is outer surface. The folds of the surgical mask should face down for liquids to drip downwards. Metal wire should be at the top. Pull top and bottom edges of mask to spread it across your face. Ensure bottom edge is under your chin. Mould the metal wire to your nose.
   b. Don white plastic apron – Unfold the plastic apron carefully and slowly, without flinging it out. Hook top strap over your neck first, and then tie the bottom knot.
   c. Don non-sterile gloves.

Question 3

How do you approach the patient?

Answer 3

a. Introduce myself
b. Double-check patient identifiers
c. Explain the procedure to the patient, and inform them that the wound dressing procedure may be slightly painful
d. Obtain patient consent”

Question 4

How do you remove existing dressing (if there is)?

Answer 4

10. Using your gloved fingers, peel off the edges of the existing dressing, and lift up half of the existing dressing and look at the dummy wound. “I will then perform a wound assessment to see how the wound is healing.”
11. Leave the existing loosened dressing on top of the wound. DO NOT discard the existing dressing to prevent any pathogens getting to the wound from now until the new dressing is placed on the wound.
12. Remove non-sterile gloves using aseptic technique – outside of glove can only touch outside of other glove. Pinch wrist part of 1st glove and pull it down, turning 1st glove inside-out along the way to trap any pathogens. Ball up 1st glove in 2nd-gloved hand. Use exposed finger to insert under the cuff of 2nd glove and pull down to remove 2nd glove inside-out. Discard both gloves into ANY rubbish bin (there will be a small plastic bag at the side of the trolley that acts as a rubbish bin, and a big rubbish bin with a foot pedal, you can choose from either one).

Question 5

How do you don your PPE (if there is no existing wound dressing)?

Answer 5

13. For wound dressing, you cannot gather equipment from the bottom of trolley and put it on the top of trolley because the top of trolley is presumed to be the disinfected working space. Hence, in the subsequent steps, you should grab the equipment one at a time from the bottom of the trolley and wear them.
14. “I will check the expiry date of each personal protective equipment before I wear them.” Look for the expiry date on the equipment packaging OR the boxes for some equipment (eg. for surgical mask, the expiry date is on the box). Some equipment may not have expiry dates, but just show that you are looking for the expiry date on both the equipment and their boxes, even if there turns out to be no expiry date in the end. You will have a lot of time anyway! 
15. Don surgical mask first, then white plastic apron. (M > A) DO NOT NEED TO WEAR GLOVES AS YOU ARE NOT GOING TO LOOSEN ANY EXISTING WOUND DRESSING.
    a. Don surgical mask – blue surface is outer surface. The folds of the surgical mask should face down for liquids to drip downwards. Metal wire should be at the top. Pull top and bottom edges of mask to spread it across your face. Ensure bottom edge is under your chin. Mould the metal wire to your nose.
    b. Don white plastic apron – Unfold the plastic apron carefully and slowly, without flinging it out. Hook top strap over your neck first, and then tie the bottom knot.

Question 6

How do you prepare the wound dressing kit at patient’s bedside?

Answer 6

16. 3rd hand rub (from bottle on trolley) – show 7 steps.
17. Grab wound dressing kit from bottom of trolley. “I will check the expiry date of the wound dressing kit before I open it.”
18. Ensuring that the yellow receptacle bin is on the top of the wound dressing kit, SLOWLY open the paper packaging of the wound dressing set near but not directly above the wound dressing kit. Open the paper packaging only halfway, if not it might fall out accidentally. Approach the trolley from the edge of the trolley to avoid crossing the top surface of the trolley. From a height of about 20cm, drop this wound dressing kit SLOWLY, such that it lands in the middle of the trolley. Discard the paper packaging into ANY rubbish bin.
19. Unfold the yellow receptacle bin and place at BOTTOM PART of where you would place the sterile drape later (ie. place the yellow receptacle bin outside the sterile field). This is for easy flow > once you have cleaned the wound in a top to bottom motion with your right hand > your right hand moves down to the receptacle at the bottom of the sterile drape > drops the gauze into the receptacle from 20cm height (see diagram).
    c. NOTE sterile fields = wound dressing kit + sterile drape!
20. Medical hand wash – show 7 steps.
21. Use the outer part of plastic packaging like a glove, and grab both the sterile drape and paper towels that have been packed at the top of the white container, then open the bottom fold of the plastic packaging + the sterile drape and paper towels towards your body, dropping the sterile drape and paper towels separately outside the white container (If you open the fold of the plastic packaging away from your body, your arms will cross the sterile field).
    a. NOTE 1: Your arms should not cross the sterile field when rearranging the items in the wound dressing kit, so always keep your hands confined to the the edges of the wound dressing kit.
    b. NOTE 2: 1-cm perimeter on the inner part of the blue plastic packaging is considered “contaminated” so you can use your fingers to freely adjust the margins of this plastic packaging
    c. NOTE 3: Ensure that the blue plastic packaging is opened fully and all flaps are laid out, if not the flaps risk folding back and contaminating your wound dressing set.
    a. To do this, pull the edges of the contaminated zone apart firmly to open the blue plastic packaging as much as possible. You can also use the outer part of the blue plastic packaging like a glove to shift the white container around and place them over the fold-lines. (In the reused packages that we use during OSCE practices, the “folding back” does not really happen because the lines have been flattened
    countless times, but in OSCEs where the wound dressing sets are really new, the tendency for the blue plastic packaging to fold back on itself is really high.)
22. Use the outer part of the blue plastic packaging like a glove to rearrange the items in the wound dressing set if they have shifted about.
    d. Put all the cotton balls into one compartment.
    e. Ensure the paper towels are in an easily accessible location for surgical handwash procedure.
23. Grab one Tegaderm from the bottom of the trolley. “I will check the expiry date of the Tegaderm before opening it.” Open the outer paper packaging of the Tegaderm near but not directly above the wound dressing kit. Open the paper packaging only halfway, if not the Tegaderm might fall out accidentally. Approach the wound dressing kit from the edge of the plastic packaging to avoid crossing the sterile field. From a height of about 20cm, drop this Tegaderm SLOWLY, such that it lands nearby but not on top of the white container. Discard the paper packaging into ANY rubbish bin. Repeat procedure again (total 2 Tegaderms).
    a. Drop the Tegaderms slowly if not they risk flying out of the wound dressing kit as they are really lightweight.
    b. Do not drop the Tegaderms onto the top of the white container because you still need to pour saline on the cotton balls in the white container after this.
24. Grab a bottle of saline from the bottom of trolley. “I will check the expiry date of the saline bottle before opening it.” Twist open a bottle of saline near but not directly above the wound dressing kit. Approach the wound dressing kit from the edge of the plastic packaging to avoid crossing the sterile field. From a height of about 20cm, squeeze out the saline onto the compartment with cotton balls. Discard the empty bottle into ANY rubbish bin.
25. Surgical hand wash all the way until elbows, DO NOT rinse in a back and forth motion, DO NOT extend elbows to avoid letting water drip back up to fingers, DO NOT let hands touch each other, and DO NOT let hand touch the basin/tap head. Leave hand under the running tap in the same location to rinse all soap in that location off. DO NOT rinse in a back and forth motion!!!

Question 7

What do you do after surgical hand wash?

Answer 7

27. Approach the wound dressing kit from the edge of the plastic packaging to avoid crossing or dripping water onto the sterile field. Use one bare hand to pick up one paper towel.
28. Dry ONE hand with ONE paper towel from dressing set in circular motions from fingers down to elbow. DO NOT dry in a back and forth motion!!! Discard first paper towel into ANY rubbish bin.
29. Approach the wound dressing kit from the edge of the plastic packaging again and use other hand to pick up other paper towel. Repeat procedure to dry other hand.
30. Approaching from the edge of the plastic packaging to avoid crossing the sterile field, use one forceps to pick up sterile drape and transfer it to other hand. Set down the forceps along the edge of the wound dressing set. Always set down forceps along the edge of the wound dressing set whenever they are not in use (see diagram).
31. Use your bare hands to unfold the sterile drape away from the plastic packaging, and set it up along the pathway between you and the wound. White absorbent side faces upwards, green side is non-absorbent/waterproof, so any liquids will flow off. Do not place the sterile drape directly underneath the wound.
    f. NOTE 1: If a small wound square is used, you should place the sterile drape directly next to the wound square to collect any dripping fluids, along the pathway between you and the wound.
    g. NOTE 2: If a mannequin arm is used, you should place the sterile drape on top of the arm, directly below the wound on the arm to collect any dripping fluids, along the pathway between you and the wound (see diagram).
32. Use one bare hand to pick up one forceps.
33. Use that forceps to pick up another forceps for the other hand.
34. Prepare the equipment in the wound dressing set.
    a. Remove gauzes from their compartment to create an empty gauze compartment.
    b. Fold the gauzes into half and place them under the container.
    c. Squeeze the soaked cotton balls over the original compartment they were in, and place them in the now-empty gauze compartment.
35. One pair of forceps can never leave the sterile field. Let’s call them the sterile-field and non-sterile-field forceps.
36. Use the non-sterile-field forceps nearest the wound to remove the wound dressing and discard both non-sterile forceps and wound dressing into yellow receptacle immediately.
37. Use the sterile-field forceps to pick up the remaining forceps for the other hand.
38. Use the sterile field forceps to transfer a cotton ball to the non-sterile-field forceps at the junction of the contaminated zone of the plastic packaging. Not over the sterile drape.
    a. Ensure that the 2 forceps do not touch when passing cotton balls.
39. Clean the wound itself first, using one cotton ball in one sweeping motion down towards gravity. One pass only! Discard cotton ball FROM A 20CM HEIGHT into the yellow receptacle immediately. Repeat for another cotton ball (total 2 cotton balls).
40. Clean the right edge of wound, using one cotton ball in one sweeping motion down towards gravity. One pass only! Discard cotton ball FROM A 20CM HEIGHT into the yellow receptacle immediately. Repeat for another cotton ball (total 2 cotton balls).
41. Clean the left edge of wound, using one cotton ball in one sweeping motion down towards gravity. One pass only! Discard cotton ball FROM A 20CM HEIGHT into the yellow receptacle immediately. Repeat for another cotton ball (total 2 cotton balls).
42. Dry the wound and its edges using folded gauze in a dab-dry motion down towards gravity. One pass only! Discard each piece of gauze FROM A 20CM HEIGHT into the yellow receptacle immediately. STOP WHEN YOU HAVE ONLY ONE PIECE OF GAUZE REMAINING.
    b. Ensure that the 2 forceps do not touch when passing gauze. To do that, you can pick up gauze using sterile forceps in the middle of the rectangle of gauze, then transfer the gauze to the other forceps by grabbing the opposite side at the middle of the rectangle of gauze also.
43. Pick up and place the final piece of folded gauze over the wound.
44. Put down the non-sterile field forceps in the blue plastic packaging (nothing much left in the sterile field so it is okay to put non-sterile field forceps in it).
45. Using the sterile-field forceps, pick up Tegaderm, transfer to your hands, and set the sterile-field forceps back down into sterile field.
46. Peel open the sticker backing. Apply Tegaderm onto half of the wound. Man symbol on the Tegaderm pack should be facing upwards (non-sticky part). Discard the Tegaderm wrapper.
47. Repeat above step to cover other half of wound with another Tegaderm.
48. Put sterile drape and yellow receptacle into blue plastic packaging. Fold up wound dressing set and discard.
49. Thank the patient.
50. Hand rub

Question 8

how do you remove the PPE?

Answer 8

51. Remove white plastic apron using aseptic technique – pull to break top loop of apron first then break bottom strap. (FOR APRON: It is top then bottom, NOT THE SAME AS YELLOW GOWN SEQUENCE OF REMOVAL). Ball up apron slowly using inner surface (do not fling it out as there may be fluids). Discard white plastic apron.
52. Hand rub
53. Remove the surgical mask using aseptic technique – ensure you do not cup/touch the front surface of the surgical mask – remove both ear straps at the same time to prevent it from brushing your clothes. Discard the surgical mask.
54. Medical hand wash
55. Document in patient records the condition of wound, and time and type of wound dressing done.