Sterile Wound Dressing Skill

Question 1

What is the critical thinking assessment done with this skill?

Answer 1

Skin color, dressing: dry/intact, drainage (COAT)
C: color (serous sanguinous – red/purulent – whitish yellow pus)
O: odor (foul or the scent with purulent)
A: amount (copious, scant)
T: time of last dressing change and the current time
DO THIS WHEN LOOKING AT THE WOUND
-unapproximated: anything changed in the wound that isn’t the initial incision
-approximated: is the incision
-check the length, width, and depth

Question 2

What is an unapproximated wound mean?

Answer 2

anything changed in the wound that isn’t the initial incision

Question 3

What is an approximated incision?

Answer 3

the surgical incision

Question 4

What does the wet to dry debriding wound dressing promote?

Answer 4

healing

Question 5

If the patient reports significant pain what must be done before the wound dressing change?

Answer 5

administration of the pain medication 30-60mins before

Question 6

What direction is the tape and dressing pulled?

Answer 6

from the farthest point to the center from each side.

Question 7

What is the procedure for this skill?

Answer 7

Opens lid of dressing kit and removes “red” bag, places moisture proof bag for discarding soiled dressings within reach.
Puts on clean gloves, removes adhesive tape from dressing, pulling the tape toward the wound.
Observes character and amount of drainage on dressing and appearance of wound.
Picks sterile barrier – touching
within 1 inch of border and
places on a clean surface.
Dons one sterile glove
(dominant)
Removes sterile supplies from
container without crossing over
or contaminating sterile fields.
Pours cleansing solution into
container with ungloved hand.
Dons second sterile glove (non-
dominant).
Cleanses wound with the prescribed solution and cleans from least contaminated to most contaminated (start at area closest to wound edge, working away from wound).
Packs wound, keeping pickup tips lower than the handles and avoids touching surrounding skin with packing.
Applies sterile dressing to wound.
Removes gloves.
Tapes dressing: records date, time and initials on tape.
Provide patient safety: bed in low position, side rails up

Position and cover patient appropriately

Question 8

How do you clean the wound?

Answer 8

like you would a meatus, in circular motions further and further out using different swabs for each circle around

Question 9

What direction are the forceps held?

Answer 9

down with the handle up

Question 10

Why is it important to know how many pieces of gauze were put in?

Answer 10

If the gauze put in doesn’t match the gauze taken out it can still be in the patient’s wound and fester.

Question 11

How is this skill documented?

Answer 11

1. ) date/time sterile wound dressing
2. ) abdominal wound
3. ) patient tolerated treatment well
4. ) premedicated with morphine
5. ) wound unapproximated
6. ) give the depth of the wound (width, length, depth)
7. ) erythema on the edges
8. ) type of drainage
9. ) Use COAT from assessment (C: color, O: odor, A: amount, T: time)