Wound Dressing

Question 1

Gather Supplies

Answer 1

1. Dressing tray
2. Disposal bag
3. Non-sterile gloves
4. Tape
5. Normal saline

Question 2

Prepare Environment

Answer 2

1. Prep workspace thats clean & place supplies within easy reach
2. Place height of bed up
3. Lower bedrail closest to you

Question 3

Prepare Client

Answer 3

1. Undrape part of wound
2. Perform HH

Question 4

Remove Existing Dressing

Answer 4

1. Put on gloves
2. Remove dressing
3. Dispose gloves & dressing

Question 5

Pre-Dressing/Assess

Answer 5

1. Open tray; add NS
2. Wear sterile gloves
3. Inspect wound
   - type of wound
   - location
   - measurement (height/width/depth)
   - partial/full thickness; type of pressure injury (stage 1,2,3,4, unstageable)
   - base: pink, red, weight, yellow, black
   - exudate: scant, minimal, moderate, large
   - drainage: sanguineous (active bleeding), serous (clear), serosanguineous (some blood), purulent (yellow)
   - infection (wound edges and periwound are red, warm, swelling, tenderness, purulence)

Question 6

Cleaning of Wound

Answer 6

1. Clean from least to most dirty (outer to inner & dispose of each swab)
2. Dry area with sterile gauze
3. Apply dressing
4. Apply cover dressing & secure with tape
5. Remove gloves and garbage

Question 6

After Wound Cleaning

Answer 6

6. Assist client to comfortable position
7. Bedrails up
8. Lower bed

Question 7

Document

Answer 7

1. Completed dressing change as per hospital policy.
2. Wound dressing had scant/moderate/ large amount of purulent/serosang/sangineous exudate on previous dressing.
3. Wound was a laceration/stage 2 pressure injury on client’s left upper thigh. Wound was 1inch by 1inch with less than 1 inch of depth.
4. Base was red with scant sanguineous discharge.
5. Periwound area had no signs of swelling, redness, warmth.
6. Wound was cleaned with normal saline and this type of dressing was applied.
7. Client tolerated the procedure well and reported no pain.