The goal of wound care is to promote tissue repair and regeneration to restore skin integrity. Often, wound care includes cleaning of the wound and the use of a dressing to maintain an environment to promote healing, absorb excess wound fluid, decrease or eliminate pain, and as a protective covering, a barrier to microorganisms (Baranoski & Ayello, 2020; Brown, 2018). Wound cleansing is indicated to remove debris, bacteria, contaminants, and inflammatory exudate from the wound surface, making the wound less conducive to microbial growth (Baranoski & Ayello, 2020, p. 150; Brown, 2018). Routine cleaning of a granulating, healthy wound, particularly acute wounds, if often not necessary and may damage fragile new tissue formation and can contribute to a delay in wound healing (Brown, 2018).

When cleaning of a wound is indicated, normal saline (0.9% sodium chloride) is traditionally recommended (Taylor et al., 2023). However, tap water of drinkable quality has been suggested as a safe alternative to normal saline, with data showing no difference in infection rates with cleansing with tap water versus normal saline (Cornish & Douglas, 2016; Fernandez & Griffiths, 2012). Home prepared saline solution has also been suggested as an inexpensive alternative (Baranoski & Ayello, 2020). Use of saline has also been identified as common for surgical wounds and tap water for chronic wounds (Annesley, 2019). Commercially prepared wound cleansing solutions, many of which contain antimicrobials and surfactants, are available, and may be considered for use with open wounds with exudate or debris (Baranoski & Ayello, 2020; Mahoney, 2020b; EPUAP, NPIAP, & PPPIA, 2019a). Sterile saline is recommended for cleaning surgical wounds up to 48 hours post surgery (NICE, 2013, as cited in Brown, 2018). Skin cleansers are harmful if used to cleanse wounds and should not be used (Baranoski & Ayello, 2020). Sterile equipment and solutions are required for irrigating an open wound, even in the presence of an existing infection (Taylor et al., 2023). Nonsterile solutions are generally used to clean the skin surface if the wound edges are approximated (Taylor et al., 2023). Clean, not sterile, dressings and gloves can usually be used in the home for care of chronic wounds, based on agency policy (Baranoski & Ayello, 2020).

There is no standard frequency for how often dressings should be changed; advances in dressing composition have resulted in the need for less frequent dressing changes (Baranoski & Ayello, 2020; Brown, 2018). Frequency of dressing changes depends on the wound characteristics, amount of drainage, and the particular wound care product being used. It is customary for the surgeon or other advanced practice provider to perform the first dressing change on a surgical wound, usually within 24 to 48 hours after surgery (Taylor et al., 2023).

There are many commercially prepared wound care products; primary dressings come in contact with the wound bed and are intended to maintain adequate moisture, absorb excess moisture, or add moisture. Secondary dressings cover a primary dressing or secure a dressing in place. The cleaning of a wound and application of many of these products is completed using similar underlying principles. It is very important for the nurse to be aware of the products available in a particular facility and be knowledgeable of the indications for and correct use of each type of dressing and wound care product in use. Refer to Fundamentals Review 8-4 and 8-5 for additional information.

This skill provides general guidelines and focuses on application of a sterile dressing; specifics may change based on the particular dressing and/or wound care product in use.

Assessment

Assess the situation to determine the need for wound cleaning and a dressing change. Confirm any prescribed interventions relevant to wound care and wound care included in the plan of care. Assess the patient's level of comfort and the need for analgesics before wound care. Assess if the patient experienced any pain related to prior dressing changes and the effectiveness of interventions employed to minimize the patient's pain. Assess the current dressing to determine if it is intact. Assess for excess drainage, bleeding, or saturation of the dressing. Inspect the wound and the surrounding tissue. Assess the appearance of the wound for the approximation of wound edges, the color of the wound and surrounding area, and signs of dehiscence. Assess for the presence of sutures, staples, or adhesive closure strips. Note the stage of the healing process and characteristics of any drainage. Also assess the surrounding skin for color, temperature, and edema, ecchymosis, or maceration.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

• Altered skin integrity risk
• Altered skin integrity
• Infection risk

Outcome Identification and Planning

The expected outcome to achieve when cleaning a wound and applying a sterile dressing is that the wound is cleaned and dressed without contaminating the wound area, causing trauma to the wound, or causing the patient to experience pain or discomfort. Other outcomes that are appropriate include the following: the wound continues to show signs of progression of healing, and the patient demonstrates an understanding of the wound care and dressing.

Implementation

Action	Rationale
1. Review the patient's health record for prescribed wound care or the care plan related to wound care. Gather necessary supplies.	Reviewing the health record and care plan validates the correct patient and correct procedure. Preparation promotes efficient time management and an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Assemble equipment on the overbed table or other surface within reach.	Organization facilitates performance of the task.
5. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why you are going to do it.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement.
6. Assess the patient for the possible need for nonpharmacologic pain-reducing interventions or analgesic medication before wound care dressing change. Administer appropriate prescribed analgesic. Allow enough time for the analgesic to achieve its effectiveness.	Pain is a subjective experience influenced by past experience. Wound care and dressing changes may cause pain for some patients.
7. Place a waste receptacle or bag at a convenient location for use during the procedure.	Having a waste container handy means the soiled dressing may be discarded easily, without the spread of microorganisms.
8. Adjust the bed to a comfortable working height (VHA Center for Engineering & Occupational Safety and Health [CEOSH], 2016).	Having the bed at the proper height prevents back and muscle strain.
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.	Patient positioning and the use of a bath blanket provide for comfort and warmth. Waterproof pad protects underlying surfaces.
10. Check the position of drains, tubes, or other adjuncts before removing the dressing. Put on gloves and loosen the tape or adhesive edge on the old dressings by removing in the direction of hair growth and the use of a push-pull method (Fumarola et al., 2020) (Figure 1). Push-pull method: lift a corner of the dressing away from the skin, and then gently push the skin down and away from the dressing/adhesive (Fumarola et al., 2020). Continue moving fingers of the opposite hand to support the skin as the product is removed (Fumarola et al., 2020). Once all adhesive is loosened from the skin, carefully lift dressing from the surrounding skin to prevent medical adhesive-related skin injury (MARSI). Remove the sides/edges first, then the center. If the patient is at increased risk for MARSI (see Box 8-2), requires repeated application or removal of adhesive devices, or there is resistance, use an adhesive remover (Barton, 2020; Fumarola et al., 2020; Kelly-O'Flynn et al., 2020).	Checking ensures that a drain is not removed accidentally if one is present. Gloves protect the nurse from contaminated dressings and prevent the spread of microorganisms. Removal of the tape in the direction of hair growth minimizes trauma to the skin (Fumarola et al., 2020). Pushing the skin down and away from the adhesive reduces the risk for MARSI (Fumarola et al., 2020). The use of adhesive remover allows for the easy, rapid, and painless removal without the associated problems of skin stripping and helps reduce patient discomfort (Barton, 2020; Fumarola et al., 2020; Kelly-O'Flynn et al., 2020).
11. 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 it.	Cautious removal of the dressing is more comfortable for the patient and ensures that any drain present is not removed. Sterile saline moistens the dressing for easier removal and minimizes damage and pain.
12. After removing the dressing, note the presence, amount, type, color, and odor of any drainage on the dressings (Figure 2). Place soiled dressings in the appropriate waste receptacle. Remove your gloves and perform hand hygiene.	The presence of drainage should be documented. Proper disposal of soiled dressings and used gloves prevents the spread of microorganisms. Hand hygiene prevents the transmission of microorganisms.
13. Inspect the wound site for size, appearance, and drainage (Refer to Fundamentals Review 8-2). 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.	Wound healing or the presence of irritation or infection should be documented.
14. Using sterile technique, prepare a sterile work area and open the needed supplies.	Supplies are within easy reach and sterility is maintained.
15. Open the sterile cleaning solution. Moisten gauze for cleaning the periwound skin. 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.	Sterility of dressings and solution is maintained.
16. Put on sterile gloves. Alternatively, clean gloves (clean technique) may be used when cleaning a chronic wound or pressure injury.	The use of sterile gloves maintains surgical asepsis and sterile technique and reduces the risk for spreading microorganisms. Aseptic technique should be used to change dressings for surgical wounds and in the acute clinical setting, to reduce the risk of transfer of pathogens, likely to be present in an acute care setting, to the wound (Brown, 2018). Clean technique is appropriate for cleaning chronic wounds, wounds in the home, or pressure injuries (Baranoski & Ayello, 2020; EPUAP, NPIAP, & PPPIA, 2019a; Taylor et al., 2023).
17. Clean the wound. Pour the cleaning solution over the wound from top to bottom. Alternatively, spray the wound from top to bottom with a commercially prepared wound cleanser. Wound irrigation is often used to clean open wounds and may also be used for other types of wounds. Refer to Skill 8-3.	Cleaning from top to bottom and center to outside ensures that cleaning occurs from the least to most contaminated area and a previously cleaned area is not contaminated again. Using a single gauze for each wipe ensures that the previously cleaned area is not contaminated again.
18. Clean the skin surrounding the wound. Clean from top to bottom and/or from the center to the outside, beginning at the wound edges. Refer to Box 8-3 (Figure 3). Use new gauze for each wipe, placing the used gauze in the waste receptacle.	Cleaning from top to bottom and center to outside ensures that cleaning occurs from the least to most contaminated area and a previously cleaned area is not contaminated again. Using a single gauze for each wipe ensures that the previously cleaned area is not contaminated again.
19. Once the wound and surrounding skin are cleaned, dry the surrounding skin area using a gauze sponge in the same manner.	Excess moisture on healthy skin increases risk for moisture-associated skin damage and interferes with proper adhesion of securement of dressings.
20. If a drain is in use at the wound location, clean around the drain. Refer to Skills 8-5, 8-6, and 8-7.	Cleaning the insertion site helps prevent infection.
21. Remove gloves and place in the waste receptacle. Perform hand hygiene.	Proper disposal of used gloves and hand hygiene prevent the spread of microorganisms.
22. Put on sterile gloves. Alternatively, clean gloves (clean technique) may be used when cleaning a chronic wound or pressure injury. Apply a skin protectant or barrier to the healthy skin around the wound where the dressing adhesive or tape will be placed and where wound drainage may come in contact with the skin (Figure 4).	The use of sterile gloves maintains surgical asepsis and sterile technique and reduces the risk for spreading microorganisms. Clean technique is appropriate for cleaning chronic wounds, wounds in the home, or pressure injuries (Baranoski & Ayello, 2020; EPUAP, NPIAP, & PPPIA, 2019a; Taylor et al., 2023). Skin barrier/protectant prevents skin irritation and excoriation from tape, adhesives, and wound drainage (Fumarola et al., 2020; Kelly-O'Flynn et al., 2020).
23. Apply any topical medications, foams, gels, and/or dressing product to the wound as prescribed; ensure products stay confined to the wound and do not impact on intact surrounding tissue/skin (Figure 5).	The growth of microorganisms may be inhibited and the healing process improved with the use of prescribed medications, foams, gels, and/or other wound care product.
24. Gently place the prescribed cover dressing at the wound center and extend it at least 1 inch beyond the wound in all directions. Alternatively, follow the manufacturer's directions for application (Figure 6).	Extending the dressing at least 1 inch past the wound edges ensures the dressing covers and protects the wound.
25. As necessary, apply a secondary dressing, based on products in use, prescribed interventions, and facility policy. Note: May not be necessary or appropriate, based on the cover dressing used in Step 23. Some dressings act as both primary and secondary dressings (Baranoski & Ayello, 2020).	Secondary dressings cover the primary dressing or secure the dressing (Baranoski & Ayello, 2020).
26. Apply additional materials, such as roller gauze, to secure the dressings as needed. Alternatively, many commercial wound products are self-adhesive and do not require additional tape. Remove gloves and perform hand hygiene.	Additional securing products keep the dressing in place. Proper disposal of gloves and hand hygiene prevent the spread of microorganisms.
27. Label the dressing with date and time. Remove all remaining equipment; place the patient in a comfortable position, with side rails up as indicated and bed in the lowest position.	Recording date and time provides communication and demonstrates adherence to care plan. Proper patient and bed positioning promotes safety and comfort.
28. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
29. Check all wound dressings at least every shift. More frequent checks may be needed if the wound is more complex.	Checking dressings ensures the assessment of changes in patient condition and timely intervention to prevent complications.

Evaluation

The expected outcomes have been met when the wound was cleaned and dressed without contaminating the wound area or causing trauma to the wound, the patient did not experience pain or discomfort, the wound has continued to show signs of progression of healing, and the patient has demonstrated an understanding of the wound care and dressing.