Changing Sterile and Nonsterile Dressings

Nursing Procedure 11.3

Changing Sterile and Nonsterile Dressings

Removes accumulated secretions and dead tissue from wound or incision site
Decreases microorganism growth on wound or incision site
Promotes wound healing

Nonsterile gloves and sterile gloves (for sterile dressing change)
2-in. tape or Montgomery straps (paper tape, if allergic to others)
Sterile dressing tray (forceps, scissors, gauze pads [optional])
Additional sterile gauze dressing pads (2 × 2-in., 4 × 4-in., or surgical [ABD] pads, depending on drainage and size of area to be covered), or transparent dressing
Sterile bowl
Towel or linen-saver pad
Sterile cotton balls and cotton-tipped swabs (optional)
Sterile irrigation saline or sterile water
Cleaning solution as ordered
Bacteriostatic ointment
Overbed table or bedside stand
Trash bag
Pen

Assessment should focus on the following:

Doctor's orders regarding type of dressing change, procedure, and frequency of change
Type and location of wound or incision
Time of last pain medication
Client's level of pain
Allergies to tape or solution used for cleaning

Nursing diagnoses may include the following:

Impaired tissue integrity related to pressure ulcer
Risk for infection related to impaired skin integrity

Outcome Identification and Planning

Desired Outcomes

A sample desired outcome is:

Client's wound is healing with no signs of infection.

Special Considerations in Planning and Implementation

General

Dressing changes are often painful. Assess pain needs and medicate client 30 min before beginning the procedure.

Pediatric

Children are often immunosuppressed and have decreased resistance; strict asepsis is needed to minimize exposure to microorganisms.

Geriatric

Elderly clients are often immunosuppressed and have decreased resistance; strict asepsis is needed to minimize exposure to microorganisms.

Home Health

Use newspaper to cover the table surface before arranging the work field. Pets should not be permitted in the area during the procedure.

Delegation

In general, procedures such as dressing changes are performed by the registered nurse or licensed practical nurse. For less complex dressings, some agencies train special personnel to assist with dressing changes. ALL ASSESSMENTS AND THE MANAGEMENT OF COMPLEX DRESSING CHANGES AND WOUND MANAGEMENT ARE THE RESPONSIBILITY OF THE LICENSED NURSE.

[Outline]

Desired Outcomes
Special Considerations in Planning and Implementation

Action		Rationale
1	Perform hand hygiene and organize equipment.	Reduces microorganism transfer
2	Explain procedure and assistance needed to client.	promotes efficiency Reduces anxiety; promotes cooperation
3	Premedicate client for pain, if not previously medicated. Assess client’s pain level and wait for medication to take effect before beginning dressing change.	Decreases discomfort
4	Place bedside table close to area being dressed.	Facilitates management of sterile field and supplies
5	Prepare supplies:
	Place supplies on bedside table.	Provides easy access to materials; promotes swift dressing change
	Tape trash bag to side of table.	Allows easy disposal of contaminated waste
	Open sterile gloves and use inside of glove package as sterile field.	Facilitates use of supplies without contamination
	Open gauze-pad packages and drop several onto sterile field; leave some pads in open packages, if in plastic container (if not, place some pads into sterile bowl).	Maintains sterile field; prepares gauze for wetting
	Open dressing tray and remove plastic from sterile bowl.	Prepares tray and bowl for wetting solutions
	Open liquids and pour saline on two gauze pads and pour ordered cleaning solution on four gauze pads (more if wet-to-dry dressing).	Prevents transmission of microorganisms from table to supplies
	Place several sterile cotton-tipped swabs and cotton balls on sterile field (use gauze instead if staples are present because cotton may catch on edges of staples).	Prepares materials needed to clean wound
6	Don nonsterile gloves.	Prevents contamination of hands; reduces risk of infection transmission
7	Position client to allow access to wound and place towel or pad under wound area.	Provides access to wound; prevents soiling linens
8	Remove old dressing: loosen the tape by pulling toward the wound and place soiled dressing in the trash bag (note appearance of dressing and wound). IF DRESSING ADHERES TO WOUND, SOAK IT WITH SALINE, THEN GENTLY PULL FREE.	Permits observation of site and exposes site for cleaning
9	Assess need for frequent (every 4–6 hr) dressing changes and effect of tape on skin. If indicated, apply Montgomery straps to hold dressings.	Clients with excessive drainage or sensitivity to prolonged tape application may need more frequent dressing change
10	If using Montgomery straps to hold dressing:
	Place an 8-in. strip of tape on table, sticky side up, and cover it with a 4-in. strip of tape, sticky side down. Apply safety pins or half-in. slits in spaces along the vertical nonsticky side of tape.
	Place sticky side of tape on client, with nonsticky end reaching across half of wound area.
	Repeat process on other side of wound; if wound is long, apply straps to upper and lower portions through the slits or using the safety pins.	Holds dressing in place while preventing skin injury
11	Remove and discard nonsterile gloves and perform hand hygiene.	Reduces microorganism transfer
12	Don sterile gloves (face mask optional) for sterile dressing change, or don nonsterile gloves for nonsterile dressing change.	Prevents contamination of hands; reduces risk of infection transmission
13	Pick up saline-soaked dressing pad with forceps (forming a large swab) and remove debris and drainage from wound; move from the center of the wound outward, using a new pad for each area cleaned (Fig. 11.3). Discard old pads away from sterile supplies. Clean or replace forceps if soiled.	Prevents contamination of wound from microorganisms on skin surface; maintains sterility of supplies
14	Wipe wound with pads soaked with ordered cleansing solution, moving from center of wound outward; discard pads and forceps.	Reduces microorganism transfer; avoids cross-contamination
15	Apply antiseptic ointment, if ordered. Then place dressings over wound or incision in the following manner:	Reduces microorganisms at site
	Pick up dressing pads by its edge (salinesoaked, if wet-to-dry dressing), using sterile gloved hand or sterile forceps.
	Place pads over wound or incision site until site is covered.
	Cover with surgical pad (if wet-to-dry dressing).	Prevents contamination of dressing or wound
16	Secure dressing by pinning, banding, or tying Montgomery straps together (the tying method may be used when frequent dressing changes are anticipated; Fig. 11.4).	Keeps dressing in place
17	Write the date and time of dressing change on a strip of tape and place tape across dressing.	Indicates last dressing change and need for next change within 24–48 hr
18	Remove gloves and discard with soiled materials.	Reduces microorganism transfer
19	Restore or discard all equipment appropriately.	Reduces transfer of microorganisms among clients; prepares equipment for future use
20	Perform hand hygiene.	Reduces microorganism transfer
21	Position client for comfort and place call light within reach.	Promotes safety; facilitates communication

Were desired outcomes achieved? Examples of evaluation include:

Desired outcome partially met: Delayed wound healing noted with poorly approximated wound borders, but no signs of infection noted.

The following should be noted on the client's record:

Location and type of wound or incision
Status of previous dressing
Status of wound/incision
Solution and medications applied to wound
Type of dressing applied to wound or incision
Client teaching done
Client's tolerance of procedure

section name header

Purpose ⬇

Equipment ⬆ ⬇

Assessment ⬆ ⬇

Nursing Diagnoses ⬆ ⬇

Outcome Id ⬆ ⬇

Implementation ⬆ ⬇

Evaluation ⬆ ⬇

Documentation ⬆