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Wound Dressing Checklist

This document is a performance evaluation checklist for wound dressing that contains 21 steps. It includes assessing the client and wound, preparing supplies, explaining the procedure to the client, performing hand hygiene, cleaning and dressing the wound using sterile technique, and documenting the procedure. The evaluator rates the student nurse on a scale of 1 to 5 for each step of preparing for and completing the wound dressing.

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BUAHIN JANNA
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3K views3 pages

Wound Dressing Checklist

This document is a performance evaluation checklist for wound dressing that contains 21 steps. It includes assessing the client and wound, preparing supplies, explaining the procedure to the client, performing hand hygiene, cleaning and dressing the wound using sterile technique, and documenting the procedure. The evaluator rates the student nurse on a scale of 1 to 5 for each step of preparing for and completing the wound dressing.

Uploaded by

BUAHIN JANNA
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Ateneo de Zamboanga University

COLLEGE OF NURSING
PERFORMANCE EVALUATION CHECKLIST

NAME: _____________________________________ DATE PERFORMED: _________________


YEAR & SECTION: ______________

WOUND DRESSING

PREPARATION 1 2 3 4 5
1. Assess:
 Client allergies to wound- cleaning agents
 The appearance and size of the wound
 The amount and character of exudate
 Client’s complaints of discomfort
 The time of the last pain medication
 Signs of systemic infection
2.  Determine any specific order about the
wound or dressing
3. Assemble equipment:
 Bath Blanket (if necessary)
 Moisture-proof bag
 Mask
 Acetone or other solution to loosen adhesive
 Clean gloves
 Sterile gloves
 Sterile dressing set or pack. If none is
available, gather the following items:
 Drape or towel
 Gauze squares
 Container for the cleaning solution
 Sterile forceps
 Gauze dressing and surgical pad
 Applicator or tongue blades to apply
ointment or cream
 Additional supplies as ordered
 Tape, tie tapes, plaster or binder
4. Prepare the client:
 Ask for assistance in changing dressing on a
restless or confused client.
 Assist the client to a comfortable position in
which the wound can be readily exposed.
Expose only the wound area.
 Make a cuff on the moisture-proof bag for
disposal of the soiled dressing, placing the
bag within reach.
PROCEDURE
1. Introduce yourself, and verify the client’s identity.
Explain to the client what you are going to do, why it is
necessary and how the client can cooperate.

2. Perform hand hygiene and observe other appropriate


infection control procedures.
3. Provide client privacy
4. Remove blinders and tape, if used, and put them aside;
untie tapes.
5. If adhesive tape was used, remove it by holding down
the skin and pulling the tape gently but firmly towards the
wound. Use acetone to loosen the tape, ir necessary.
6. Remove and dispose of soiled dressing appropriately.
7. Put on clean disposable gloves and remove the outer
abdominal dressing and surgical pad. Lift the outer
dressing such that the underside is away from the client’s
face.
8. Place the soiled dressing in the moisture-proof bag
without it touching the outside of the bag.
9. When removing the outer dressing, be careful not to
dislodge any drains. If the gauze sticks to the drain,
support the drain with one hand, and remove the gauze
with the other hand.
10. Assess the location, type, odor of the wound drainage
and the number of gauze saturated with drainage.
11. Dispose soiled dressing in the bag as before. Remove
gloves and dispose them in the moisture-proof bag. Wash
hands.
12. Open the sterile pack using aseptic technique and set
up the sterile supplies.
13. Open the sterile cleaning solution and pour it on the
gauze sponges in the plastic container. Put on sterile
gloves.
14. Clean the wound with the moistened gauze.
15. When using forceps, keep the tips lower than the
handles at all times.
16. Use a separate swab for each stroke. Dispose swab in
the moisture –proof bag.
17. If a drain is present, clean it taking care to avoid
reaching across the incision. Clean the skin around the
drain by swabbing in half or full circle from around the
drain site outward using separate swab for each stroke.
18. Support and hold the drain erect while cleaning around
it. Clean as many time as necessary.
19. Dry the surrounding skin with gauze swab. Do not dry
the incision or wound itself because moisture facilitates
healing.
20. Apply sterile dressing one at a time to the drain site
and incision. Place the bulk of the dressing over the drain
area.
21. Remove gloves and dispose them. Secure the
dressing with tape or ties.
22. Document the procedure and assessment findings.

______________________________________________
Clinical Instructor

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