Learning Guide: WOUND CARE

Indication: When carrying out any procedure that bypasses the bodies natural defence mechanisms
e.g. skin to protect patients from possible infections

Equipment:
 Sterile dressing pack  Adhesive Tape
 Swabs  Bandages
 Forceps  Clean scissors
 Sterile towels  Sterile gloves and clean gloves
 Fluids for cleaning/ irrigation  Apron
 Gallipot  Cheatel forceps
 Kidney dish  Procedure trolley
 Appropriate dressings  Infection prevention buckets
 Drapes  0.5% chlorine solution

ACTION RATIONALE
Identify client/patient To ensure procedure is carried out on correct
patient.

Greet client/patient and introduce self To build therapeutic relationship and rapport. To
maintain professionalism and accountability.

Discuss and explain the procedure with the To ensure the patient gives their valid consent,
patient. Provide psychological support and co-operation. To alleviate anxiety.
throughout.

Assess the patient's level of pain and administer To ensure patient comfort during procedure.
analgesia prior to procedure if necessary.

Gather equipment. Check that equipment is Damaged equipment loses its sterility.
sterile and packaging is undamaged.

Wash and dry hands thoroughly. To prevent cross contamination

Clean trolley with the chlorine solution To provide a clean working surface

Place all the equipment required on the bottom of To maintain the top shelf as a clean working
the trolley surface

Put on apron and non sterile gloves. To protect yourself from any bodily fluids when
assisting the patient

Position the patient comfortably either in the To allow dust to settle before the sterile field
dressing room or on their bed. Screen the area and wound are exposed, and to maintain
as appropriate. privacy.
Place drapes under affected area To protect bedding and closes and prevent
contamination

Remove dressing and discard old dressing in To prevent contamination from used dressing.
clinical waste.

Assess appearance of wound. To identify most appropriate method of cleaning

Remove gloves and wash hands thoroughly To maintain infection control and prevent cross
contamination

Open sterile pack using only the corners of the To keep potential areas of contamination to a
cloth and arrange inner contents using forceps, minimum
without touching equipment with hands.

Place all other sterile equipment on the sterile Pre-prepare equipment to ensure minimum
field being careful to avoid contamination time the wound is exposed.
including cleansing solution.

Apply sterile gloves To maintain a sterile working condition. To

Use forceps and swabs dipped in cleansing To reduce the risk of infection. So as not to
solution to clean the wound as appropriate contaminate sterile area.
following your assessment. Cleansing of wound with sterile swabs should
begin at the wound outwards towards
Cleansing should take place from the inside of surrounding skin so as not to introduce new
the wound outwards towards the surrounding bacteria from surrounding skin to wound.
skin in a circular motion. One direction cleaning when using sterile swab
should take place to remove bacteria, rubbing
Any swab should be used for only one wipe and up and down can leave bacteria remaining in
the wound.
then discarded. Continue until wound is clean.
Dry surrounding skin with sterile gauze To allow a dry area for the dressing to be
secured to the skin

Cover wound with sterile gauze or appropriate To reduce the risk of contamination.
dressing following assessment and secure with To prevent dressing falling off and leaving
adhesive. wound exposed. To create an environment
conducive for moist wound healing

If patient is mobile or wound is on a mobile limb, So that dressing does not fall off when patient
apply bandages to further secure dressing. moves.

Ensure the patient is comfortable and not left To promote and maintain patient comfort,
exposed. privacy and dignity.

Dispose of waste appropriately and clean down To prevent environmental contamination and
trolley. reduce the risk of spreading infection

Remove gloves and apron, wash hands. To reduce the risk of spreading infection

Document findings, include condition of wound, For a point of reference and continuity of care.
care carried out and type of dressing applied. For clear and accurate records.