COLLEGE OF NURSING Visca, Baybay City, Leyte, Philippine Telephone: (053) 565-0600, local 1012 Email: nursing@vsu.edu.ph Website: www.vsu.edu.ph Name of Student: Section: Date: WOUND CARE: REMOVING AND APPLYING DRY DRESSING Scale of Achievement: 4 Exemplary (95 -100%) 3 Proficient (89 - 94%) 2 Developing (82- 88%) 1 Emerging (75-81% ) Performed the step with no prompting or input from the faculty. Performed the step with minimal (1 or less) prompting from the faculty Performed the step with multiple (2 or more) prompts from the faculty Did not perform the step. Faculty guided the student to demonstrate the step. Purpose : _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Articles Needed: STEPS RATIONALE 4 3 2 1 PREPROCEDURAL STEPS -Provide privacy as needed. -Introduce yourself to the client. -Perform hand hygiene and put on appropriate PPE if indicated. Assessment: Assess client for pain and provide non pharmacological and pharmacological interventions. Gather supplies and clear working area at bedside. Place a waste receptacle or red bag Vision: Mission: A globally competitive university for science, technology, and environmental conservation. Development of a highly competitive human resource, cutting-edge scientific knowledge and innovative technologies for sustainable communities and environment. Commen ts/ Remar ks COLLEGE OF NURSING Visca, Baybay City, Leyte, Philippine Telephone: (053) 565-0600, local 1012 Email: nursing@vsu.edu.ph Website: www.vsu.edu.ph close to work area. Adjust the bed to comfortable working height Assist the client into a comfortable position, using a bath blanket provide cover to expose areas other than the wound. Place an absorbent pad beneath the client. Apply clean gloves Remove the old dressing Loosen the tape or adhesive edges by removing in the direction of hair growth. Lift a corner of the dressing away from the skin with dominant hand, while gently pushing the skin away from the dressing with nondominant hand. Apply small amounts of sterile water to loosen the dressing if sticks to wound. Note the presence, amount, color, and odor of any drainage. Place old dressing in appropriate receptacle Assess the wound for size, appearance, and drainage. Note the presence of any sutures and drains. Remove soiled gloves and perform hand hygiene. Use sterile technique. Prepare a sterile work area and open supplies Open sterile cleaning solution and pour directly over gauze pack or into a sterile basin. Vision: Mission: A globally competitive university for science, technology, and environmental conservation. Development of a highly competitive human resource, cutting-edge scientific knowledge and innovative technologies for sustainable communities and environment. COLLEGE OF NURSING Visca, Baybay City, Leyte, Philippine Telephone: (053) 565-0600, local 1012 Email: nursing@vsu.edu.ph Website: www.vsu.edu.ph Put on sterile gloves. Clean wound from top to bottom or from center to the outside. Select a new gauze or sterile swab for each wipe. Dispose used gauze or swab in appropriate receptacle. Remove and dispose of gloves. Perform hand hygiene. Apply sterile gloves unless it is a chronic wound or pressure injury. Once the wound is cleaned and dry, apply a skin protectant on healthy skin around the wound. Place a layer of sterile gauze dressing over wound or as prescribed by the provider. Extend at least 1 inch past the wound edges. This dressing can be applied with forceps if desired. Apply a surgical or abdominal pad over the gauze if needed. Apply tape to dressing edges Remove gloves and discard. Perform hand hygiene Position client, and cover client with bed linens. Lower the height of the bed. Ensure that the client is in a safe position prior to leaving the room and has the call light within reach. Perform hand hygiene after removing all PPE. Document the procedure with time, date and remarks if any like condition of the skin and client’s response. Vision: Mission: A globally competitive university for science, technology, and environmental conservation. Development of a highly competitive human resource, cutting-edge scientific knowledge and innovative technologies for sustainable communities and environment. COLLEGE OF NURSING Visca, Baybay City, Leyte, Philippine Telephone: (053) 565-0600, local 1012 Email: nursing@vsu.edu.ph Website: www.vsu.edu.ph Knowledge (30%) ___________ Skills (50%) ___________ Attitude (20%) __________ General Comments/ Suggestions: __________________ Clinical Instructor Vision: Mission: ______________________ Student’s Signature A globally competitive university for science, technology, and environmental conservation. Development of a highly competitive human resource, cutting-edge scientific knowledge and innovative technologies for sustainable communities and environment.
