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Sterile Dressing Application

Introduction

Date of Last Review 9/5/08
SME:
Infection Control Manager

This topic explains how the nursing staff applies a sterile dressing.

Application process

This table describes the application process:

Stage

Description

1

Preparing for the application.

2

Removing the existing dressing.

3

Applying the new dressing.

4

Educating the patient.

Personal protective equipment (PPE)

Wear the following PPE when performing this procedure:

Gown

Sterile gloves

Mask

Supplies and equipment

Supplies:

Medicated ointment and/or solutions as ordered by a physician

Dressings and applicators as needed
Examples
: 4x4s, 2x2s, Kerlex

Plastic disposal bag and red bio-hazard bag

Tape

Antiseptic solution
Examples
: Cliniscrub, 4-oz. Plastic bottle

Sterile saline

Equipment:

Appropriate containers for medicated ointment and/or solutions

Instrument set if needed
Example
: Scissors and forceps

Sterile basin

Preparing

The nurse follows these steps to prepare for dressing application:

Step

Action

1

Gather the following as detailed above:

PPE

Supplies

Equipment

2

Make the necessary arrangements to maintain privacy during the procedure.

Note: Dressing changes should take place in the examination room.

3

Explain the procedure to the patient.

4

Position the dressing set on the table.

5

Wash your hands with antiseptic solution.

6

Open the dressing set without touching the contents.

7

Leave the dressing set on the open wrapper.

Reason: The wrapper provides a sterile environment for the dressing set.

8

Open the sterile supplies and pour the necessary solutions.

Removing existing dressing

The nurse follows these steps to remove the patient's existing dressing:

Step

Action

1

Loosen the tape on the patient's existing dressing.

2

Put on sterile gloves.

3

Remove the dressing, using forceps, if required

4

Place the used dressing and forceps in a plastic bag.

5

Does the wound require cleaning?

If yes, go to Step 6.

If no, go to Step 8.

6

Clean the wound with a sterile applicator using a circular motion beginning at the center of the wound and extending outward.

7

Place the used applicator(s) in a plastic bag.

Caution: Do not touch the wound site with a used applicator(s).

8

Observe the wound for complications.

Examples: Discoloration, edema, purulent drainage

Applying the sterile dressing

The nurse follows these steps to apply sterile dressing:

Step

Action

1

Apply the sterile dressing.

2

Remove your gloves and place them in a plastic bag.

3

Tape the new dressing in place.

4

Double-bag the contaminated articles closing each bag securely.

5

Place these bags inside a red plastic bag outside of the room.

6

Wash your hands using the proper technique.

Reference: See Hand Washing.

7

Clean up the treatment room and complete the charge tickets for materials used.

8

Document the following in the patient's record:

Name of person performing the procedure

Time of procedure

Description of the wound
Example
: Absence or presence of edema, discoloration, and/or drainage

Patient's reaction to dressing change

9

Report any unusual findings to the physician.

Educating the patient

The nurse follows these steps to educate the patient about the care of his/her wound and dressing:

Step

Action

1

Instruct the patient to keep his/her hands off of the wound.

2

Instruct the patient to report the following about the wound site to a nurse or physician:

Tenderness

Pain

Redness

Swelling

3

Is the patient returning home or to a halfway house?

If yes, instruct the patient and/or family how to change the dressing.

If no, you have completed this procedure.

Related standard

The Joint Commission : Surveillance, Prevention, and Control of Infection

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Harris County Psychiatric Center University of Texas Health Science Center