NURS 275-11 Skills Check Off #1 Wound Care: Moist-Moist Packing

Step 1

- Confirms Physicians order

- Performs standard greeting and prep.

- Gathers supplies

- Raises Bed to comfortable height

- Position patient for wound access.

Wound Packing Supplies

- Sterile 4x4 Gauze

- Cover Gauze

- Sterile Saline

- Clean Gloves

- Cotton Tipped Applicator with Measurement markings.

Step 2

- Performs hand hygiene

- Applies:

1. Moisture Impervious Gown

2. Face Shield

3. Clean Gloves

Step 3

- Remove soiled dressings into biohazard waste.

- Removes gloves and performs hand hygiene.

Step 4

- Perform Essential Wound Assessment:

1. Anatomic Location

2. Size: Diameter, Length, Width, Depth in centimeters.

3. Presence of undermining or tunneling.

4. Appearance of wound base: granulation, epithelialization, muscle, subcu tissue, color, exudate.

5. Using the provided Application Q-Tip, perform measurements.

Providing Wound Measurements

- Using the pts head and feet as clock face indications, measure the wound by length and width.

- Starting with the first sign of undermining or tunneling, measure the depth by inserting Q-tip into wound and use finger to mark where it stops. Document clock location and depth in cm.

- Proceed to move to other areas of undermining and tunneling and and document and measure using the clock face indication and cm.

- Using the Q-tip, indicate the depth measurement of the deepest area.

Step 5

- Without contamination, opens packages & places supplies on work surface that has been cleaned with disinfectant using twice-wipe procedure

- Aseptically pours sterile normal saline into sterile bowl (or plastic Kerlix gauze

container).

Step 6

- Primary Dressing Layer (Moist)

- Clean the wound with normal saline - Wets sterile gauze with sterile saline (squeezes out excess).

- Opens each gauze pad fully

- Using a cotton-tipped applicator, gently packs gauze into wound beginning at deepest area of wound bed, touching gauze to all aspects of the floor & walls of the wound

- Adds more gauze until wound is filled to skin level

- Counts total number of pads placed for documentation

Step 7

- Secondary Dressing (DRY)

- Applies ABD pads over moist layer to completely cover the wound.

- Applies tape to create an occlusive dressing. WINDOW STYLE

- Verbalize rationale: creates a barrier and prevents drying between dressing changes.

Step 8

- Disposes of materials

- Removes Gloves

- Disposes waste in biohazard container.

- Perform hand hygiene.

- Writes on dressing:

1. Initials

2. Date/Time of Dressing Change