NURS 3802 - Clean Dressing Change Competency Check-Off

what do you do first when you enter a patient's room before a clean dressing change?

Introduce yourself, ask the patient to state their name and date of birth, then ask them to rate their pain.

what is the first step for a clean dressing change? (check-off)

identify risk factors for skin breakdown, impaired wound healing, and preventive measures.

what are some risk factors for skin breakdown?

- fecal and/or urinary incontinence

- loss of sensory perception

- shear or friction

- advanced age

- immobility; lack of activity

- tobacco use (smoke or smokeless)

- poor nutrition

what are some risk factors for impaired wound healing?

- poor cardiovascular or pulmonary function

- infection

- steroids

- diabetes

- immunosuppressants

- poor nutrition

- advanced age

- obesity

- tobacco use (smoke or smokeless)

what are some anatomical sites that are at risk for pressure injuries?

- occiput

- heels

- sacrum

- scapulae

- coccyx

- iliac crests

- ischial tuberosities

- lateral malleoli

- greater trochanters

- medial malleoli

what are some measures taken to prevent pressure injuries?

- turn every two hours

- keep skin clean and dry

- pressure redistribution

- avoid friction and shear

- keep linen free of folds

- ensure no foreign objects are under patient

- wedges or cushions

- chair pads

what is the second step for a clean dressing change? (check-off)

pre-procedure tasks

what are the steps under pre-procedure tasks for a clean dressing change?

1. verify the provider's order

2. review notes from previous wound assessment for comparison

3. gather supplies

4. provide privacy

5. identify patient

6. determine patient's pain level

7. places supplies on overbed table

8. explain procedure

9. perform hand hygiene

10. prepare supplies

what are the "two identifiers" you use to identify your patient before preparing for the procedure?

full name and date of birth

what supplies is "gathered" in preparation for the procedure?

- gauze

- normal saline

- tape

- dressing material(s)

- wound measuring device

- cotton-tip applicator

what tool is used when determining a patient's pain level, and what does it help indicate?

use the pain scale (1-10) which indicates whether or not to premedicate

what is the third step for a clean dressing change? (check-off)

principles of assessing wounds

what steps are taken when assessing wounds?

- applies gloves

- raises bed to waist height

- positions patient exposing only the wound area

- removes soiled dressing, one layer at a time

- describes color, consistency, and amount of drainage

- determines presence of odor

- discards soiled dressing

- removes gloves, performs hand hygiene, applies clean gloves

- inspects color, wound bed, and skin adjacent to wound

- describes edema, exudate, loss of skin integrity

- measures length, width, and depth

- determines tunneling or undermining using face clock to describe location

- removes gloves, performs hand hygiene, applies clean gloves

what is the fourth step for a clean dressing change? (check-off)

principles of cleansing wounds

what steps are taken when cleansing wounds?

- cleanses from the least contaminated area to most contaminated area

- blots the wound dry from least contaminated area to most contaminated area

- removes gloves, performs hand hygiene, applies clean gloves

what is the fifth step for a clean dressing change? (check-off)

principles of redressing wounds

what steps are taken when redressing wounds?

- using prepared supplies

- wrings out excess solution

- applies moistened gauze to the wound bed

- if deep, use gloved hand or cotton-tipped applicator to gently pack until wound bed and all wound surfaces are in contact with the moistened gauze

- ensures moistened gauze does not touch the skin around the wound

- applies dry gauze over the moist gauze

- covers with ABD pad and secure with tape

- labels dressing with initials, time, and date

- assists patient to a safe and comfortable position

- returns bed to lowest position

- removes gloves, performs hand hygiene

what is the sixth step for a clean dressing change? (check-off)

principles of documentation of wound care

what steps are taken when documenting wound care?

- records assessment findings and compares to previous findings

- records patient response and expected or unexpected outcomes

- records administration of pain-relief medications if given prior to procedure