Skin Integrity and Wound Care Skill Check Off

Step 1:

review patient’s record for prescribed wound care

Step 2:

gather supplies

Step 3:

hand hygiene

Step 4:

identify patient

Step 5:

provide patient education

Step 6:

provide privacy

Step 7:

• assemble equipment on the bedside table

• place waste receptacle nearby for use during the procedure

• adjust bed to workable height

Step 8:

• assist patient to a comfortable position that provide easy access to the wound area

• use bath blanket to cover any exposed area other than the wound

• place a waterproof pad under the wound site

Step 9:

• put on gloves and loosen the tape or adhesive edge on the old dressing using the push-pull method (life a corner of the dressing away from the skin, ten gently push the skin down and away from the dressing adhesive)

• continue moving fingers of the opposite hand to support the skin as the product is removed

• once all adhesive is loosened from the skin, carefully life dressing from the surrounding skin

• remove the sides/edges first, then the center

Step 10:

• after removing the dressing, note the presence, amount, type, color, and odor of any drainage on the dressings

• place soiled dressings in the appropriate waste receptacle

• remove gloves and perform hand hygiene

Step 11:

• inspect the wound site for size appearance, and drainage

• assess if any pain is present

• check the status of sutures, adhesive closure strips, staples, and drains or tubes, if present

• note any problems to include in your documentation

Step 12:

using sterile technique, prepare a sterile work area and open needed supplies

Step 13:

• open the sterile cleaning solution

• moisten gauze for cleaning the periwound skin while maintaining sterility

Step 14:

put on sterile gloves

Step 15:

• clean the wound and the surrounding skin from the top to bottom and/or from the center to the outside

• use a new gauze for each wipe, placing the used gauze in the waste receptacle after each use

Step 16:

once the wound and surrounding skin are cleaned, dry the surrounding skin area using a gauze sponge in the same manner

Step 17:

remove gloves and perform hand hygiene

put on clean gloves

Step 18:

apply any topical medications, foams, gels, and/or dressing product to the wound as prescribed; ensure products stay confined to the wound and do not impact on the intact surrounding tissue/skin

Step 19:

gently place the prescribed cover dressing at the wound center and extend it at least 1 inch beyond the wound in all directions

Step 20:

• remove gloves

• hand hygiene

Step 21:

• label the dressing with date, time, initials

• remove all remaining equipment

• place patient in a comfortable position, with side rails up as indicated and bed in lowest position

Step 22:

• hand hygiene

• document wound assessment and dressing change

• check wound dressings at least once a shift

Assessment of Wound Drainage: Type and Color

• Serous: clear and watery

• Sanguineous: looks like blood, bright red, indicate fresh bleeding

• Serosanguineous: light pink, mixture of serum and red blood cells

• Purulent: thick, musty or foul odor, color may be dark yellow or green

Assessment of Wound Drainage:

• Scant: Wound tissue is moist, but there is no measurable drainage on the dressing

• Small/Minimal: Drainage stains less than 25% of the dressing

• Moderate: Drainage stains 25% to 75% of the dressing

• Large/Copious: Drainage saturates more than 75% of the dressing