WOUND CARE MOIST-MOIST: Skill Stack

Verbalize all of it

Purpose/Outcome of Wound care

Purpose/outcome is to maintain moist wound environment to contain natural therapeutic wound chemicals; speed granulation tissue proliferation; provide barrier to bacterial contamination

Protocol method & frequency of wound packing (without specific physician prescription)

dressing change Q 8 hours with primary layer [touches tissue] of saline-moistened sterile gauze & dry secondary dressing layer; increase to Q 6 hours if gauze dries between changes

Patient preparation

Assess need for analgesia; medicate 30 minutes before procedure; evaluate effectiveness

Essential wound assessments

- Anatomic location; size dimensions of wound surface (diameter or length/width; depth measured in centimeters and/or estimate of extent of tissue layer involvement-full or partial thickness);

- Presence of undermining or tunneling

- Appearance of wound base (granulation, epithelialization, muscle, subcutaneous tissue, nonviable tissue, color, exudate amount/odor/color);

- Appearance of open wound edge; condition of surrounding skin

Current Evidence

Current evidence suggests no greater contamination using clean gloves compared with sterile gloves to pack wounds; *consult agency policies to direct choice of glove

Removing soiled dressing:

if dressing sticks to wound bed, moisten primary dressing that touches tissue with sterile normal saline; bleeding indicates disruption of new capillary buds

Standard Documentation:

Date, time, signature, procedure; skin/wound/drainage observations per above criteria; type & location of dressing applied; solution type used to moisten gauze; patient tolerance

1st

Verifies physician's order

2nd

Performs standard greeting & prep

3rd

Gathers supplies: sterile 4X4 gauze to fill wound bed (e.g. Kerlix fluffs); cover gauze (e.g. ABD pads); sterile saline at room temperature; clean gloves (2 pairs); cotton-tipped applicators (swabs) X2

4th

Raises bed to comfortable height; positions patient for wound access

5th

Performs hand hygiene; applies moisture-impervious gown, face shield/goggles, clean gloves

6th

Removes soiled dressing & disposes in biohazard waste; removes gloves & performs hand hygiene

1st Primary Dressing Layer (Moist)

Performs hand hygiene

2nd Primary Dressing Layer (Moist)

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)

3rd Primary Dressing Layer (Moist)

Performs hand hygiene & applies clean gloves

4th Primary Dressing Layer (Moist)

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

1st Secondary Dressing Layer (Dry)

Applies ABD pads over moist layer to completely cover; applies tape to create an occlusive dressing (verbalizes rationale: creates barrier & prevents drying between dressing changes)

2nd Second Dressing Layer (Dry)

Disposes materials, removes gloves, disposes in biohazard waste; performs hand hygiene

3rd Second Dressing Layer (Dry)

Writes on dressing: nurse initials, date/time of dressing application