Equipment
- Moisture-proof bag
- Clean gloves
- Sterile gloves
- Sterile dressing set; if none is available, gather the following sterile items:
Gauze squares
Cleaning solution (ex: normal saline)
Container for the cleaning solution
Two pairs of forceps
Applicators or tongue blades to apply ointments
Gauze dressings and surgipads
Tape, tie tapes, or binder
- Bath blanket (if necessary)
- Acetone or another solution (if necessary to loosen adhesive)
- Mask (optional)
Assessment
- Any client allergies to wound cleaning agents
- The appearance and size of the wound
- The amount and character of exudates
- Client complaints of discomfort
- The time of the last pain medication
- Signs of systemic infection (ex: elevated body temperature, diaphoresis, malaise, leukocytosis)
Key Points
- Before changing a dressing, determine any specific orders about the wound or dressing
- Acquire assistance for changing a dressing on a restless or confused adult
- Assist the client to a comfortable position in which the wound can be readily exposed. Expose only the wound area, using a bath blanket to cover the client, if necessary
- Make a cuff on the moisture-proof bag for disposal of the soiled dressings, and place the bag within reach. It can be taped to the bed linens or bedside table
- Put on a face mask, if required
- Remove and dispose of soiled dressings appropriately
- If using forceps to clean the wound, keep the forceps tips lower than the handles at all times
- Use a separate swab for each stroke and discard each swab after use
- If a drain is present, clean it while taking care to avoid reaching across the cleaned incision. Clean the skin around the drain site by swabbing in half or full circles from around the drain site outward, using separate swabs for each wipe
- Always clean from least contaminated to most contaminated (start closest to wound/drain and work away)
- Record date, time, and initials on new tape or dressing
Sample Documentation
9/25/2012 1100 Abdominal dressing changed. Small amount of sero-sanguinous drainage -- size of a half dollar in middle of dressing. Incision approximated with slight redness at edges. Sutures intact.-------------------------------------------------------- R. Quaco, RN
Evaluation
- Conduct appropriate follow-up, such as amount of granulation tissue or degree of healing; amount of drainage and its color, consistency, and odor; presence of inflammation; and degree of discomfort associated with the incision or drain site
- Compare to previous findings, if available
- Report significant deviations from normal to the primary care provider
Sterile Technique Versus Clean Technique
Sterile
- Sterile dressing technique is considered most appropriate in acute care hospital settings, for patients at high risk for infection, and for certain procedures such as sharp instrumental wound debridement. Check the patient's chart for specific orders about the wound or dressing.
- "Sterile to sterile" rules involve the use of only sterile instruments and materials in dressing change procedures and avoiding contact between sterile instruments or materials and any non-sterile surface or products.
- In general, sterile dressing technique is used when the wound cleaning and dressing change is invasive which a high risk for infection.
- Clean dressing technique is considered most appropriate for long-term care, home care, and some clinic settings; for patients who are not at high risk for infection; and for patients receiving routine dressings for chronic wounds such as venous ulcers, or wounds healing by secondary intention with granulation tissue. Check the patient's chart for specific orders about the wound or dressing.
Questions
1. The client has a large, deep abdominal incision that requires a dressing. The incision is packed with sterile half-inch packing and covered with a dry 4 x 4 inch gauze. When changing the dressing, the nurse accidentally drops the packing onto the client’s abdomen. The nurse should:
a. Add alcohol to the packing and insert it into the incision
b. Throw the packing away, and prepare a new one
c. Pick up the packing with sterile forceps, and gently place it into the incision
d. Rinse the packing with sterile water, and put the packing into the incision with sterile gloves
Correct Answer: B
Explanation: A sterile object (the packing) remains sterile only when touched by another sterile object. The client’s abdomen is not sterile; therefore the nurse should throw the packing away and prepare a new one.
2. The nurse recognizes the appropriate procedures for sterile technique. Of the following, which action is consistent with sterile technique?
a. Clean forceps may be used to move items on the sterile field
b. Sterile fields may be prepared well in advance of the procedures
c. The first small amount of sterile solution should be poured and discarded
d. Wrapped sterile packages should be opened starting with the flap closest to the nurse
Correct Answer: C
Explanation: Before pouring the solution into the container, the nurse pours a small amount (1 to 2 ml) into a plastic-lined waste receptacle. The discarded solution cleans the lip of the bottle. This action is consistent with sterile technique.
Reference
Berman, A., Snyder, S. J., Kozier, B., & Erb, G. (2008). Fundamentals of nursing: Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Pearson Education.
a. Add alcohol to the packing and insert it into the incision
b. Throw the packing away, and prepare a new one
c. Pick up the packing with sterile forceps, and gently place it into the incision
d. Rinse the packing with sterile water, and put the packing into the incision with sterile gloves
Correct Answer: B
Explanation: A sterile object (the packing) remains sterile only when touched by another sterile object. The client’s abdomen is not sterile; therefore the nurse should throw the packing away and prepare a new one.
2. The nurse recognizes the appropriate procedures for sterile technique. Of the following, which action is consistent with sterile technique?
a. Clean forceps may be used to move items on the sterile field
b. Sterile fields may be prepared well in advance of the procedures
c. The first small amount of sterile solution should be poured and discarded
d. Wrapped sterile packages should be opened starting with the flap closest to the nurse
Correct Answer: C
Explanation: Before pouring the solution into the container, the nurse pours a small amount (1 to 2 ml) into a plastic-lined waste receptacle. The discarded solution cleans the lip of the bottle. This action is consistent with sterile technique.
Reference
Berman, A., Snyder, S. J., Kozier, B., & Erb, G. (2008). Fundamentals of nursing: Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Pearson Education.