Wound Dressing Change
Category: Wound Care
Overview
A sterile or clean procedure to remove old dressings, assess wound healing, and apply new protective dressings.
Indications
Wound care maintenance, assessment of healing progress, prevention of infection, absorption of wound drainage, protection from further injury.
Contraindications
Newly sutured wounds (unless ordered), wounds with active bleeding requiring pressure, physician preference for specific dressing protocols.
Equipment Needed
Sterile gloves, normal saline or prescribed wound cleanser, gauze pads, tape or adhesive dressings, scissors, measuring device, disposal bag for contaminated materials.
Procedure Steps
1. Explain procedure to patient
2. Position patient for optimal access and comfort
3. Perform hand hygiene
4. Don clean gloves to remove old dressing
5. Assess wound for size, depth, drainage, odor, and healing
6. Dispose of old dressing and gloves appropriately
7. Perform hand hygiene and don sterile gloves
8. Cleanse wound as ordered (usually center to periphery)
9. Apply prescribed topical medications if ordered
10. Apply appropriate dressing based on wound type
11. Secure dressing with tape or adhesive
12. Label dressing with date, time, and initials
13. Document wound assessment and care provided
Safety Considerations
Use appropriate PPE to prevent contamination. Assess for signs of infection. Use proper disposal methods for contaminated materials. Maintain sterile technique when indicated.
Potential Complications
Wound infection, delayed healing, allergic reaction to dressing materials, skin breakdown from adhesive, disturbed wound edges.
Documentation
Record wound location, size (length, width, depth), drainage characteristics, surrounding skin condition, treatment provided, patient response, and healing progress.
References
Wound, Ostomy and Continence Nurses Society. (2019). Guideline for Management of Wounds in Patients with Lower-Extremity Venous Disease. Journal of Wound, Ostomy & Continence Nursing, 46(4), 302-310.