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Verify Provider Order: I have verified the provider order for wound care.
Introduce Self: Good morning, my name is Jincey and I will be your nurse today.
Explain Procedure: Today I am going to change and clean your wound dressing to assess healing
and prevent infection.
Assess Comfort Level: I previously assessed for pain and provided medication. Can you rate your level
of current pain on a scale of 0-10? 0 being no pain and 10 being the worst.
-sterile kit, tape, gloves, measuring device, sterile q-tips, biohazard bag
Raise Bed/Lower Rails: I am going to raise the raise your bed & lower side rail.
*Prepare tape (4 strips) & write date, time, and initials. (Use military time)
Preform Hand Hygiene: I am going to wash my hands & put on clean gloves
Remove Old Dressing: *Pull tape edges to loosen. *Remove from toe to head (so patient can’t see)
*Pinch and pull old dressing
Odor- no odor
Prepare Sterile Field: *Open kit, pull out gloves and set to side. *Remove drape & set up field *Dump
kit contents onto field *Take saline bottle out and pour solution into kit
*Through away *Open q-tips and dump on field *Open q-tips and take one out
to measure depth
Measure Depth: *Dip q-tip into solution *Measure depth of wound (Note measurement) *State
if there is any tunneling present *Throw away q-tip
Don Sterile Gloves: Perform hand hygiene & *use technique to put on gloves
Clean Wound: *Dip gauze into solution *Make a poof with gauze *Wipe head to toe *Center-
trash, Distal- trash, Proximal- trash
Pack Wound (Wet): *Dip gauze into solution *Fluff in hand *Pack wound using q-tip to lead the
gauze *Do not let q-tip touch wound *Throw away each q-tip after one use
Apply Dry: *Apply clean layer of gauze *Apply sterile ABD pad (blue up)
Secure Dressing: *Use tape to “window pane” the dressing on all 4 sides
Hand Hygiene & Gloves: I am going to wash my hands and put on clean gloves.
Patient Comfort: *Raise rails & lower bed *Place call light w/n reach *Assess comfort
Cleaning Done-