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UNIT 4 Supporting Physiological Functioning
Procedure 32-4 ■ Removing and Applying Dry Dressings (continued)
with sterile saline dressings. Notify primary healthcare provider. This could indicate wound dehiscence. ■ The skin surrounding the incision is not intact? Clean the area with sterile saline, dry thoroughly, and apply protective mois- ture barrier dressing. Consider using Montgomery straps.
Montgomery straps are useful when dress- ings must be changed frequently because they do not cause trauma to the skin. ■ A drain or drainage tube is present? Always clean the drain site after clean- ing the primary incision site. Reduces the risk of cross-contamination.
What if . . . ■ Signs of infection are noted with wound assessment? Notify the healthcare provider. Cultures, wound care interventions, and poten- tially even antibiotics may be required. ■ The wound is not approximated? Place the patient in a supine position, apply adhesive skin closures, and cover
Evaluation ■ Determine whether the dressing is clean, dry, and intact. ■ Verify that the patient had minimal discomfort during the procedure. Patient Teaching ■ Teach the patient about the expected healing process. ■ Inform the patient and caregiver about the signs and symptoms of infection and the need to report these findings. Home Care ■ Help the patient to store dressings appropriately to keep them clean, for example, in a plastic container with a lid. ■ Teach the patient or caregivers to dispose of contaminated dressings and gloves by double-bagging them in mois- ture-proof bags (e.g., plastic grocery bags). ■ Advise the patient and family whether they can get the wound wet (e.g., during bathing). If it must be kept dry, demonstrate how to cover it with a waterproof barrier (e.g., a plastic bag).
Documentation Sample Documentation 00/00/0000 1420
Pt with no report of pain. Gauze dressing removed from lateral aspect of right forearm without difficulty. No drainage noted on gauze. Surrounding skin intact. Abrasion on right, lateral forearm cleansed with normal saline. Sterile gauze dressing reapplied to wound and anchored with cloth tape. Pt instructed to report any change at wound site, such as bleeding, drainage, or increase in pain. —D. Enferma, RN Practice Resources Armstrong & Meyer (2022, July 9, updated); Baranoski & Ayello (2020); Dabri & Phillips (2016).
Thinking About the Procedure
The video Removing and Applying Dry Dressings, along with questions and suggested responses, is available on the Davis’s Nursing Skills Videos Web site on FADavis.com.
Procedure 32-5 ■ Removing and Applying Wet-to-Damp Dressings ➤ For steps to follow in all procedures, refer to the Universal Steps for All Procedures on the inside back cover. ➤ Note: This procedure uses clean technique, because wound care is now usually done using a clean or modified sterile approach rather than sterile technique. However, sterile technique is recommended for wounds that have recently had sharp debridement, have a drain, or are fresh surgical wounds; also used for patients with immunodeficiency.
■ Tape or Montgomery straps ■ Adhesive removal pads
Equipment ■ Three pairs of clean nonsterile gloves ■ Sterile or clean solution, typically normal saline or water, warmed to body temperature when possible Cold solution reduces the temperature of the wound bed and slows the healing process. ■ Water-resistant disposable drapes ■ Sterile fine-mesh gauze in a tray for dressing ■ Thick surgical pad
Delegation This is an invasive procedure that requires knowledge of wound healing. It should be performed by a registered nurse. Do not delegate this skill to unlicensed assistive personnel (UAP).
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