By Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS
Each month, Apple Bites brings you a tool you can apply in your daily practice.
Description
• Nonsterile dressings protect open wounds from contamination and absorb drainage.
• Clean aseptic technique should be used to change nonsterile dressings.
• In the event of multiple wounds, each wound is considered a separate treatment.
Equipment
• Disinfectant solution
• Antiseptic hand gel
• Normal saline solution, or cleansing agent
• 4″ × 4″ gauze pads
• Prescribed topical agent or surgical dressing
• Liquid barrier film or moisture barrier
• Secondary cover dressing, if needed
• Scissors
• Tape
• Nonsterile gloves
• Trash bag
• Linen saver
Steps
1. Provide privacy and explain the procedure to the patient.
2. Prepare a clean, dry work area at bedside. Use disinfectant solution to prepare the work surface.
3. Place the trash bag at the end of the bed or within easy reach of the work area.
4. Wash your hands and apply gloves.
5. Prepare dressing items on the table. If dressings need to be cut to size, use clean or sterile scissors (clean the scissors with an alcohol wipe before and after using). Open the packages and cut the tape. Place your initials and the date on a piece of tape or on the dressing.
6. Position the patient to expose the area to be dressed; expose the smallest area possible.
7. Place the linen saver or a towel under the patient.
8. Remove the soiled dressing, and place it in the trash bag. Note the date on the old bandage before you remove it.
9. Remove your gloves, wash your hands, and apply new gloves.
10. Clean the wound with normal saline solution or prescribed cleanser.
11. Use a dry 4 × 4 to pat the tissue surrounding the wound dry.
12. Remove your gloves, wash your hands, and apply new gloves.
13. Assess wound characteristics to determine appropriate interventions.
14. Trim or clip hair surrounding the dressing securement site as needed. Don’t allow clippings to fall into the wound bed. Upon completion, remove your gloves, wash your hands, and apply new gloves.
15. Apply liquid barrier film or moisture barrier to the periwound area. This prevents tissue maceration and skin stripping when the tape is removed.
16. Apply the prescribed topical agent to the wound.
17. Apply the wound dressing. Cover the entire wound with the dressing; otherwise, the exposed wound bed could dry out, impairing healing.
18. Tape the dressing in place as indicated. Apply the tape without tension, gently but firmly stroking the surface to maximize adhesion. The tape should extend at least ½ inch beyond the dressing. Don’t pull or stretch the tape when applying it. Ensure an adequate seal around the dressing to prevent cooling of the wound bed and contamination.
19. Apply the tape with the date and your initials to the outside of the dressing if the secondary dressing isn’t dated.
20. Reposition the patient.
21. Discard your gloves and all used supplies in the trash bag and discard the bag in a biohazardous waste receptacle.
22. Wash your hands.
23. Document the dressing change, including the appearance of the wound and the type of dressing applied, in the patient’s medical record.
Nancy Morgan, cofounder of Wound Care Education Institute, combines her expertise as a Certified Wound Care Nurse with an extensive background in wound care education and program development as a nurse entrepreneur. Read her blog “Wound Care Swagger.”
Information in Apple Bites is courtesy of the Wound Care Education Institute (WCEI), copyright 2012.
I am confused in regard to the use of antimicrobial cleansers, specifically the use of
Chlorhexidine Irrigation Solution. I know it can be used on “dirty wounds” but i would like more clarifacation on depth of wounds. Is it safe for use on full thickness wounds? What would you recommend for cleaning a full thickness wound with confirmed MRSA infection.
Hi Rose,
Antiseptic agents like Chlorhexidine are typically used when a wound has 3 or more s/s of infection present on a full thickness or partial thickness wound and our goal is to get the bacterial levels under control. We use these products for limited time frames as they can be toxic to healthy tissues. Recommendations are for 2 weeks. As far as eliminating MRSA from the wound bed it will depend on the type of wound, tissue in the wound, depth of the wound, exudate amount etc (overall assessment of the wound and patient). There are many topical antibiotics like Bactroban, topical antiseptics like Dakins solution and even wound cleansers or hydrogels like ANASEPT that are broad range and can kill MRSA in a wound. It really depends on what the wound requires as far a dressing goes to the product you will choose.
Good luck!
Nancy WCEI