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Simple Wound Dressing Change

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Simple Wound Dressing Change

Key Points

  • Use the smallest effective dressing size and bring only required supplies to bedside.
  • Premedicate when indicated and reassess pain before and during dressing care.
  • Cleanse from least contaminated to more contaminated areas, using one gauze/swab per stroke.
  • Maintain aseptic handling during new dressing application and document comparison with prior wound status.

Equipment

  • Nonsterile gloves and sterile gloves per policy/order
  • Wound cleanser or sterile normal saline
  • Sterile 2 x 2 gauze for cleansing strokes
  • Sterile 4 x 4 gauze for dressing layer
  • Scissors and tape/securement materials as needed
  • Water-resistant underpad and indicated PPE (for example mask/eye protection)

Procedure Steps

  1. Verify order/policy, perform hand hygiene, and complete patient identification and safety checks.
  2. Assess wound pain (for example PQRSTU) and premedicate when ordered before dressing manipulation.
  3. Prepare environment: lighting, bed height/body mechanics, privacy, and patient comfort.
  4. Set up a clean barrier workspace; create sterile field when policy requires.
  5. Moisten cleansing gauze with sterile saline (or prepare commercial cleanser per policy).
  6. Perform hand hygiene, don clean gloves, expose wound, and remove outer then inner dressing.
  7. Remove soiled dressing without contaminating wound bed/environment; discard safely.
  8. Remove gloves, hand hygiene, and don new gloves before wound assessment/cleansing.
  9. Perform focused wound assessment (location, dimensions, tissue type, exudate, periwound findings, infection cues).
  10. Apply indicated PPE and protect linens/clothing with water-resistant pad if needed.
  11. Cleanse wound using one moistened 2 x 2 gauze per stroke:
    • move from clean to dirty area
    • use straight strokes moving away from wound
    • for suture lines, cleanse incision line first (least contaminated)
  12. If a drain is present, cleanse around drain in expanding circular strokes with a new swab each pass.
  13. Remove gloves, perform hand hygiene, and apply new gloves for dressing placement.
  14. Apply sterile dressing using nontouch technique so the dressing surface contacting wound remains sterile.
  15. Add outer layer and secure with tape/ordered fixation method.
  16. Remove gloves, perform hand hygiene, reposition patient comfortably, and complete room-safety checks.
  17. Document procedure and reassessment findings; compare with prior documentation and report concerns per policy.

Special Considerations

  • Normal saline container handling: dedicate to one patient and discard per policy (commonly within 24 hours after opening).
  • Contamination prevention: change gloves between soiled-dressing removal and clean/sterile phases.
  • Technique selection: follow agency/provider requirements for clean versus sterile workflow.
  • Escalation: report new purulent drainage, progressive periwound erythema/warmth/tenderness, or worsening pain/dehiscence cues.

Common Errors

  • Reusing cleansing gauze/swabs across strokes → contamination carryover risk.
  • Cleansing from dirty to clean direction → increased inoculation risk.
  • Applying new dressing without nontouch/aseptic control → avoidable wound contamination.
  • Incomplete post-procedure documentation → missed trend detection and delayed escalation.

Graph View

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