WOUND

Equipment

 Clean gloves
 Sterile gloves
 Sterile dressing set (scissors, forceps) ( optional, check agency policy)
 Sterile drape (optional)
 Sterile dressings: fine mesh gauze, 4 × 4-inch gauze, abdominal (ABD) pads
 Sterile basin (optional)
 Antiseptic ointment (as prescribed)
 Wound cleanser (as prescribed)
 Sterile normal saline or prescribed solution
• Debriding gel as ordered
 Tape, Montgomery ties, or bandage as needed (include nonallergenic tape if necessary)
• Skin barrier (optional if using Montgomery ties)
 Protective waterproof underpad
 Waterproof bag
 Adhesive remover (optional)
 Measurement devices (optional): Cotton-tipped applicator, measuring guide, camera
 Protective gown, goggles, mask (used when splashing from wound is a risk)
 Additional lighting if needed (e.g., flashlight, treatment light)

PROCEDURE RATIONALE
1. Ask patient to rate his or her level of pain using a pain • Superficial wounds with multiple exposed nerves
scale of 0 to 10 and assess character of pain. may be intensely painful, whereas deeper
wounds with destruction of dermis should be less
Administer prescribed analgesic as needed 30 minutes
painful (Krasner, 2011). A comfortable patient will
before dressing change.
be less likely to move suddenly, causing wound
or supply contamination. Serves as baseline to
measure response to dressing therapy.
2. Assess size, location, and condition of wound. Review • Helps to plan for proper dressing type,
previous nurses’ notes and electronic health record securement and supplies needed, and if
(EHR). assistance is needed during procedure.
3. Assess patient for allergies, especially antiseptics, • Patients with allergies may have localized or
tape, or latex. systemic allergic reactions to these supplies.
4 . Assess patient’s and family caregiver’s knowledge of • Determines level of support and explanation
purpose of dressing change. required.
5. Assess need, readiness, and willingness for patient or • Prepares patient or family caregiver if dressing
family caregiver to participate in dressing wound. must be changed at home.
6. Review medical orders for dressing change procedure. • Indicates type of dressing or applications to use.
7. Identify patients at risk for wound-healing problems, • Physiologic changes resulting from aging,
including aging, premature infant, obesity, diabetes chronic illness, poor nutrition, medications that
mellitus, circulation disorders, nutritional deficit, affect wound healing, and cancer treatments
immunosuppression, radiation have potential to affect wound healing (Doughty,
Sparks-DeFriese, 2011).
therapy, high levels of stress, and use of steroids.
PLANNING
1. Expected outcomes following completion of procedure:

• Patient’s wound shows evidence of healing

by decrease in size and less drainage,
redness, or swelling. • Indicates that wound is healing appropriately.
• Patient reports pain less than previous
assessment after dressing change.
• Dressing remains clean, dry, and intact.
• Indicates that dressing procedure and choice are
 appropriate.
• Patient or family explains purpose of • Indicates that proper application and securement
dressing and method of dressing application. are used for dressing.
• Indicates that learning has occurred.
2 Explain procedure to patient. Decreases patient’s anxiety.
IMPLEMENTATION
1. Identify patient using two identifiers (i.e., name and • Ensures correct patient. Complies with The Joint
birthday or name and account number) according to Commission standards and improves patient
agency policy. Compare identifiers with information on safety (TJC, 2012).
patient’s identification
bracelet.
2. Close room or cubicle curtains. Perform hand hygiene. • Provides for privacy.
3. Position patient comfortably and drape to expose only • Draping provides access to wound while
wound site. Instruct patient not to touch wound or sterile minimizing exposure. Dressing supplies become
supplies. contaminated when touched by patient’s hand.
4. Place disposable waterproof bag within reach of work • Ensures easy disposal of soiled dressings.
area. Fold top of bag to make cuff. Perform hand hygiene Prevents contamination of outer surface of bag.
and apply clean gloves. Apply gown, goggles, and mask if Use of personal protective equipment reduces
risk for splashing transmission of microorganisms.
exists.
5. Gently remove tape, bandages, or ties: use • Pulling tape toward dressing reduces stress on
nondominant hand to support dressing and, with your suture line or wound edges and reduces irritation
dominant hand, pull tape parallel to skin and toward and discomfort.
dressing. If dressing is over hairy area, remove in
direction of hair growth. Get patient permission to clip or
shave area (check agency policy). Remove any adhesive
from skin.
6. With gloved hand or forceps remove dressing one • Purpose of primary dressing is to remove
layer at a time, observing appearance and drainage of necrotic tissue and exudate. Appearance of
dressing. Carefully remove outer secondary dressing first; drainage may be upsetting to patient. Avoids
then remove inner primary dressing that is in contact with accidental removal of drain.
wound bed. If drains are present, slowly and carefully
remove dressings (see illustration) and avoid tension on
any drainage devices. Keep soiled undersurface from
patient’s sight.

Penrose drain with split gauze.

a. If moist-to-dry dressing adheres to wound,

gently free dressing and alert patient of
discomfort.
b. If dry dressing adheres to wound that is not
to be debrided, moisten with normal saline
and remove.
• Moist-to-dry dressing should debride wound. Do
not wet dressing; it should be dry.
 • Prevents injury to wound surface and periwound
during dressing removal.
7. Inspect wound and periwound for appearance, color, • Assesses condition of wound and periwound
size (length, width, and depth), drainage, edema, condition. Indicates status of healing.
presence and condition of drains, approximation (wound
edges are together), granulation tissue, or odor. Use
measuring guide or ruler to measure size of wound.
Gently palpate wound edges for bogginess or patient
report of increased pain.
8. Fold dressings with drainage contained inside and • Contains soiled dressings, prevents contact of
remove gloves inside out. With small dressings remove nurse’s hands with drainage, and reduces cross-
gloves inside out over dressing (see illustrations). contamination.

Dispose of soiled dressings by placing in gloved hand and

pulling glove off over dressing and then off hand.

Dispose of gloves and soiled dressing according to

agency policy. Cover wound lightly with sterile gauze pad
and perform hand hygiene.
9. Describe appearance of wound and any indicators of • Wounds may appear unsettling and frightening to
wound healing to patient. patients; it helps patient to know that wound
appearance is as expected and whether healing
is taking place.
10. Create sterile field with sterile dressing tray or • Sterile dressings remain sterile while on or within
individually wrapped sterile supplies on over-bed table. sterile surface. Preparation of all supplies
prevents break in technique during dressing
change.
11. Cleanse wound:

a. Perform hand hygiene and apply clean • Prevents transfer of organisms from previously
gloves. Use gauze or cotton ball moistened cleaned area.
in saline or antiseptic swab (per health care
provider order) for each cleansing stroke or
spray wound surface with wound cleanser.
b. Clean from least to most contaminated
area(see illustration).

• Cleaning in this direction prevents introduction of

organisms into wound.
Methods for cleansing a wound, cleansing from least to most
contaminated.

c. Clean around any drain (if present), using

circular strokes starting near drain and
moving outward and away from insertion site
(see illustration).
• Correct aseptic technique in cleaning prevents
contamination.

Cleaning around a drain site.

12. Use sterile dry gauze to blot in same manner as in • Drying reduces excess moisture, which could
Step 11 to dry wound. eventually harbour microorganisms.
13 . Apply antiseptic ointment (if ordered) with sterile Q-tip • Helps reduce growth of microorganisms.
or gauze, using same technique to apply as for cleaning.
Dispose of gloves. Perform hand hygiene.
14. Apply dressing (see agency policy):

a. Dry sterile dressing:

1. Apply clean gloves (see agency policy). • Some agencies or condition of wounds may require
2. Apply loose woven gauze as contact sterile gloves.
layer (seeillustration). • Promotes proper absorption of drainage.

Placing dry gauze dressing over simple wound.

3. If drain is present, apply precut, split 4 ×

4–inch gauze around drain.
4. Apply additional layers of gauze as
needed.
5. Apply thicker woven pad (e.g.,
• Secures drain and promotes drainage absorption
Surgipad, abdominal [ABD] pad) (see
at site.
illustration).
• Ensures proper coverage and optimal absorption.

• This type of cover dressing is used on

postoperative wounds when there is excessive
drainage.

Placing ABD pad over gauze dressing.

 b. Moist-to-dry dressing:
1. Apply sterile gloves (see agency policy).
2. Place fine-mesh or loose 4 × 4–inch
gauze in container of prescribed sterile
solution. Wring out excess solution.
3. Apply moist fine-mesh or open-weave
gauze as single layer directly onto
wound surface. If wound is deep, gently
pack gauze into wound with sterile • Reduces transmission of infection.
gloved hand or forceps until all wound
surfaces are in contact with moist gauze, • Moist gauze absorbs drainage and, when
including dead spaces from sinus tracts, allowed to dry, traps debris.
tunnels, and undermining (see
illustration). • Inner gauze should be moist, not dripping wet, to
absorb drainage and adhere to debris. When
packing a wound, gauze should conform to base
and side of wound (Rolstad et al, 2011). Wound
is loosely packed to facilitate wicking of drainage
into absorbent outer layer of dressing. Moisture
that escapes dressing often macerates the
periwound area.

Packing wound with fine-mesh gauze

Be sure that gauze does not touch
periwound skin (see illustration).

Cross-section of deep wound packed loosely with gauze roll

4. Apply dry sterile 4 × 4–inch gauze over

moist gauze.

5. Cover with ABD pad, Surgipad, or

gauze.

Dry layer pulls moisture from wound.

Protects wound from entrance of microorganisms.

15 . Secure dressing.

a. Tape: Apply tape 1 to 2 inches (2.5 to 5 cm) Supports wound and ensures placement and stability of
beyond dressing. Use nonallergenic tape dressing.
when necessary.
b. Montgomery ties (see illustrations):
Ties allow for repeated dressing changes without removal
 of tape

Montgomery ties. Each tie is placed at side of gauze dressing.

Securing ties encloses dressing.

1. Be sure that skin is clean. Application of skin

barrier is recommended.
2. Expose adhesive surface of tape ends.
3. Place ties on opposite sides of dressing over
skin or skin barrier
4. Secure dressing by lacing ties across
dressing snugly enough to hold it secure but
without placing pressur on skin.
c. For dressing an extremity, secure with roller
gauze (see illustration) or elastic net.

Wrap roller gauze around extremity to secure dressing.

• Roller gauze conforms to contour of foot or hand.

16. Dispose of all dressing supplies. Remove cover gown • Reduces transmission of microorganisms. Clean
and goggles and remove gloves inside out; dispose of environment enhances patient comfort.
them according to agency policy.
17. Label tape over dressing with your initials and date • Provides timeline for when next dressing change
dressing is changed. is to be scheduled.
18. Help patient to comfortable position. • Promotes patient’s sense of well-being.
19. Perform hand hygiene. • Reduces transmission of microorganisms.
EVALUATION
1. Observe appearance of wound for healing: measure • Determines rate of healing.
size of wound; observe amount, color, and type of
drainage and periwound erythema or swelling.
2. Ask patient to rate pain using a scale of 0 to 10. • Increased pain is often indication of wound
complications such as infection or result of
dressing pulling tissue.
3. Inspect condition of dressing at least every shift. • Determines status of wound drainage.
4 . Ask patient and/or family caregiver to describe steps • Evaluates learning.
and techniques of dressing change.
Recording and Reporting

• Record appearance and size of wound,

characteristics of drainage, presence of
necrotic tissue, type of dressing applied,
patient’s response to dressing change, and
level of comfort in nurses’ notes and EHR
• Report any unexpected appearance of
wound drainage, accidental removal of drain,
bright red bleeding, or evidence of wound
dehiscence or evisceration.

MEDICATION ADMINISTRATION

EQUIPMENT
 Medication card
 Medication cup, dropper and spoon
 Medication cart (optional)
 Glass of water, juice or other liquid

TYPES OF ORAL ADMINISTRATION

1. Oral Route : given through mouth and swallowed
2. Sublingual route : drugs being placed under the tongue to dissolve
3. Buccal Route : involves placing the solid medication against the mucous
membranes of the cheek until dissolves

PROCEDURE RATIONALE
1. Verify written orders. • To determine the kind of drugs to be administered.
2. Review each drug to be given, its action, • Pre-administration assessment for specific
dosage, side effects, expiry dates and nursing medication.
consideration.
3. Wash hands. • Infection control
4. Identify client. • To perform the procedure to the right client.
5. Assess ability to swallow foods and fluids. • It allows the care provider to hold medication if not
tolerated. Consult Physician.
6. Prepare medications
A. Clarify incomplete or unclear orders with the • Never give doubtful orders.
prescriber.
B. Prepare medications one client at a time. • To prevent errors and confusion.
C. Determine if medications will be given orally, • The route for administering drugs depends on its
sublingually, or bucally. properties and desired effects.
D. Discard medications that are cloudy or alterd • To ensure administering non-contaminated or
color. unexpired drugs.
 E. Place tablets/ capsule requiring pre • Allows health care provider to observe nursing
administration assessment in a separate cup. consideration in giving medications.

How to prepare: • The wrapper maintains cleanliness and identification until

A. To prepare unit dose tablet/ capsule, it is administered.
place pack directly into medicine cup without
removing the wrapper.
B. To prepare tablet/ capsule for floor stocks pour • Avoid wasting and contamination of medication.
required amount to medicine cup
and return extra pills to the bottle. Never hold
with you fingers.
 C. Use gloves or cutting device on pills that
can be broken in order to administer half.
D. When using a blister pack, pop medicine into • Avoid contamination of medication.
the cup or through a foil or paper.
E. When preparing a liquid, mix thoroughly. • Holding the medication cup at eye level ensures an
Hold label against palm and fill medicine accurate dose.
cup at eye level.
F. If client has difficulty in swallowing, use a • A large tablet is usually easier to swallow if it is
mortar and pestle to grind pills or pill ground and mixed with soft food.
crushing device. Mix ground tablet in small
amount of soft food.
G. For narcotic preparations check narcotic • Control substance laws require records of each dose
record and get from the stocks. dispensed.
7. Administering medications: • Allows health care provider to observe nursing
consideration in giving medications
A. Take medications to client within 30 minutes • Allow care provider to assess client first.
before time.
B. Assist client to sitting or side lying position. • Sitting or side lying position promote swallowing.

C. Client may wish to hold solid medications in • Allow client’s preferred way in taking drugs but
hand before placing in mouth. always assess the needs for assistance.
D. If client is unable to hold medications, place it • Showing concern that client is dependent to the
to medication cup and gently health care provider.
introduce drugs into the mouth, one at a time.

E. Offer juice or water. • To help client swallow medications.

F. For sublingually administered drug, have • Sublingual drugs are designed to be readily
client place drug under the tongue and allow absorbed under the tongue.
it to dissolve completely. Caution client
against swallowing tablets.
G. For bucally administered drugs, have client • A buccal medication acts locally on the mucosa.
place medications in mouth against mucous
membranes of the cheek until it dissolves.

8. Stay until client has completely dissolved • To be certain client receives the prescribed
each medication. medications.
9. Leave client in comfortable position. • To alleviate discomfort.
10. Replenish stocks used and clean work area. • For the next used. Client comfort.

11. Document • For legal purposes.

• To evaluate the effect of drug administration.