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Step A.

Perform task according to protocol.

Step B.

Check order, collect supplies, and wash hands.

Step C.

Identify and prepare patient.

Step D.

Provide privacy, institute safety precautions; arrange supplies.

Step E.

Use Standard Precautions and aseptic technique as appropriate.

Supplies

1. Gauze sponges
2. Sterile basin
3. Tape or binder
4. Discard bag
5. Sterile normal saline
6. Sterile gloves
7. Clean gloves
8. Underpad

1. ACTION
Check order.
Assess old dressing.
Determine patient is ready for procedure.

1. RATIONALE
Ensures proper dressing is applied to right patient

2. ACTION
Plan time in your schedule to do dressing change.
Determine if supplies are on hand at bedside.
Wet-to-damp is changed more often that wet-to-dry.

2. RATIONALE
Assures the procedure goes smoothly and quickly.

3. ACTION
Prepare work space.
Open packages.
Perform hand hygiene.
Don clean gloves.

3. RATIONALE
Readies dressing and solution.
Institutes Standard Precautions.

4. ACTION
(wet-to-damp) Carefully remove gauze. If stuck, use saline to loosen.
(wet-to-dry) Gently pull gauze to remove, debriding necrotic tissue.
Place used dressings in discard bag.

4. RATIONALE
Pulling stuck dressing loose damages new tissue.
Wet-to-dry is not remoistened when removing.

5. ACTION
Remove gloves.
Perform hand hygiene.
Pour sterile wetting solution into basin.

5. RATIONALE
Solution should be poured before donning sterile gloves.

6. ACTION
Done sterile gloves.

6. RATIONALE
Prepares hands for sterile procedure.

7. ACTION
Place dressings in solution or pour solution on them.

7. RATIONALE
Dressings should be thoroughly soaked.

8. ACTION
Wring out dressings 1-by-1 and lightly press fluffed gauze into wound covering all exposed surface.

8. RATIONALE
Dressings should be moist without dripping.
Moisture encourages healthy tissue growth.
Gauze pads must be unfolded and lightly packed to be effective.

9. ACTION (wet-to-damp) Cover with 2nd moist dressing, then sterile 4 x 8 combined dressing in a single layer on top of wet dressings. More dry dressings may be added as needed to keep outside dry.

9. RATIONALE
To promote healing, wet-to-damp must be changed regularly before dressing dries.
Physician may order frequency of dressing changes, but if not, every 2 hours.
Moisture that reaches outside dressing provides avenue for pathogens to enter wound.

10. ACTION
Remove and discard gloves.
Tape edges of dressing.
Perform hand hygiene.

10. RATIONALE
Secures dressing.
Binder may be used in place of tape.

11. ACTION
(wet-to-damp)
Did inner dressing stay damp?
Did oute dressing stay dry?
(wet-to-dry)
Necrotic tissue removed?
Granulation tissue appearing?

11. RATIONALE
Determines if procedure is successful.

12. ACTION
Document times of dressing changes, procedure, appearance of wound at end of shift.

12. RATIONALE
Verifies orders were carried out.
Documents course of healing.

Step X.

Remove gloves and other protective equipment.

Step Y.

Restore the unit. Collect the used equipment; dispose of, clean, or store items in the proper places.

Step Z.

Record and report findings.

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