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Sterile Dressing

Lab skill exam

QuestionAnswer
1. Checks chart for order 2. Review policy and procedure
3. state goals of procedure: a.apply sterile dxg, w/ sterile tech b.wound will heal w/o infection c.pxt will have minimal discomfort 4. Gather equip needed
5. Provides privacy 6. Perform hand hygiene, put on PPE
7. Prepare pxt: a. ID 2 ways - band, state name. b. check pxt allergies. c. explain procedure d. Allow pxt verbalization, e. Est. method of comm during procedure, f. Place waste container in place 8. Pxt assessment: a. size/location of dxg, b. need for premeds for pain, c. pxt understanding
9. Raise bed to comfortable height, side rail up on opposite side. 10. Position pxt and drapes to expose only wound site
11. Implement the procedure STEPS 1. Instruct pxt not to touch wound or sterile supplies and why
STEPS 2. Apply clean gloves and when apply PPE is spray risk STEPS 3. remove dxg and tape and outer dxg keeping soiled away from pxt view
STEPS 4. remove inner dxg, if sticks, use saline to loosen STEPS 5. observe for drainage on dxg: amount, color, odor, consistency, type
STEPS 6. dispose of soiled dxg STEPS 7. Inspect wounds for: a. size, approximation of wound edges, presence and anture of drainage, presence of pain, signs of infection, presence of drains, any sutures/staples
STEPS 8. Remove soiled gloves, hand hygiene ** STEPS 9. open sterile supplies creating and maintaining sterile field on table
STEPS 10. open saline ** STEPS 11. Put on sterile gloves correctly
STEPS12. Moisten 4x4's correctly, pick up NS with non-sterile hand ** STEPS 13. Clean/dries wound a. use separate swab for ea stroke b. clean from least to most contaminated c. clean drain insertion site, in circle motion from insertion site to periphery
STEPS 14. Apply loose 4x4 gauze as contact layer, not topper sponge STEPS 15. applies drain sponges
STEPS 16. apply second layer of gauze, assess if needed STEPS 17. apply outer dxg, sterile abd or surgipad
STEPS 18. removes gloves STEPS 19. secure dxg with tape and label with date, time, initials, how many strips of gauze if packed in
CLEAN UP 20. Dispose of trash/equip to policy and procedure CLEAN UP 21. remove PPE, hand hygiene
CLEAN UP 22. Follow up care: a. continue dxg changes as ordered b. assess every shift or more. Dxg needs to stay dry, clean, intact c. Assess wound healing for complications d. Maintain pain control CLEAN UP 23. Pxt Education a. keep dxg clean/dry b. report soiled, pain c. teach sx of infection to report d. well balanced diet high in protein and Vit B&C
CLEAN UP 24. Leave pxt safe and comfortable: a. side rails up b. bed to lowest position c. call light in reach d. reposition pxt CLEAN UP 25. hand hygiene
26. Document: a. date, time, b. appearance of wound,(amount,type,color,odor), c. wound cleansing, d. type of dxg applied, e. pxt tolerance, f. pxt teaching, g. signature
Created by: palmerag
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