Page 496 - Saunders Comprehensive Review For NCLEX-RN

procedure.

▪ Assess the client’s pain level using an appropriate pain scale and medicate as
necessary.
▪ Assess the client for allergies, particularly to tape or latex.

▪ Perform hand hygiene and don PPE.
▪ Position the client appropriately, apply clean gloves, and place the underpad
underneath the client.

▪ Remove the soiled dressing, assess and characterize drainage noted on the
dressing, and discard the removed dressing in the biohazard waste; note: if a
moist-to-dry dressing adheres to the wound, gently free the dressing and warn
the client of the discomfort; if a dry dressing adheres to the wound that is not to
be debrided, moisten the dressing with normal saline and remove.
▪ Assess the wound and periwound for size (length, width, depth; measure using
measuring tool), appearance, color, drainage, edema, approximation,
granulation tissue, presence and condition of drains, and odor; and palpate
edges for tenderness or pain.
▪ Cover the wound with sterile gauze by opening a sterile gauze pack and lightly
placing the gauze on the wound without touching the dressing material;
remove gloves and perform hand hygiene.
▪ Set up the sterile field: prepare sterile equipment using sterile technique on an
overbed table. If irrigation is prescribed, pour any prescribed irrigation solution
into a sterile basin and draw solution into the irrigating syringe. Gently irrigate
the wound with the prescribed solution from the least contaminated area to the
most contaminated area. Use an approved irrigation basin to collect solution
from the irrigating procedure.
▪ Cleanse the wound with sterile gauze from the least contaminated area to the
most contaminated area, using single-stroke motions. Discard the gauze from
each stroke and use a new one for the next stroke. If drains are present, use
cotton-tipped applicators to hold drains up and clean around drain sites using
circular strokes, starting near the drain and moving outward from the insertion
site using cotton-tipped applicators or sterile gauze. Dry sites in the same
manner using sterile gauze.
▪ Apply any prescribed wound antiseptic with a cotton-tipped applicator or sterile
gauze, using the same technique as when cleansing the wound.
▪ Dress the wound with the prescribed dressings using sterile technique and
secure in place.
▪ Date/time/initial the dressing and discard supplies as indicated per agency
procedures, and remove gloves.
▪ Assist the client to a comfortable position and ensure safety; assess pain level.
▪ Document the procedure, any related assessments, client response, and any
additional procedural responses.

Adapted from Perry A, Potter P, Ostendorf W: Clinical nursing skills and techniques, ed
8, St. Louis, 2014, Mosby.

496