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Changing Sterile and Clean Wound Dressings (Adult & Pediatric) (4.23-AP)

Changing Sterile and Clean Wound Dressings (Adult & Pediatric) (4.23-AP) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Integumentary

4.23-AP

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
December 26, 2016

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 4.23AP

Original
Revision

Page
1
of 5

Title: Changing Sterile and Clean Wound
Dressings (Adult & Pediatric)

I. PURPOSE

The purpose of this policy is to establish guidelines for sterile and clean dressing
changes to protect open wounds from contamination.
This policy does not pertain to dressings applied to acute post-operative incisions
approximated with sutures or staples. For adult patients refer to policy 4.25A, Care of
the Acute Postoperative Surgical Incisions Approximated with Sutures or Staples.

II. POLICY

A. All dressing changes require a provider’s order.
B. For patients managed by Burn Service, refer to Burn Guidelines (available in the
Burn Trauma Manual on U-Connect).
C. The provider must specify if a sterile dressing change is required.
D. If no order for wound care exists, the nurse will contact the provider for
instructions.
E. Dressing changes provide an opportunity for nursing staff to assess wounds.
Therefore, dressing changes on hospitalized patients shall be performed by nurses
unless otherwise specified.
F. Standard and isolation precautions shall be followed according to UWHC
Administrative Policy 13.07, Standard Precautions and Transmission-based
Precautions.
G. Hand hygiene shall be performed when indicated according to UWHC
Administrative Policy 13.08, Hand Hygiene.
H. Patients and/or families will be educated on wound care and dressing changes, if
needed prior to discharge.

III. DEFINITIONS

A. Sterile technique: Strategies are used to reduce patient exposure to
microorganisms and maintain objects and areas as free from microorganisms as
possible. Sterile technique includes meticulous hand hygiene, use of sterile field,
use of sterile gloves for application of sterile dressing, and use of sterile supplies
and instruments. Contact between sterile instruments or materials and any
nonsterile surface or product must be avoided.
B. Clean technique: Strategies are used to reduce patient exposure to the overall
number of microorganisms or to prevent/reduce the risk of transmission of
microorganisms from one person to another, or from one place to another. Clean
technique includes meticulous hand hygiene, maintaining a clean environment by

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preparing a clean field, using clean (nonsterile) gloves, sterile supplies and
instruments, and prevention of direct contamination of materials and supplies. For
example, chronic wounds, wounds healing by secondary intention with
granulation tissue, healing intact incisions generally require clean technique for
routine dressing changes.

IV. EQUIPMENT

A. Non-sterile (clean) examination gloves
B. Appropriate tape or Montgomery straps (Central Services [CS] Item Number
2200243)
C. Sterile forceps and scissors if needed
D. Sterile 4x4 gauze pads (CS Item Number 1219158)
E. Sterile rolled gauze, e.g., Kerlix (optional)
F. Additional sterile gauze dressing pads (2x2, 4x4, or surgical [ABD] pads [CS
Item Number 1216014], depending on drainage and size of area to be covered)
(optional)
G. Sterile gloves (for a sterile dressing change)
H. Waterproof disposable pad (e.g., Chux [CS Item Number 1216070])
I. Sterile cotton-tipped applicator (optional)
J. Sterile saline
K. Cleaning solution as ordered
L. Bacteriostatic ointment as ordered
M. Overbed table or bedside stand
N. Adhesive remover (optional)
O. Skin barrier (optional)
P. Red biohazard bag (if needed)
Q. Disinfecting wipe or spray

V. PROCEDURE

A. Pre- procedure Review:
1. Provider’s orders regarding type of dressing change procedure (e.g., dry
dressing, wet-to-dry dressing) and frequency of change
2. Type, size and location of wound or incision
3. Time of last pain medication
4. Patient’s level of pain
5. Allergies to tape or solution used for cleaning
6. Need for patient or family member to participate in dressing wound
B. Pain medication: Pre-medicate patient for pain if needed. Wait for medication to
take effect before beginning dressing change.
C. Dressing change
1. Gather the necessary supplies and bring into the patient’s room.
2. Obtain any assistance that may be needed with the dressing change,
close door to room.
3. Identify patient and explain procedure.
4. Perform hand hygiene according to Hospital Administrative Policy
13.08, Hand Hygiene. Apply appropriate personal protective equipment
(gloves, goggles/mask or face shield, gown according to Hospital

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Administrative Policy 13.07, Standard Precautions and Transmission-
based Precautions (Isolation) for Inpatient Settings).
5. Place bedside table close to area being dressed. Wipe table with
disinfecting solution or wipe.
6. Perform hand hygiene and don nonsterile gloves.
7. Position patient to allow access to wound and place waterproof pad
under wound area.
8. Remove old dressing: loosen the tape using adhesive remover as needed
for patient comfort and/or prevention of skin stripping and place soiled
dressing in the appropriate waste receptacle. If dressing is heavily
saturated with body fluids, place in red biohazard bag.
9. If dressing adheres to wound, soak it with saline, then gently pull free.
10. Note odor and appearance of wound and drainage on dressing. Assess
need for frequency of dressing changes. Based on assessment, if more
frequent dressing changes are needed or a different type of dressing is
needed, discuss with the provider.
11. Assess integrity of skin and effect of tape on skin. Use Montgomery
straps or skin barrier to optimize skin integrity.
12. DISCARD GLOVES by pulling them inside out AND PERFORM
HAND HYGIENE. Hand hygiene must be performed with each glove
change.
13. Prepare supplies
a. Place supplies on bedside table.
b. Lay out supplies
i. For sterile dressing change:
• Open sterile gloves and use the inside of the glove
wrapper as sterile field.
• Open three (3) plastic containers of gauze-pads
and drop one (1) container of gauze pads onto
sterile field.
• Keep gauze in second open plastic container.
• Open liquids and pour saline into empty plastic
gauze container and, if ordered, pour cleaning
solution into second gauze container.
• Place several sterile cotton-tipped swabs and
gauze on sterile field.
ii. For clean dressing change:
• Place waterproof pad on bedside table as clean
field.
• Open three (3) plastic gauze-pad container
packages, leave pads in container.
• Open liquids and pour saline into plastic gauze
container.
• Open several sterile cotton-tipped swabs and
leave in packages.
14. Don sterile gloves (face mask optional) for sterile dressing change.
15. Don nonsterile gloves for clean dressing change.
16. Pick up saline-soaked dressing pad with forceps (forming a large swab)

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and use to remove debris and drainage from wound; move from least-
contaminated area to most-contaminated area. Discard pads away from
sterile supplies. Replace forceps if soiled.
17. For sterile dressings, it is acceptable to use a sterile-gloved hand to pick
up gauze instead of forceps to cleanse the wound.
18. Wipe wound with pads soaked with ordered cleaning solution, moving
from least-contaminated area to most-contaminated area; discard pads
and forceps.
19. Use dry gauze to blot dry; move from least-contaminated area to most-
contaminated area.
20. Apply ointment, if ordered, using same technique as for cleansing.
21. Apply dressing over wound or incision in the following manner:
a. Dry dressing:
i. Pick up dressing pads by edge using sterile gloved hand or
sterile forceps.
ii. Place pads over wound or incision site until site is covered.
b. Wet-to-dry dressing:
i. Moisten gauze with prescribed solution. Wring gauze out.
Unfold.
ii. Apply moist fine-mesh, open weave gauze as a single layer
directly onto the wound surface. If wound is deep with
tunnels present, gently fill the wound with one contiguous
piece of sterile roller gauze (i.e., Kerlix) assuring all wound
surfaces are in contact with the gauze. If tunneling is
present, use a cotton-tipped applicator to place gauze into
tunneled area. Be sure gauze does not touch the
surrounding skin.
iii. Cover with sterile dry gauze and surgical pad.
D. Secure dressing
1. Tape: apply non-allergenic tape to dressing.
2. Montgomery ties
a. Expose adhesive surface of tape on end of each tie.
b. Place ties on opposite sides of dressing.
c. Place adhesive directly on skin or use skin barrier.
d. Secure dressing by lacing ties across it.
3. For dressings on an extremity, secure dressing with roller gauze or
Spandage elastic net.
E. Dispose of materials and then remove and dispose of gloves.
F. Perform hand hygiene.
G. Position client for comfort with call light within reach.
H. Perform hand hygiene prior to exiting room.
I. Document wound dressing change and assessment in the patient’s clinical record.

VI. UWHC CROSS REFERENCES

A. Hospital Administrative Policy 13.07, Standard Precautions and Transmission-
based Precautions (Isolation) for Inpatient Settings
B. Hospital Administrative Policy 13.08, Hand Hygiene
C. Nursing Patient Care Policy 4.25A, Care of Acute Postoperative Surgical

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Incisions Approximated with Sutures or Staples (Adult)

VII. REFERENCES

A. Anderson, D., Kaye, K., Classen, D., Arias, K., & et al. (2008). Strategies to
prevent surgical site infections in acute care hospitals. J Hosp Infect Control
Epidem, 29(Supp 1), S51-S61.
B. Centers for Disease Control and Prevention (2002). Recommendations of the
Healthcare Infection Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR, 51(No. RR-16),
32-34.
C. Mangram, A. J., Horan, T. C., Pearson, M. L., Silver, L. C., Jarvis, W. R., & The
Hospital Infection Control Practices Advisory Committee. Guideline for
prevention of surgical site infection, 1999. Accessed at
http://www.cdc.gov/hicpac/pdf/SSIguidelines.pdf on December 4, 2016
D. Perry, A. G., & Potter, P. A. (2017). Fundamentals of Nursing (8
th
Ed.). St. Louis,
MO: Elsevier
E. Wound Ostomy and Continence Nurses Society, Clean vs Sterile Dressing
Techniques for Management of Chronic Wounds: A Fact Sheet. J Wound Ostomy
Continence Nurs. 2012; 39(2S) S30-S34

VIII. REVIEWED BY

Clinical Infection Control Practitioners, Infection Control
Clinical Nurse Specialists, Wound & Skin
Nursing Patient Care Policy and Procedure Committee, December 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer