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Changing a Wet-to-Dry Dressing (102.149)

Changing a Wet-to-Dry Dressing (102.149) - Policies, Clinical, UWMF Clinical, UWMF-wide, Clinical Policies and Procedures, Wound and Skin

102.149

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UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE

TITLE: CHANGING A WET-TO-DRY DRESSING

Effective Date: April, 2002 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education

Reviewed October, 2003 March, 2005 February, 2008 May 2010
October 2011

PURPOSE: To provide guidelines for changing a wet-to-dry dressing at UWMF Clinics.

DEFINITION: A wet-to-dry dressing is used for wounds requiring debridement. The
wet portion of the dressing effectively cleans an infected and necrotic wound. The moist
gauze directly absorbs all exudate and wound debris. The dry outer layer helps pull
moisture from the wound into the dressing by capillary action.

POLICY: The clinical staff who has had proper training in aseptic technique will utilize
the following guidelines to properly change a wet dressing for a UWMF patient.
.

EQUIPMENT:
A sterile dressing set or individual supplies of following: gloves, scissors and forceps,
drape (optional), gauze dressing (thin mesh) and/or pads, basin for antiseptic or cleaning
solution, antiseptic ointment (optional), cleaning solution (prescribed by provider) sterile
normal saline or water, clean disposable gloves, tape, ties, or bandage as needed, gown,
mask/goggles (required if risk of splash of secretions from the wound).

PROCEDURE:

1. Check provider’s order and clarify any inconsistencies.

2. Wash hands and gather equipment.

3. Introduce yourself, identify patient by verifying name and date of birth and provide
good light and privacy.

4. Check patient allergies to any antiseptic solutions; ie. Betadine. (if going to be used)

5. Explain procedure and assist patient to comfortable position.

6. Drape patient - to expose only wound site.




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7. Wash hands thoroughly. Apply protective gear if appropriate.

8. Put on clean disposable gloves and remove tape or ties, and old bandage.
9. Remove tape by loosening end and pulling gently, parallel to skin and toward
dressing.

 If adhesive remains on skin, it may be removed with acetone wipes.

10. With gloved hand or forceps, lift old outer secondary cover dressing off first.
 Gently remove this inner dressing, and inform patient about possible discomfort.

10. If dressing adheres to tissues, loosen gauze by moistening with sterile normal saline
or water.

11. Observe the dressing for amount of drainage, color and odor on dressing.
12. Dispose of soiled dressings in proper container.
 If drainage is grossly bloody in nature, dispose in “red bio-hazard” bag.

13. Remove disposable gloves and dispose of them properly, then wash hands.
14. Inspect wound.
 Note condition, color, odor, depth, width and margins or wound
placement of drain, integrity of sutures or skin closure, and character of drainage.

15. Prepare sterile dressing supplies onto sterile field.
 Pour the prescribed solution into a sterile basin and add fine-mesh gauze.
 Don sterile gloves.

16. Cleanse wound with prescribed solution.
 Clean from least contaminated to most contaminated area.
 Move in progressive strokes away from incision line or wound edges.
 Use of forceps prevents contamination of your gloved fingers.

17. Apply moist fine-mesh gauze directly on wound surface. If wound is deep and
packing is needed, contact physician for order to pack wound. Pack wound by
gently feeding packing material into wound to all surfaces of wound are in contact
with packing material.

18. Apply dry sterile gauze (4 x4) over wet gauze.
19. Cover with gauze, Surgipads, or ABD pad.
20. Apply tape over dressing or secure with Montgomery ties, bandage, or binder.

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21. Document in patient’s chart, using .npdress. Documentation should also include all
or some of the following items: -
 the wounds condition: color of drainage, odor, depth, width and margins or
 placement of drain(s) (if applicable),
 integrity of suture or skin closure,
 additional procedures: packing wound, irrigating wound, or application of topical
medication.. .

22. Assist the patient to a comfortable position.

REVIEWED BY:

LaVay Morrison, RN, BSN, Clinical Staff Educator

WRITTEN BY:

Ronnie Peterson, R.N., M.S., Manager of Clinical Support

REFERENCES:

1. Perry, A.G. & Potter, P.A. (2002). Clinical nursing skills & techniques. (5
th
ed.). St.
Louis, MO: Mosby.
2. Perry, A.G. & Potter, P.A. (2009). Fundamentals of nursing. (7
th
ed.). Hall, A. &
Stockert, P.A. (Eds.). St. Louis, MO: Mosby Elsevier.
3. Kowalak, J. P. (Ed.). (2009). Lippincott’s Nursing Procedures (5
th
ed.). Ambler,
PA: Lippincott Williams & Wilkins.


AUTHORIZATION:



Medical Director Date