Changing Wound Dressings

  1. Check order for dressing change
    1. How often dressing is to be changed
    2. Type of dressing to apply
    3. Cleansing agents
  2. Assess patient need for dressing change and pain status
    1. Is dressing intact?
    2. What supplies will you need to change the dressing?
    3. Has the patient been medicated for pain?
  3. Gather needed suplies for the type of wound.
  4. Wash hands
  5. Don procedure gloves and remove old dressing
  6. Assess wound and drainage
    1. Measure the wound in centimeters · Length (head to toe) X width (side to side) X depth
      • Indicate deepest point using clock method (e.g. 6:00 5 cm)
      • Depth cannot be accurately measured in the presence of necrotic tissue
      • Measure depth and tunneling with a cotton swab
      • Sketch wound in notes
    2. Assess phase of wound healing
      • Reaction
      • Regeneration
      • Remodeling
    3. Wound location, color of wound bed, condition of wound margins, integrity of surrounding skin
    4. S/S infection
    5. Drainage: amount, color, consistency, odor
  7. Set up sterile field and supplies; think over what steps you will be doing before donning your sterile gloves.
  8. Cleanse wound if needed
  9. Apply sterile dressing
  10. Chart dressing change

Abdominal Wound   Thigh Wound
Hand Wound   Foot Wound