Other
Considerations:
- Be sure to take steps to ensure patient privacy when performing procedure.
- The health care provider’s order should include:
- The type of dressing to be used,
- The frequency of the dressing change,
- Any solutions or ointments to be applied to the wound.
- If using commercially available dressings, be sure to review the manufacturer’s instructions for use.
Supplies:
- Water
- Sterile saline, if ordered
- Mild soap, if ordered
- Clean basin, cups, or medicine cups for solution
- Cotton-tip applicators, if needed
- Sterile or clean gauze, per health care provider’s order
- Soft cloth or gauze
- Kerlix or gauze wrap, if needed
- Skin preparation, if ordered
- Medical or paper tape
- Adhesive remover, if ordered/used
- Scissors, if needed
- Measuring guide, if needed to assess the size of the wound
- Sterile gloves, if sterile technique is ordered
- Clean gloves
- Student’s Individualized Health Care Plan (IHCP) and health care provider’s orders
- Parent/Guardian authorization form
Procedure:
- Review health care provider’s order and the student’s IHCP
- Review the health care provider’s order to determine if the student has a pain medication (i.e., acetaminophen, Tylenol) prescribed to be administered before the dressing change is to be performed
- Ensure proper documentation of parent/guardian authorization to perform this procedure
- Assemble equipment and place on a clean surface
- Place waste receptacle or bag at a convenient location for use during the procedure
- Explain the procedure to the student at their level of understanding
- Wash hands
- Assist the student to a comfortable position that provides easy access to the wound area
- Use a towel or blanket to cover any exposed area other than the wound
- Place disposable pad or towel under the area of the student’s wound
- Put on gloves
- Remove the old bandage
- Loosen the tape or adhesive edge on the old dressing by removing in the direction of hair growth and use the push-pull method
- Push-pull method: Lift a corner of the dressing away from the skin, and gently push the skin away from the dressing/adhesive
- Continue moving fingers of the opposite hand to support the skin as the product is removed
- Carefully lift the adhesive barrier from surrounding skin to prevent medical adhesive-related skin injury
- Remove the sides/edges first, then the center
- If there is resistance, use an adhesive remover
- Carefully remove the soiled dressing
- If any part of the dressing sticks to the underlying skin, use small amounts of sterile saline to help loosen and remove it
- After removing the dressing, inspect the bandage for the following:
- Presence of drainage
- Amount of drainage
- Type of drainage
- Color of the drainage
- Any odor associated with the drainage
- Dispose of old bandage in waste receptacle or in appropriate receptacle, per school policy
- Assess the wound:
- Describe the body site where the wound is located
- Describe the wound size
- Measure the length, width, and depth of the wound using clean (or sterile) wound measurement device, per health care provider’s order
- If depth of the wound is to be measured, use sterile cotton-tip applicator
- Examine the skin for breaks, dryness, maceration*, and the presence of rash, swelling, redness, or warmth.
- Measure the length, width, and depth of the wound using clean (or sterile) wound measurement device, per health care provider’s order
- Remove gloves
- Perform hand hygiene
- Put on clean gloves
- If dressing change is ordered to be performed using sterile technique put on sterile gloves and perform the rest of the steps using sterile technique
- Note, the procedure below is outlined using CLEAN technique
- If dressing change is ordered to be performed using sterile technique put on sterile gloves and perform the rest of the steps using sterile technique
- Open gauze packages (clean or sterile, per health care provider order) or cotton tip applicators
- Open the prescribed cleaning solution (sterile saline, or water)
- Depending on the amount of cleaning needed, the solution might be poured directly over gauze sponges or in a container for small cleaning jobs
- Clean the wound
- Clean the wound from top to bottom and/or from the center to the outside
- Use new gauze or cotton tip applicators for each wipe
- Place the used gauze/cotton tip applicators into waste receptacle
- Once the wound is cleaned, dry the area using a gauze sponge in the same manner as outlined above
- Remove gloves
- Perform hand hygiene
- Put on clean gloves
- If ordered, apply skin protectant or barrier to the healthy skin around the wound where the dressing adhesive or tape will be placed and where the wound drainage may come in contact with skin
- Apply any topical medications, foam, gels, and/or gauze to the wound as prescribed by the health care provider
- Be sure the products stay confined to the wound and do not impact the intact surround tissue/skin
- Gently place a layer of dry, sterile or clean dressing (as prescribed by health care provider) at the wound center and extend at least 1 inch beyond the wound in all directions or follow manufacturer’s instructions
- If needed, apply tape or roller gauze to secure the dressing
- Many commercial wound products are self-adhesive and do not require additional tape
- If applying rolled gauze on a limb, start from the bottom and work your way up the limb
- This helps to ensure the gauze is not applied too tightly
- After securing the dressing, label with date and time
- Dispose of old bandage and other used supplies in appropriate receptacle, per school policy
- Remove gloves
- Wash hands
- Document assessment, intervention, and outcomes in student’s health care record
- Report any problems or concerns to parents/guardian and health care provider
*Maceration: skin that looks soggy, feels soft, or appears whiter than usual. There may be a white ring around the wound in wounds that are too moist or have exposure to too much drainage.
References:
Children’s National Hospital. (2018, October, 9). After the burn: At home dressing changes. . Retrieved June 26, 2023, from https://www.youtube.com/watch?v=KCPa5uUpCZg
Cincinnati Children’s. (2022, September). Burn dressing changes. Retrieved June 26, 2023, from https://www.cincinnatichildrens.org/health/b/burndress#:~:text=Changing%20the%20Burn%20Dressing&text=Assemble%20all%20supplies%20and%20place,Promptly%20discard%20the%20old%20dressing
Lynn, P. (2019). Cleaning a wound and applying a dressing (general guidelines). In Skill checklists for Taylor’s clinical nursing skills. A nursing process approach. (5th ed.). (pp. 162-164).
Potter, P. A., Griffin Perry, A. G., Stockert, P. A., & Hall, A. (2023). Chapter 48 Skin integrity and wound care. In Fundamentals of Nursing. (11th ed.). (pp.1318-1388). St. Louis, MO: Elsevier.
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Acknowledgement of Reviewers:
Angie Bulmahn, MSN, RN, NCSN
School Nurse Specialist
Missouri Department of Health and Senior Services
Marjorie Cole, MSN, RN, FASHA
State School Nurse Consultant
Missouri Department of Health and Senior Services
Renee Falkner, BSN, RN
vision Specialist | Therapylog
Katherine Park, DNP, RN, NCSN
Nationally Certified School Nurse, Pierremont Elementary
Adjunct Professor, Maryville University School of Nursing
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Page last updated: February 20, 2024
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The information and materials presented in this Website are intended for informational purposes only and are not designed to diagnose or treat a health problem or disease, or assist in diagnosis or treatment of the same. The information is not intended to substitute for, supplement or replace clinical judgment. If there are any concerns or questions about or relating to a nursing or medical procedure, contact the individual’s healthcare provider. The information provided on this Website is not intended to be a substitute for medical orders and persons without the proper education, training, supervision and/or licensure should not perform the procedures.
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