Nurse Catherine is changing a dressing and providing wound care. Which activity should she perform first?
A. Assess the drainage in the dressing.
B. Slowly remove the soiled dressing.
C. Wash hands thoroughly.
D. Put on latex gloves.
Correct Answer: C. Wash hands thoroughly.
When caring for a client, the nurse must first wash her hands. Putting on gloves, removing the dressing, and observing the drainage are all parts of performing a dressing change after hand washing is completed. When applying or changing dressings, an aseptic technique is used in order to avoid introducing infections into a wound. Even if a wound is already infected, an aseptic technique should be used as it is important that no further infection is introduced.
Option A: Complete a wound assessment. This includes a visual check and comparing and evaluating the smell, amount of blood or ooze (excretions) and their color, and the size of the wound. If the site has not improved as expected, then the treating physician or senior charge nurse must be informed so they too can evaluate it and consider changing the care plan.
Option B: Wash hands and put on non-sterile gloves (to protect yourself) before removing an old dressing. Dispose of this dressing in a separate dirty clinical waste bag. Start from the dirty area and then move out to the clean area. Be very careful when doing this as the tissue or skin may be tender and there may also be sutures in place. Clean the area without causing further damage or distress to the patient.
Option D: Wash hands and put on sterile gloves. If the gloves become desterilized, remove them, re-wash hands, and put on new sterile gloves. This is best practice, but where resources are not available, safe modifications to this process can be made, for example by using non-sterile gloves to protect the nurse while removing the dressing
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