Wound Care Check-Off

Verify Provider Order: I have verified the provider order for wound care.

Introduce Self: Good morning, my name is Jincey and I will be your nurse today.

Verify Patient: Can you tell me your name and DOB?

Assess for Allergies: Do you have any allergies?

Explain Procedure: Today I am going to change and clean your wound dressing to assess healing
and prevent infection.

Assess Comfort Level: I previously assessed for pain and provided medication. Can you rate your level
of current pain on a scale of 0-10? 0 being no pain and 10 being the worst.

Provide Privacy: I am going to provide privacy. *Pull curtain

Verbalize Hand Hygiene: I am going to wash my hands.

Gather Supplies: Should be done ahead of time.

-sterile kit, tape, gloves, measuring device, sterile q-tips, biohazard bag

Raise Bed/Lower Rails: I am going to raise the raise your bed & lower side rail.

Hand Hygiene: I am going to wash my hands.

Prepare for Procedure: *Place biohazard bag w/n reach

*Prepare tape (4 strips) & write date, time, and initials. (Use military time)

Position Patient: *Expose patient wound

*Place linen saver pad

Preform Hand Hygiene: I am going to wash my hands & put on clean gloves

Remove Old Dressing: *Pull tape edges to loosen. *Remove from toe to head (so patient can’t see)
*Pinch and pull old dressing

Assess Wound: Amount of Drainage- moderate

Color of Drainage- sanguineous

Odor- no odor

Color of Wound Bed-

 Wound Edges- unrolled

Wound Closure- unapproximated

Presence of Drains- none

Measure Length: *Use measuring device (Note measurement)

Measure Width: *Same as above

Hand Hygiene: Remove gloves & wash hands

Prepare Sterile Field: *Open kit, pull out gloves and set to side. *Remove drape & set up field *Dump
kit contents onto field *Take saline bottle out and pour solution into kit
*Through away *Open q-tips and dump on field *Open q-tips and take one out
to measure depth

Gloves (if needed):

Measure Depth: *Dip q-tip into solution *Measure depth of wound (Note measurement) *State
if there is any tunneling present *Throw away q-tip

Don Sterile Gloves: Perform hand hygiene & *use technique to put on gloves

Clean Wound: *Dip gauze into solution *Make a poof with gauze *Wipe head to toe *Center-
trash, Distal- trash, Proximal- trash

Pack Wound (Wet): *Dip gauze into solution *Fluff in hand *Pack wound using q-tip to lead the
gauze *Do not let q-tip touch wound *Throw away each q-tip after one use

Apply Dry: *Apply clean layer of gauze *Apply sterile ABD pad (blue up)

Secure Dressing: *Use tape to “window pane” the dressing on all 4 sides

Remove Sterile Gloves:

Hand Hygiene & Gloves: I am going to wash my hands and put on clean gloves.

Clean: Clean & discard supplies per agency policy

Remove Gloves: I am going to remove my gloves and wash my hands

Patient Comfort: *Raise rails & lower bed *Place call light w/n reach *Assess comfort

Document: Amount of Drainage- moderate

Color of Drainage- sanguineous

Odor- no odor

Color of Wound Bed-

Wound Edges- unrolled

Wound Closure- unapproximated

Measurements- Length, Width, Depth (No Tunneling)

Cleaning Done-

Type of Dressing Applied-

Patient Response- Patient tolerated the patient with no complaints of pain