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NNA E5 AF 5.3

NNA E5 AF 5.3 NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIA ELEMENT 5 : CONTINUUM OF

NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIA ELEMENT 5: CONTINUUM OF CARE

5.3 ASEPTIC WOUND DRESSING

  • 1. INTRODUCTION Wound dressing is one of the major nursing responsibilities. Aseptic technique is mandatory to minimize complications. Effective wound dressing promotes wound healing and lead to early discharge and thus save cost.

  • 2. OBJECTIVES :

    • 1. To ensure nurses perform wound dressing using aseptic technique

    • 2. To assess the caring component during dressing

    • 3. To document wound findings after the procedure in the

appropriate patient’s records.

3. STANDARD :

  • 1. Nurses perform wound dressing using aseptic technique

  • 2. Nurses exhibit the caring component during dressing

  • 3. Nurses document wound findings in the appropriate

patient’s

records.

NNA E5 AF 5.3

4.

CRITERIA

 

Structure

Process

Outcome

  • 1. Screen / Procedure

  • 1. Greet patient and

1.

Dressing

Room.

introduce self.

performed

  • 2. Dressing trolley.

  • 2. Perform pain assessment

 

adhering to

  • 3. Hand-washing facilities/

(if indicated).

principles

hand rub.

  • 3. Administer analgesic (if

 

of aseptic

  • 4. Relevant protective

  • 5. Clinical waste bin.

indicated).

personal

  • 4. Place sterile dressing set

technique.

on

2.

Patient is

equipment (PPE).

clean dry trolley.

informed

  • 6. Domestic waste bin.

  • 5. Inform patient and explain

 

of the progress of

  • 7. Protective cover.

procedure.

his/her wound.

  • 8. Sterile dressing set.

  • 6. Provide privacy to the

3.

Respect and

  • 9. Sterile soft dressings.

patient.

comfort

  • 10. Cleansing agent.

  • 7. Place patient in confortable

 

of patient is

  • 11. Adhesive tapes.

  • 12. Nursing Operating

position.

maintained.

  • 9. Perform hand hygiene.

4.

Wound findings and

Procedure (N.O.P.) / Manual of wound

  • 10. Wear mask.

its progress are

dressing.

  • 11. Open outer layer of

documented.

  • 13. Copy of Standard

  • 14. The nurse is competent

dressing set.

 

Precautions by Ministry

  • 12. Discard soiled dressing.

of Health is available.

in performing aseptic wound dressing.

  • 13. Perform hand hygiene.

  • 14. Open inner layer of dressing set.

15.

Nurse need to verify patient and verify type of dressing.

  • 15. Pour cleansing agent. Add soft dressings / supplementary.

 
  • 16. Perform hand hygiene.

  • 17. Wear sterile gloves

NNA E5 AF 5.3

 

(optional).

 

Structure

Process

Outcome

 
  • 18. Perform dressing

 
  • 19. Make patient

comfortable

after procedure.

  • 20. Discard used dressing

set

  • 21. Perform hand hygiene.

  • 22. Document findings.

  • 5. AUDIT GUIDE FOR ASEPTIC WOUND DRESSING

    • 5.1. INCLUSION CRITERIA

NNA E5 AF 5.3

All adult patients in surgical and orthopedic wards.

  • 5.2. EXCLUSION CRITERIA Patients with burn dressings.

  • 5.3. INSTRUMENT Check list (E5-AF 5.3) – one check list for one observation.

  • 5.4. Methodology.

    • 5.4.1. Direct observation of wound dressing being

performed.

  • 5.4.2. Sample Frame: All in-patients

  • 5.4.3. Setting : All adult Surgical / Orthopedic / Medical

wards

  • 5.4.4. Population : Staff Nurses

  • 5.5. Sample Design

    • - Simple random sampling of nurses

  • 5.6. Sample Size

    • - 10 staff nurses of each discipline

  • 6. DEFINITION OF OPERATIONAL TERMS :

    • - Hand hygiene - include both hands washing with either plain or

antiseptic-

containing soap and water, or use of alcohol-base hand rub.

[WHO, 2007]

  • - Sterile soft dressings – refer to sterile swab / gauze / gamgee

  • - Cleansing agent - refers to any lotion used to clean

the wound

  • - Sterile field refers to the area within the sterile packaging, i.e. 1

inch

around the working area be kept free of instruments.

NNA E5 AF 5.3

-

ensure body / any part of uniform of nurse does not touch sterile

field.

assessment of pain should be done prior to procedure and should include

-

 

administration of analgesic if indicated.

-

aseptic technique includes:

- discard soiled forceps after use.

  • - keep forceps facing downwards and above waist line.

  • - no contact of forceps when transferring soft dressing from one hand to

another.

  • - correct technique of pouring of cleansing agent (no touching

and

 

spillage) and topping up of supplementary.

- body / any part of uniform of nurse must not touch sterile field.

  • - does not cross sterile field at all

times.

  • - clean the skin area around wound thoroughly.

  • - cover wound appropriately.

-

pain assessment – use pain score format from KKM to assess

pain.

-

Discard soiled dressing involves loosening dressing, removing soiled dressing, discard soiled dressing forceps and observing condition of wound.

*

Failure to comply with any of the above will be considered non-conformance to aseptic technique.

-

documentation of wound finding includes – wound size and depth, nature of wound-swelling, dirty, clean, slough, gangrene, healing process and nature of discharge - smell, color, serous, bloody, pus

NNA E5 AF 5.3

7. Compliance of Aseptic Wound Dressing Audit.

Every step in the process must be performed.

a) Technical

  • - Perform hand hygiene.

  • - Wear mask.

  • - Open outer layer of dressing set.

  • - Perform hand hygiene.

  • - Open inner layer of dressing set.

  • - Pour cleansing agent.

  • - Add soft dressings / supplementary.

  • - Assess patient’s pain threshold (observe / ask).

  • - Perform hand hygiene.

  • - Wear sterile gloves (optional).

  • - Remove soiled dressing with forceps.

  • - Discard used forceps into receiver.

  • - Perform dressing.

  • - Cover the wound with appropriate dressing.

  • - Discard used dressing set.

  • - Perform hand hygiene.

b) Essence of care (soft skills)

  • - Greet patient and introduce self.

  • - Perform pain assessment (if indicated).

  • - Administer analgesic (if indicated). (Do not score if not

indicated)

  • - Inform patient and explain procedure.

  • - Provide privacy to the patient.

  • - Place patient in a comfortable position before procedure.

NNA E5 AF 5.3

- Make patient comfortable after procedure – involves placing

patient

in a comfortable position and reassess pain.

c) Documentation

Documentation of wound finding includes:

– wound size and depth, healing process

  • - nature of wound-swelling, dirty, clean, slough, gangrene,

  • - nature of discharge - smell, color, serous, bloody, pus

8. Audit Form

NATIONAL NURSING

NATIONAL

NURSING AUDIT,

AUDIT, MINISTRY

MINISTRY OFOF

HEALTH MALAYSIA.

HEALTH

MALAYSIA.

VERSION 1/08

NNA E5 AF 5.3

ELEMENT 5 : CONTINUUM OF CARE

DATE: 1.11.08

TOPIC : 5.3 ASEPTIC WOUND DRESSING

DOCUMENT NO : E5 AF 5.3

PAGE NO 1/3

STANDARD :

  • 1. Nurses perform wound dressing using aseptic technique

  • 2. Nurses exhibit the caring component during dressing

  • 3. Nurses document wound findings in the appropriate patient’s records.

OBJECTIVES :

  • 1. To ensure nurses perform wound dressing using aseptic technique

  • 2. To assess the caring component during dressing

  • 3. To document wound findings after the procedure in the appropriate patient’s records.

Date of Audit:………………………………………

Locality : …………………………………………….

Auditors: 1 ...............................................

............................................... 2

NB. Instruction for Auditors

  • 1. To tick [] at the appropriate column.

NNA E5 AF 5.3

S/N

ITEM

SOURCE OF

YES

NO

N/A

O

INFORMATIO N

1.

Greet patient and introduce self.

Listen/Observe

 

nurse.

2.

Perform pain assessment.

Observe nurse

3.

Administer analgesic (if indicated).

Observe nurse

     

4.

Place sterile dressing set on clean

Observe nurse

dry trolley.

5

Inform patient and explain procedure.

Observe nurse.

     

6.

Provide privacy to the patient.

Observe nurse.

7.

Place patient in comfortable position.

Observe nurse.

     

8.

Place protective cover.

Observe nurse

9.

Perform hand hygiene.

Observe nurse.

10.

Wear mask.

Observe nurse.

11.

Open outer layer of dressing set.

Observe nurse.

12.

Discard soiled dressing.

Observe nurse

13.

Perform hand hygiene.

Observe nurse

     

14.

Open inner layer of dressing set.

Observe nurse

15.

Pour cleansing agent and add soft

Observe nurse

dressings / supplementary.

16.

Perform hand hygiene.

Observe nurse.

17.

Wear sterile gloves (optional).

Observe nurse.

NNA E5 AF 5.3

S/N

 

ITEM

SOURCE OF

YES

NO

N/A

O

 

INFORMATIO N

  • 18. Perform dressing :

 
 

18.

Swab from clean area to

Observe nurse.

1

dirty area.

18.

Keep forceps facing

Observe nurse.

     

2

downwards and above

waist line.

18.

Maintain sterile field.

Observe nurse.

3

18.

Avoid contamination of

Observe nurse.

4

equipments.

18.

Use one swab for each

Observe nurse.

5

stroke.

18.

Clean skin area around

Observe nurse.

6

wound.

18.

Apply appropriate dressing

Observe nurse.

7

for wound.

18.

Secure wound dressing.

Observe nurse.

8

  • 19. Make patient comfortable.

Observe nurse.

  • 20. Clear dressing set.

Observe nurse.

  • 21. Perform hand hygiene.

Observe nurse.

22

Document findings:

Observe nurse.

22.

wound size and depth.

1

22.

nature of wound-swelling,

       

2

dirty, clean, slough, gangrene, healing process.

22.

nature of discharge - smell,

3

colour, serous, bloody, pus.

NNA E5 AF 5.3

AUDIT REPORT

AUDIT

REPORT

(please [√] the appropriate box)

Conformance

NNA E5 AF 5.3 AUDIT REPORT AUDIT REPORT (please [√] the appropriate box) Conformance REMARKS Non-

REMARKS

NNA E5 AF 5.3 AUDIT REPORT AUDIT REPORT (please [√] the appropriate box) Conformance REMARKS Non-

Non- Conformance

Auditor 1 (name and signature):………………………………………….

…………………………………………..

Auditor 2 (name and signature):………………………………………….

…………………………………….