Aseptic Wound Dressing Edited 3 Dec 2008

NNA E5 AF 5.
3
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 fndings after the procedure in the
appropriate
patients records.
3. STANDARD :
1. Nurses perform wound dressing using aseptic technique
2. Nurses exhibit the caring component during dressing
3. Nurses document wound fndings in the appropriate
patients
records.
National Nursing Audit, Ministry of Health Malaysia: Revised June 2008
Nursing Division, Ministry of Health Malaysia
1
NNA E5 AF 5.3
4. C!T"!#
Structure Process Outcome
1. Screen !rocedure
"oom.
#. $ressing trolley.
%. &and'washing facilities
hand rub.
(. "elevant protective
personal
equipment )!!E*.
+. ,linical waste bin.
-. $omestic waste bin.
.. !rotective cover.
/. Sterile dressing set.
0. Sterile soft dressings.
11. ,leansing agent.
11. Adhesive tapes.
1#. 2ursing 3perating
!rocedure )2.3.!.*
4anual of wound
dressing.
1%. ,opy of Standard
!recautions by 4inistry
of &ealth is available.
1(. 5he nurse is competent
in performing aseptic
wound dressing.
1+. 2urse need to verify
patient and verify
type of dressing.
1. $reet patient and
introduce se%f.
2. &erform pain assessment
'if indicated(.
3. #dminister ana%gesic 'if
indicated(.
4. &%ace steri%e dressing set
on
c%ean dr) tro%%e).
*. !nform patient and exp%ain
procedure.
+. &ro,ide pri,ac) to the
patient.
-. &%ace patient in confortab%e
position.
.. &erform hand h)giene.
1/. 0ear mas1.
11. 2pen outer %a)er of
dressing set.
12. 3iscard soi%ed dressing.
13. &erform hand h)giene.
14. 2pen inner %a)er of
dressing set.
1*. &our c%eansing agent.
#dd soft dressings 4
supp%ementar).
1+. &erform hand h)giene.
1-. 0ear steri%e g%o,es
1. 3ressing
performed
adhering to
princip%es
of aseptic
technique.
2. &atient is
informed
of the progress of
his4her wound.
3. espect and
comfort
of patient is
maintained.
(. Wound findings and
its progress are
documented.
2
NNA E5 AF 5.3
'optiona%(.
Structure Process Outcome
15. &erform dressing
1.. 6a1e patient
comfortab%e
after procedure.
2/. 3iscard used dressing
set
#1. !erform hand hygiene.
22. 3ocument fndings.
*. AUDIT GUIDE FOR ASEPTIC WOUND DRESSING
5.1. INCLUSION CRITERIA
3
NNA E5 AF 5.3
#%% adu%t patients in surgica% and orthopedic wards.
5.2. EXCLUSION CRITERIA
&atients with burn dressings.
5.3. INSTRUMENT
Chec1 %ist '"*7#8 *.3( 9 one chec1 %ist for one obser,ation.
5.4. Met!"!#!$%.
*.4.1. 3irect obser,ation of wound dressing being
performed.
*.4.2. :amp%e 8rame; #%% in7patients
*.4.3. :etting ; #%% adu%t :urgica% 4 2rthopedic 4 6edica%
wards
*.4.4. &opu%ation ; :ta< Nurses
5.5. S&'(#e De)*$+
7 :imp%e random samp%ing of nurses
5.,. S&'(#e S*-e
7 1/ sta< nurses of each discip%ine
,. DEFINITION OF OPERATIONAL TERMS :
7 =and h)giene 7 inc%ude both hands washing with either p%ain or
antiseptic7
containing soap and water> or use of a%coho%7base hand rub.
?0=2> 2//-@
7 :teri%e soft dressings 9 refer to steri%e swab 4 gauAe 4 gamgee
7 C%eansing agent 7 refers to an) %otion used to c%ean the wound
7 :teri%e fe%d refers to the area within the steri%e pac1aging> i.e. 1
inch
around the wor1ing area be 1ept free of instruments.
4
NNA E5 AF 5.3
7 ensure bod) 4 an) part of uniform of nurse does not touch steri%e
fe%d.
7 assessment of pain shou%d be done prior to procedure and shou%d
inc%ude
administration of ana%gesic if indicated.
7 aseptic technique inc%udes;
7 discard soi%ed forceps after use.
7 1eep forceps facing downwards and abo,e waist %ine.
7 no contact of forceps when transferring soft dressing from one
hand to
another.
7 correct technique of pouring of c%eansing agent 'no touching
and
spi%%age( and topping up of supp%ementar).
7 bod) 4 an) part of uniform of nurse must not touch steri%e fe%d.
7 does not cross steri%e fe%d at a%% times.
7 c%ean the s1in area around wound thorough%).
7 co,er wound appropriate%).
7 pain assessment 9 use pain score format from BB6 to assess
pain.
7 3iscard soi%ed dressing in,o%,es %oosening dressing> remo,ing
soi%ed dressing> discard soi%ed dressing forceps and obser,ing
condition of wound.
C 8ai%ure to comp%) with an) of the abo,e wi%% be considered
non7conformance to aseptic technique.
7 documentation of wound fnding inc%udes 9 wound siAe and
depth> nature of wound7swe%%ing> dirt)> c%ean> s%ough> gangrene>
hea%ing process and nature of discharge 7 sme%%> co%or> serous>
b%ood)> pus
*
NNA E5 AF 5.3
.. C!'(#*&+/e !0 A)e(t*/ W!1+" D2e))*+$ A1"*t.
",er) step in the process must be performed.
&3 Te/+*/&#
7 &erform hand h)giene.
7 0ear mas1.
7 2pen outer %a)er of dressing set.
7 2pen inner %a)er of dressing set.
7 &our c%eansing agent.
7 #dd soft dressings 4 supp%ementar).
7 #ssess patients pain thresho%d 'obser,e 4 as1(.
7 0ear steri%e g%o,es 'optiona%(.
7 emo,e soi%ed dressing with forceps.
7 3iscard used forceps into recei,er.
7 &erform dressing.
7 Co,er the wound with appropriate dressing.
7 3iscard used dressing set.
' !erform hand hygiene.
43 E))e+/e !0 /&2e 5)!0t )6*##)3
7 $reet patient and introduce se%f.
7 &erform pain assessment 'if indicated(.
7 #dminister ana%gesic 'if indicated(. '3o not score if not
indicated(
7 !nform patient and exp%ain procedure.
7 &ro,ide pri,ac) to the patient.
7 &%ace patient in a comfortab%e position before procedure.
+
NNA E5 AF 5.3
7 6a1e patient comfortab%e after procedure 9 in,o%,es p%acing
patient
in a comfortab%e position and reassess pain.
/3 D!/1'e+t&t*!+
3ocumentation of wound fnding inc%udes;
9 wound siAe and depth> hea%ing process
7 nature of wound7swe%%ing> dirt)> c%ean> s%ough> gangrene>
7 nature of discharge 7 sme%%> co%or> serous> b%ood)> pus
7. A1"*t F!2'
NATIONAL NURSING AUDIT, MINISTRY OF NATIONAL NURSING AUDIT, MINISTRY OF
HEALTH HEALTH MALAYSIA. MALAYSIA.
VERSION 1897
-
NNA E5 AF 5.3
ELEMENT 5 : CONTINUUM OF CARE
DATE: 1.11.97
TOPIC : 5.3 ASEPTIC WOUND DRESSING
DOCUMENT NO : E5 AF 5.3
PAGE NO 183
STANDARD ;
1. Nurses perform wound dressing using aseptic technique
2. Nurses exhibit the caring component during dressing
3. Nurses document wound fndings in the appropriate patients
records.
OBJECTIVES ;
1. To ensure nurses perform wound dressing using aseptic
technique
2. To assess the caring component during dressing
3. To document wound fndings after the procedure in the
appropriate
patients records.
3ate of #udit;DDDDDDDDDDDDDDD
Eoca%it) ; DDDDDDDDDDDDDDDDD.
#uditors; 1...............................................
2...............................................
NB. Instruction for Auditors
1. o ti!" #$ at the a%%ro%riate !olu&n.
5
NNA E5 AF 5.3
S8N
O
ITEM SOURCE OF
INFORMATIO
N
:ES NO N8A
1. $reet patient and introduce se%f. Eisten42bser,e
nurse.
2. &erform pain assessment.

2bser,e nurse
3. #dminister ana%gesic 'if
indicated(.
2bser,e nurse
4. &%ace steri%e dressing set on c%ean
dr) tro%%e).
2bser,e nurse
* !nform patient and exp%ain
procedure.
2bser,e nurse.
+. &ro,ide pri,ac) to the patient.

2bser,e nurse.
-. &%ace patient in comfortab%e
position.
2bser,e nurse.
5. &%ace protecti,e co,er. 2bser,e nurse
.. &erform hand h)giene. 2bser,e nurse.
1/. 0ear mas1. 2bser,e nurse.
11. 2pen outer %a)er of dressing set. 2bser,e nurse.
12. 3iscard soi%ed dressing. 2bser,e nurse
13. &erform hand h)giene. 2bser,e nurse
14. 2pen inner %a)er of dressing set. 2bser,e nurse
1*. &our c%eansing agent and add soft
dressings 4 supp%ementar).
2bser,e nurse
1+. &erform hand h)giene. 2bser,e nurse.
1-. 0ear steri%e g%o,es 'optiona%(. 2bser,e nurse.
.
NNA E5 AF 5.3
S8N
O
ITEM SOURCE OF
INFORMATIO
N
:ES NO N8A
15. &erform dressing ;
15.
1
:wab from c%ean area to
dirt) area.
2bser,e nurse.
15.
2
Beep forceps facing
downwards and abo,e
waist %ine.
2bser,e nurse.
15.
3
6aintain steri%e fe%d. 2bser,e nurse.
15.
4
#,oid contamination of
equipments.
2bser,e nurse.
15.
*
Fse one swab for each
stro1e.
2bser,e nurse.
15.
+
C%ean s1in area around
wound.
2bser,e nurse.
15.
-
#pp%) appropriate dressing
for wound.
2bser,e nurse.
15.
5
:ecure wound dressing. 2bser,e nurse.
1.. 6a1e patient comfortab%e. 2bser,e nurse.
2/. C%ear dressing set. 2bser,e nurse.
21. !erform hand hygiene. 2bser,e nurse.
22 3ocument fndings;
2bser,e nurse.
22.
1
wound siAe and depth.
22.
2
nature of wound7swe%%ing>
dirt)> c%ean> s%ough>
gangrene> hea%ing process.
22.
3
nature of discharge 7 sme%%>
co%our> serous> b%ood)> pus.
1/
NNA E5 AF 5.3
AUDIT REPORT AUDIT REPORT
'%lease #($ the a%%ro%riate )o*+
C!+0!2'&+/e N!+; C!+0!2'&+/e
REMAR<S

#uditor 1 'name and signature(;DDDDDDDDDDDDDDDD.
DDDDDDDDDDDDDDDD..
#uditor 2 'name and signature(;DDDDDDDDDDDDDDDD.
.
11

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