Mosby's Nursing Video Skills

Student __________________________________________________ Date ________________________

Instructor ________________________________________________ Date ________________________

PERFORMANCE CHECKLIST FOR CHANGING A DRESSING

S U NP Comments

1. Performed hand hygiene, and provided for the

patients privacy.
2. Gathered the necessary equipment and
supplies.
3. Verified the health care providers orders.
4. Introduced self to the patient and family.
5. Identified the patient using two identifiers.
Compared the identifiers with the information
on the patients identification bracelet.
6. Assessed pain status while explaining the
procedure to the patient.
7. Applied a gown, goggles, and mask if there is a
risk of spray.
8. Positioned the patient comfortably, and draped
him or her to expose only the wound site.
Instructed the patient not to touch the wound
or the sterile supplies.
9. Placed a disposable biohazard bag within reach
of work area. Folded the top of the bag to
make a cuff.
10. Applied clean disposable gloves.
11. Pull the tape parallel to the skin, toward the
dressing, while holding down the uninjured
skin. Pulled in the direction of any hair
growth. If necessary, secured the patients
permission to clip or shave the area
according to agencys policy. Removed any
adhesive from the skin.
12. With a clean, gloved hand or forceps,
removed the old dressing one layer at a time.
Observed the appearance of any drainage.
Discarded the outside dressing first. Worked
slowly and carefully. Kept the soiled
underside of the dressings out of the patients
sight.
13. Folded the dressing so that the drainage is
contained inside it, and removed gloves

Copyright 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

 2

inside out. If the dressing is small, pulled one

glove inside out over the dressing.
14. Disposed of the gloves and soiled dressing
according to agencys policy. Performed
hand hygiene. Applied clean gloves.
15. Inspected the color and integrity of the
wound. Looked for edema, exudate, and loss
of skin integrity. Observed the skin around
any drainage devices. Assessed for odor.
Applied sterile gloves, and gently palpated
the edges of the wound to determine whether
the patients pain has increased and to assess
for drainage and bogginess. Measured the
length, width, and depth of the wound if
indicated.
16. Disposed of gloves and performed hand
hygiene.
17. Created a sterile field on the overbed table,
using a sterile dressing tray or individually
wrapped sterile supplies.
18. Applied sterile gloves, or applied clean gloves
and used sterile forceps for a no-touch
technique.
19. Cleansed the wound. Used an antiseptic swab
for each cleansing stroke, or sprayed the
wound surface with antiseptic.
20. Used dry gauze to blot the wound dry. If the
patient has a drain, blotted around it.
21. Applied an antiseptic ointment, if ordered.
22. Applied a dressing:
A. Dry dressing:
(1) Applied loosely woven gauze as the
contact layer.
(2) If a drain is present, applied a pre-cut 4
4 gauze to sit flat around the drain.
(3) Applied additional layers of gauze as
needed.
(4) Applied a thicker woven pad.
B. Moist-to-dry dressing:
(1) Poured sterile solution over the opened
package of 4x4 gauze or placed a strip of fine
mesh gauze in a container of the prescribed
sterile solution.
(2) Applied sterile gloves.
(3) Wrung out the excess solution.
(4) Applied the moistened fine-mesh, open-

Copyright 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

 3

weave gauze as a single layer directly onto the

surface of the wound. If the wound is deep,
used sterile gloved hand or forceps to gently
pack the gauze into the wound until all wound
surfaces are in contact with the moistened
gauze. Ensured that any dead space from sinus
tracts, undermining, or tunneling has been
loosely packed with gauze.
(5) Did not let the gauze touch the skin
around the wound. Filled the wound, but
avoided packing it too tightly or allowing the
gauze to extend beyond the top of the wound.
(6) Applied a dry, sterile gauze pad over the
wet gauze.
(7) Covered the wound with an ABD pad,
Surgipad, or gauze.
23. Secured the dressing with rolled gauze for
circumferential dressings; with tape,
Montgomery ties, or straps applied
perpendicular to the wound; or with a binder.
24. Initialed the tape with the date and time.
25. Removed any personal protective equipment
used. Applied clean gloves to dispose of
soiled supplies.
26. Disposed of used supplies and equipment.
27. Helped the patient into a comfortable position,
and placed toiletries and personal items within
reach.
28. Placed the call light within easy reach, and
made sure the patient knows how to use it to
summon assistance.
29. Raised the appropriate number of side rails
and lowered the bed to the lowest position.
30. Removed and disposed of gloves, if used.
Performed hand hygiene.
31. Documented and reported the patients
response and expected or unexpected
outcomes.

Copyright 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.