Wound Care


  • Clean gloves
  • Sterile gloves
  • Sterile drape
  • Sterile cotton swab
  • Sterile saline
  • Sterile 4 X 4-gauze
  • Sterile tray
  • ABD pad
  • Measuring device
  • Tape
  • Scissors


  1. WIIAPA:
    1. Wash hands
    2. Introduce self
    3. Identify patient (use 2 identifiers)
    4. Allergies – don’t forget food allergies
    5. Plan of care
    6. Assess patient

  1. Educate patient on dressing change.
  2. Provide patient privacy.
  3. Assemble supplies at bedside and place trash can within reach.
  4. Apply clean gloves.
  5. Remove taped bandage and with clean glove or forceps removing dressing one layer at a time, noting amount, color, and odor of drainage.
  6. Dispose of gloves and soiled dressing. Wash hands.
  7. Apply clean gloves.
  8. Inspect wound for color, drains, exudate, and integrity. Measure wound size, length, width, and depth if indicated.
  9. Dispose gloves and wash hands.
  10. Create sterile field with a sterile drape or dressing tray, pour sterile saline after lipping into sterile tray.
  11. Apply clean gloves.
  12. Wet sterile gauze using sterile saline, clean from least contaminated to most contaminated.
  13. Use dry gauze to blot wound bed dry.
  14. Wash hands.
  15. Apply sterile gloves and place sterile gauze into sterile saline solution.
  16. Wring out excess sterile saline.
  17. Open gauze to single layer of mesh and apply to wound bed makingsure, to pack any dead space or sinus tracts, continue until wound bed is covered. If wound is deep, gently pack gauze into wound with sterile gloved hand until all wound surfaces are in contact with damp gauze. Be sure that gauze does not touch periwound skin.
  18. Apply dry sterile gauze over moistened 4 x 4 gauze.
  19. Cover with an ABD pad and tape. Initial, date, and time dressing.
  20. Dispose of gloves and wash hands.
  21. Assist patient to a comfortable position with pressure off wound.
  22. Document.

Reference: Laplante, N., Perry, A.G, Potter, P.A., & Ostendorf, W.R. (2022). Clinical Nursing Skills & Techniques (10th ed., pp. 1178-1184). Elsevier