How do you chart a sterile dressing change on wound?

Step-by-Step Guide to Charting a Sterile Dressing Change on Wound

1. Assessment

- Assess the wound and surrounding skin for signs of infection, such as redness, swelling, drainage, or pain.

- Note the size and location of the wound, as well as any drainage.

- Document the patient's pain level and any other relevant symptoms.

2. Preparation

- Gather the necessary supplies, including sterile gloves, dressing materials, antiseptic solution, and saline.

- Wash your hands and put on sterile gloves.

- Cleanse the wound and surrounding skin with antiseptic solution and saline.

3. Dressing Change

- Remove the old dressing carefully, being careful not to disturb the wound.

- Apply a new sterile dressing to the wound.

- Secure the dressing with tape or a bandage.

4. Documentation

- Document the date and time of the dressing change.

- Describe the procedure in detail, including the type of dressing used.

- Note any observations made during the assessment, such as signs of infection or changes in the wound.

- Document the patient's response to the dressing change, including any pain relief.

5. Follow-up

- Schedule a follow-up visit to assess the wound and change the dressing as needed.

- Provide the patient with instructions for wound care at home.

Additional Tips:

- Always follow standard precautions when performing a sterile dressing change.

- If the wound is infected, be sure to use sterile instruments and dressing materials.

- Avoid touching the wound with your bare hands.

- Document the procedure thoroughly and accurately in the patient's medical record.