12 Changing a Sterile Dressing (& Removing Sutures/Staples)
Assessment
- Reviewed client medical record, physician’s order and need for appropriate protective wear.
- Accurately assessed size location of wound; risk for wound healing problems; client’s comfort and need for pain medication and knowledge about dressing.
- Assessed any allergies.
Nursing Diagnosis
- Developed appropriate nursing diagnosis based on assessment data.
Planning
- Explained procedure to client.
Evaluation
- Assessed condition of wound and status of sutures/staples.
- Assessed client for discomfort during procedure.
- Recorded and reported dressing change, wound appearance and amount removed.
- Reported unexpected outcomes to co-assigned nurse or physician.
Changing a Sterile Dressing (& Removing Sutures/Staples) – Implementation
- Performed hand hygiene. Donned appropriate personal protective wear.
- Provided privacy. Positioned and draped client.
- Applied clean disposable gloves and removed tape and dressing properly.
- Inspected wound, observed drainage on dressing and described appearance of wound to client.
- Properly disposed of dressing. Removed and disposed of gloves properly.
- Prepared sterile tray and sterile field, dressing supplies and cleansing solution.
- Applied appropriate gloves.
- Cleaned wound (clean to dirty) using aseptic technique.
REMOVED STAPLES:- Applied staple extractor correctly
- Carefully controlled staple extractor.
- Moved staple away from skin surface.
- Released handles of staple extractor allowing staple to fall into refuse bag, maintain asepsis.
- Repeated steps, removing alternate staples. Observed level of healing.
- Removed remaining staples if warranted.
REMOVED SUTURES:
- Placed sterile gauze and grasped scissors and forceps correctly. Held scissors in dominant hand and forceps in non-dominant hand.
- Grasped knot of suture with forceps and gently pulled up knot while slipping tip of scissors under suture.
- Grasped knotted end with forceps and removed suture. Observed level of healing.
- Repeated step, removing alternate sutures.
- Removed remaining sutures if warranted.
- Applied antiseptic ointment if ordered. Inspected incision line. Cleaned suture line.
- Applied dressing(s) to incision or wound; cut to fit around drains if necessary.
- Secured dressing. Note number of sutures/staples removed.
- Removed and disposed of gloves, supplies, etc. properly.
- Positioned client comfortably.
- Performed hand hygiene.
Faculty Comments
| Assessment | Nursing Diagnosis | Planning | Implementation | Evaluation |
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| Student Signature
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Faculty Signature |
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| The student was unable to perform the skill competently and will be retested. |
Faculty Signature |
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