Aseptic Wound Dressing Edited 3 Dec 2008

NNA E5 AF 5.3

NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIAELEMENT 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 findings after the procedure in the

appropriate

patient’s records.

3. STANDARD :

1. Nurses perform wound dressing using aseptic technique

2. Nurses exhibit the caring component during dressing

3. Nurses document wound findings in the appropriate

patient’s

records.

National Nursing Audit, Ministry of Health Malaysia: Revised June 2008Nursing Division, Ministry of Health Malaysia

1

NNA E5 AF 5.3

4. CRITERIA

Structure Process Outcome

1. Screen / Procedure

Room.

2. Dressing trolley.

3. Hand-washing facilities/

hand rub.

4. Relevant protective

personal

equipment (PPE).

5. Clinical waste bin.

6. Domestic waste bin.

7. Protective cover.

8. Sterile dressing set.

9. Sterile soft dressings.

10. Cleansing agent.

11. Adhesive tapes.

12. Nursing Operating

Procedure (N.O.P.) /

Manual of wound

dressing.

13. Copy of Standard

Precautions by Ministry

of Health is available.

14. The nurse is competent

in performing aseptic

wound dressing.

15. Nurse need to verify

patient and verify

type of dressing.

1. Greet patient and

introduce self.

2. Perform pain assessment (if indicated).

3. Administer analgesic (if indicated).4. Place sterile dressing set

on

clean dry trolley.

5. Inform patient and explain

procedure.

6. Provide privacy to the

patient.

7. Place patient in confortable

position.

9. Perform hand hygiene.

10. Wear mask.

11. Open outer layer of

dressing set.

12. Discard soiled dressing.


14. Open inner layer of

dressing set.

15. Pour cleansing agent.

Add soft dressings /

supplementary.

1. Dressing

performed

adhering to

principles

of aseptic

technique.

2. Patient is

informed

of the progress of

his/her wound.

3. Respect and

comfort

of patient is

maintained.

4. Wound findings and

its progress are

documented.


2

NNA E5 AF 5.3


17. Wear sterile gloves

(optional).

Structure Process Outcome

18. Perform dressing

19. Make patient

comfortable

after procedure.

20. Discard used dressing

set


22. Document findings.

5. AUDIT GUIDE FOR ASEPTIC WOUND DRESSING

5.1. INCLUSION CRITERIA

All adult patients in surgical and orthopedic wards.

5.2. EXCLUSION CRITERIA

Patients with burn dressings.

5.3. INSTRUMENT

Check list (E5-AF 5.3) – one check list for one observation.

5.4. Methodology.


3

NNA E5 AF 5.3

5.4.1. Direct observation of wound dressing being performed.

5.4.2. Sample Frame: All in-patients 5.4.3. Setting : All adult Surgical / Orthopedic / Medical wards

5.4.4. Population : Staff Nurses

5.5. Sample Design

- Simple random sampling of nurses

5.6. Sample Size

- 10 staff nurses of each discipline

6. DEFINITION OF OPERATIONAL TERMS :

- Hand hygiene - include both hands washing with either plain or

antiseptic-

containing soap and water, or use of alcohol-base hand rub.

[WHO, 2007]

- Sterile soft dressings – refer to sterile swab / gauze / gamgee

- Cleansing agent - refers to any lotion used to clean the wound

- Sterile field refers to the area within the sterile packaging, i.e. 1

inch

around the working area be kept free of instruments.

- ensure body / any part of uniform of nurse does not touch sterile

field.

- assessment of pain should be done prior to procedure and should

include

administration of analgesic if indicated.

- aseptic technique includes:

- discard soiled forceps after use.

- keep forceps facing downwards and above waist line.


4

NNA E5 AF 5.3

- no contact of forceps when transferring soft dressing from one

hand to

another.

- correct technique of pouring of cleansing agent (no touching

and

spillage) and topping up of supplementary.

- body / any part of uniform of nurse must not touch sterile field.

- does not cross sterile field at all times.

- clean the skin area around wound thoroughly.

- cover wound appropriately.

- pain assessment – use pain score format from KKM to assess

pain.

- Discard soiled dressing involves loosening dressing, removing

soiled dressing, discard soiled dressing forceps and observing

condition of wound.

* Failure to comply with any of the above will be considered

non-conformance to aseptic technique.

- documentation of wound finding includes – wound size and depth, nature of wound-swelling, dirty, clean, slough, gangrene, healing process and nature of discharge - smell, color, serous, bloody, pus

7. Compliance of Aseptic Wound Dressing Audit.

Every step in the process must be performed.

a) Technical

- Perform hand hygiene.

- Wear mask.

- Open outer layer of dressing set.


5

NNA E5 AF 5.3


- Open inner layer of dressing set.

- Pour cleansing agent.

- Add soft dressings / supplementary.

- Assess patient’s pain threshold (observe / ask).


- Wear sterile gloves (optional).

- Remove soiled dressing with forceps.

- Discard used forceps into receiver.

- Perform dressing.

- Cover the wound with appropriate dressing.

- Discard used dressing set.


b) Essence of care (soft skills)

- Greet patient and introduce self.

- Perform pain assessment (if indicated).

- Administer analgesic (if indicated). (Do not score if not indicated)

- Inform patient and explain procedure.

- Provide privacy to the patient.

- Place patient in a comfortable position before procedure.

- Make patient comfortable after procedure – involves

placing patient

in a comfortable position and reassess pain.

c) Documentation

Documentation of wound finding includes: – wound size and depth, healing process

- nature of wound-swelling, dirty, clean, slough, gangrene, - nature of discharge - smell, color, serous, bloody, pus


6

NNA E5 AF 5.3

8. Audit Form

NATIONAL NURSING AUDIT, MINISTRY OFNATIONAL NURSING AUDIT, MINISTRY OF HEALTHHEALTH MALAYSIA.MALAYSIA.

VERSION 1/08

ELEMENT 5 : CONTINUUM OF CARE DATE:

1.11.08TOPIC : 5.3 ASEPTIC WOUND DRESSING

DOCUMENT NO : E5 AF 5.3PAGE NO 1/3

STANDARD :

1. Nurses perform wound dressing using aseptic technique

2. Nurses exhibit the caring component during dressing

3. Nurses document wound findings in the appropriate patient’s

records.

OBJECTIVES :


7

NNA E5 AF 5.3

1. To ensure nurses perform wound dressing using aseptic

technique

2. To assess the caring component during dressing

3. To document wound findings after the procedure in the

appropriate

patient’s records.

Date of Audit:………………………………………

Locality : …………………………………………….

Auditors: 1...............................................

2...............................................

NB. Instruction for Auditors

1. To tick [√] at the appropriate column.

S/NO

ITEM SOURCE OF INFORMATIO

N

YES NO N/A

1. Greet patient and introduce self. Listen/Observe nurse.

2. Perform pain assessment.

Observe nurse

3. Administer analgesic (if indicated).

Observe nurse

4. Place sterile dressing set on clean dry trolley.

Observe nurse

5 Inform patient and explain procedure.

Observe nurse.

6. Provide privacy to the patient.

Observe nurse.

7. Place patient in comfortable position.

Observe nurse.


8

NNA E5 AF 5.3

8. Place protective cover. Observe nurse

9. Perform hand hygiene. Observe nurse.

10. Wear mask. Observe nurse.

11. Open outer layer of dressing set. Observe nurse.

12. Discard soiled dressing. Observe nurse

13. Perform hand hygiene. Observe nurse

14. Open inner layer of dressing set. Observe nurse

15. Pour cleansing agent and add soft dressings / supplementary.

Observe nurse


17. Wear sterile gloves (optional). Observe nurse.

S/NO

ITEM SOURCE OF INFORMATIO

N

YES NO N/A

18. Perform dressing :

18.1

Swab from clean area to dirty area.

Observe nurse.

18.2

Keep forceps facing downwards and above waist line.

Observe nurse.

18.3

Maintain sterile field. Observe nurse.

18.4

Avoid contamination of equipments.

Observe nurse.

18.5

Use one swab for each stroke.

Observe nurse.

18.6

Clean skin area around wound.

Observe nurse.


9

NNA E5 AF 5.3

18.7

Apply appropriate dressing for wound.

Observe nurse.

18.8

Secure wound dressing. Observe nurse.

19. Make patient comfortable. Observe nurse.

20. Clear dressing set. Observe nurse.


22 Document findings: Observe nurse.22.

1wound size and depth.

22.2

nature of wound-swelling, dirty, clean, slough, gangrene, healing process.

22.3

nature of discharge - smell, colour, serous, bloody, pus.

AUDIT REPORT AUDIT REPORT

(please [√] the appropriate box)

Conformance Non- Conformance

REMARKS


10

NNA E5 AF 5.3

Auditor 1 (name and signature):………………………………………….

…………………………………………..

Auditor 2 (name and signature):………………………………………….

…………………………………….


11

Documents

Aseptic Wound Dressing Edited 3 Dec 2008