Performing a sterile dressing change for a client with a superficial partial-thickness burn on the shoulder and back requires meticulous attention to detail to prevent infection and promote wound healing. Nurse Malcolm, an experienced healthcare professional, follows a specific sequence of steps to ensure the procedure is conducted safely and effectively. In this article, we will arrange the steps in the order in which each should be performed, providing a comprehensive guide to this crucial nursing intervention.
Step 1: Gather Supplies
Before initiating the dressing change, Nurse Malcolm ensures all necessary supplies are within reach. These typically include:
- Sterile gloves
- Sterile dressing kit (sterile drapes, sterile dressings, sterile saline or prescribed wound cleansing solution)
- Non-sterile gloves (for the nurse)
- Clean towels or disposable paper towels
- Aseptic technique supplies (e.g., clean disposable bags for waste)
- Adhesive tape
- Prescribed topical medications or ointments
- Wound assessment tools (e.g., measuring tape)
- Waste disposal container
Step 2: Hand Hygiene
Nurse Malcolm performs thorough hand hygiene using soap and water for at least 20 seconds or employs an alcohol-based hand sanitizer. Clean hands are essential to prevent contamination during the dressing change.
Step 3: Don Personal Protective Equipment (PPE)
To maintain a sterile field and protect both the nurse and the client from potential infection, Nurse Malcolm dons sterile gloves, a sterile gown, and a facemask if necessary.
Step 4: Position the Client
The client is appropriately positioned for ease of access to the burn wound while ensuring their comfort and dignity. For burns on the shoulder and back, the client may be in a prone position or a lateral recumbent position.
Step 5: Assess the Burn Wound
Nurse Malcolm begins by assessing the burn wound, documenting its appearance, size, and any signs of infection or complications. This assessment provides a baseline for monitoring the wound’s progress.
Step 6: Remove the Old Dressing
Using non-sterile gloves, the nurse gently removes the old dressing, starting from the edges and moving inward. Care is taken not to disrupt any healing tissue or grafts. Adhesive tape may need to be carefully cut to avoid damaging the wound.
Step 7: Dispose of Waste
Waste, including the old dressing, non-sterile gloves, and any used supplies, is disposed of in a designated waste container following aseptic technique guidelines.
Step 8: Cleanse the Wound
Using sterile saline solution or the prescribed wound cleansing solution, Nurse Malcolm carefully cleanses the burn wound, ensuring that any debris, exudate, or contaminants are removed. This step helps maintain a sterile environment for the new dressing.
Step 9: Apply Medication (if prescribed)
If the healthcare provider has prescribed any topical medications or ointments, Nurse Malcolm applies them to the wound as directed, ensuring even coverage.
Step 10: Measure and Cut Dressing
Using measuring tape, the nurse measures the dimensions of the wound. A sterile dressing is then cut to an appropriate size to cover the burn adequately, allowing for a slight overlap beyond the wound edges.
Step 11: Dress the Wound
Nurse Malcolm carefully places the sterile dressing over the burn wound, ensuring it adheres securely. Gauze or other dressings may be used, depending on the healthcare provider’s orders.
Step 12: Secure the Dressing
The dressing is secured in place using adhesive tape, which should be applied without excessive tension to prevent damage to the fragile burn tissue.
Step 13: Dispose of Supplies and Remove PPE
All used supplies and PPE are disposed of properly. Nurse Malcolm removes the sterile gloves first, followed by the gown and facemask if worn.
Step 14: Hand Hygiene
After removing PPE, Nurse Malcolm performs hand hygiene once more, ensuring that hands are thoroughly clean.
Step 15: Document the Procedure
The final step involves documenting the dressing change procedure, including wound assessment findings, any prescribed medications applied, and the condition of the wound post-dressing change.
A sterile dressing change for a client with a superficial partial-thickness burn is a meticulous and well-organized procedure. Nurse Malcolm follows these steps in a specific order to ensure the process is conducted safely, maintains a sterile field, and promotes optimal wound healing. Proper documentation is crucial for tracking the wound’s progress and facilitating communication among the healthcare team.