Aseptic Wound Dressing Edited 3 Dec 2008

NNA E5 AF 5.
NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIA ELEMENT 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. 2. 3. To ensure nurses perform wound dressing using aseptic technique To assess the caring component during dressing To document wound findings after the procedure in the appropriate patients 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 patients records.
National Nursing Audit, Ministry of Health Malaysia: Revised June 2008 Nursing Division, Ministry of Health Malaysia
NNA E5 AF 5.3
4.
CRITERIA
Structure
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 of Health is available. 14. The nurse is competent in performing aseptic wound dressing.
Process
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.
Outcome
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.
Precautions by Ministry 12. Discard soiled dressing.
13. Perform hand hygiene. 14. Open inner layer of dressing set. 15. Pour cleansing agent. Add soft dressings / supplementary. 16. Perform hand hygiene. 17. Wear sterile gloves
15. Nurse need to verify patient and verify type of dressing.
NNA E5 AF 5.3 (optional).
Structure
Process
18. Perform dressing 19. Make patient comfortable after procedure. 20. Discard used dressing set 21. Perform hand hygiene. 22. Document findings.
Outcome
5. 5.1.
AUDIT GUIDE FOR ASEPTIC WOUND DRESSING INCLUSION CRITERIA

National Nursing Audit, Ministry of Health Malaysia: Revised June 2008 Nursing Division, Ministry of Health Malaysia 3
NNA E5 AF 5.3 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. 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 6. 10 staff nurses of each discipline
DEFINITION OF OPERATIONAL TERMS : Hand hygiene - include both hands washing with either plain or containing soap and water, or use of alcohol-base hand rub. [WHO, 2007] inch around the working area be kept free of instruments. 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 antiseptic-
field. -
NNA E5 AF 5.3 ensure body / any part of uniform of nurse does not touch sterile assessment of pain should be done prior to procedure and should administration of analgesic if indicated.
include aseptic technique includes: - discard soiled forceps after use. - keep forceps facing downwards and above waist line. - 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 - cover wound appropriately. 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
times.
- clean the skin area around wound thoroughly. pain assessment use pain score format from KKM to assess
NNA E5 AF 5.3
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. - Perform hand hygiene. - Open inner layer of dressing set. - Pour cleansing agent. - Add soft dressings / supplementary. - Assess patients pain threshold (observe / ask). - Perform hand hygiene. - 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. - Perform hand hygiene.
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.
NNA E5 AF 5.3 - 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
8. Audit Form
NATIONAL NURSING AUDIT, MINISTRY OF HEALTH MALAYSIA.
VERSION 1/08
NNA E5 AF 5.3 ELEMENT 5 : CONTINUUM OF CARE TOPIC : 5.3 ASEPTIC WOUND DRESSING DOCUMENT NO : E5 AF 5.3 DATE: 1.11.08 PAGE 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 patients records. 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 patients records. Date of Audit: Locality : . Auditors: 1............................................... 2............................................... NB. Instruction for Auditors 1. To tick [] at the appropriate column.
S/N O
ITEM
SOURCE OF INFORMATIO N
YES
NO
N/A
NNA E5 AF 5.3 1. 2. 3. 4. 5 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
S/N O
Greet patient and introduce self. Perform pain assessment. Administer analgesic (if indicated).
Listen/Observe nurse. Observe nurse Observe nurse
Place sterile dressing set on clean Observe nurse dry trolley. Inform patient and explain Observe nurse. procedure. Provide privacy to the patient. Place patient in comfortable position. Place protective cover. Perform hand hygiene. Wear mask. Open outer layer of dressing set. Discard soiled dressing. Perform hand hygiene. Open inner layer of dressing set. Pour cleansing agent and add soft dressings / supplementary. Perform hand hygiene. Wear sterile gloves (optional). ITEM Observe nurse. Observe nurse. Observe nurse Observe nurse. Observe nurse. Observe nurse. Observe nurse Observe nurse Observe nurse Observe nurse Observe nurse. Observe nurse. SOURCE OF INFORMATIO N
YES NO N/A
18.
Perform dressing : 18. Swab from clean area to
Observe nurse.
9
NNA E5 AF 5.3 1 18. 2 18. 3 18. 4 18. 5 18. 6 18. 7 dirty area. Keep forceps facing downwards and above waist line. Maintain sterile field. Avoid contamination of equipments. Use one swab for each stroke. Clean skin area around wound. Apply appropriate dressing for wound. Observe nurse. Observe nurse. Observe nurse. Observe nurse. Observe nurse. Observe nurse. Observe nurse. Observe nurse. Observe nurse. Observe nurse. Observe nurse. 22. 1 22. 2 22. 3 wound size and depth. nature of wound-swelling, dirty, clean, slough, gangrene, healing process. nature of discharge - smell, colour, serous, bloody, pus.
19. 20. 21. 22
18. Secure wound dressing. 8 Make patient comfortable. Clear dressing set. Perform hand hygiene. Document findings:
AUDIT REPORT
(please [] the appropriate box)
10
NNA E5 AF 5.3
Conformance
Non- Conformance
REMARKS
Auditor 1 (name and signature):. .. Auditor 2 (name and signature):. .
11

Aseptic Wound Dressing Edited 3 Dec 2008

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NNA E5 AF 5.

NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIA ELEMENT 5: CONTINUUM OF CARE

5.3 ASEPTIC WOUND DRESSING

Precautions by Ministry 12. Discard soiled dressing.

15. Nurse need to verify patient and verify type of dressing.

NNA E5 AF 5.3 (optional).

AUDIT GUIDE FOR ASEPTIC WOUND DRESSING INCLUSION CRITERIA

5.6. Sample Size 6. 10 staff nurses of each discipline

NATIONAL NURSING AUDIT, MINISTRY OF HEALTH MALAYSIA.

Listen/Observe nurse. Observe nurse Observe nurse

Perform dressing : 18. Swab from clean area to

19. 20. 21. 22

Auditor 1 (name and signature):. .. Auditor 2 (name and signature):. .

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