1. Wound Care Guide using Sterile Technique
Assess the patient for the need for pain control
Inform the patient about the procedure
Remove the old dressing and note drainage including amount, color, and any odor. Also note the type and number of dressings removed
Assess and measure the wound: length, width and depth
Set up sterile field- be careful not to cross over the field or turn your back to it
Discard any supplies that “might” of been contaminated (sterile touching clean becomes dirty), and start with new sterile ones
Cleanse the wound, pack the wound, cover with dressing and secure with tape, and mark it with date, time, your initials.
As you are performing the wound care assess the patient for any s/s of pain and at the end ask them how they tolerated the procedure

2. Wound Care Documentation Guidelines
Date & time
What packing or dressings did you remove? (“Removed 2, 4x4 gauze from the wound”)
What kind of drainage was present? (“Moderate amount of sero- sanguinous drainage, no odor present”)
What was the size and appearance of the wound? (“Wound was 10cm long, 3cm wide, and 3cm deep. Beefy read appearance”)
State the technique you used (“Using sterile technique…”)
What did you use to clean it? (“Cleansed the wound with sterile NS”)
What did you dress it with? (“Packed with 2 NS soaked 4x4 gauzes, covered with 2 dry 4x4 gauzes and covered with ABD pad, secured with tape)
How did the patient do? (“Patient tolerated the procedure well”)