The nurse is performing a damp-to-damp dressing change, and is removing the old dressing. Part of the dressing is adhered to the tissue. Which action by the nurse is the most appropriate?

Question

1. Removing that part of the dressing quickly, to reduce the pain
2. Wetting the dressing with alcohol to release the section adhered to the wound
3. Wetting the dressing with tap water to release the section adhered to the wound
4. Wetting the dressing with sterile saline to release the section adhered to the wound

Answer 1

4
Rationale 1: Removing the dressing quickly would debride the new, healthy tissue forming inside the wound and would retard wound healing.
Rationale 2: Alcohol would be excruciatingly painful and would slow tissue healing.
Rationale 3: Tap water would not be sterile and could introduce pathogens into the wound.
Rationale 4: The dressing would be removed using sterile saline, which will allow the dressing to peel away from the wound without removing the new tissue forming to heal the wound. Removing the dressing quickly would debride the new, healthy tissue forming inside the wound and would retard wound healing. Alcohol would be excruciatingly painful and would slow tissue healing. Tap water would not be sterile and could introduce pathogens into the wound.
Global Rationale: The dressing would be removed using sterile saline, which will allow the dressing to peel away from the wound without removing the new tissue forming to heal the wound. Removing the dressing quickly would debride the new, healthy tissue forming inside the wound and would retard wound healing. Alcohol would be excruciatingly painful and would slow tissue healing. Tap water would not be sterile and could introduce pathogens into the wound.