The nurse is performing a dressing change on a client with a stage 3 sacral wound. Once the old dressing is removed, the nurse would perform which step next?

  1. wash hands
  2. chart the findings
  3. assess the wound
  4. prepare the sterile field
Number 3 is correct.
Rationale: When performing a dressing change, the nurse first removes the old dressing while wearing clean gloves. The wound is assessed by noting drainage color, amount, and odor if any drainage is present. The color of the skin around the wound and in the wound bed is assessed, and the wound may be measured to ensure that the wound is healing as planned. Once the wound is thoroughly assessed, the gloves are discarded, hand hygiene is performed, and the sterile field is prepared for the dressing change. Charting the dressing change is the last step.