10.
1: Performing a Wound Dressing
DEFINITION
Cleansing a wound or incision and applying sterile protective covering using aseptic technique.
PURPOSES
1. To protect the wound from contamination with microorganisms.
2. To promote wound granulation and healing. 3. To support or splint the wound site.
4. To promote thermal insulation to the wound surface.
5. To provide for maintenance of high humidity between the wound and dressing. 6. To promote
physical, psychological and esthetic comfort.
ARTICLES
Sterile dressing tray containing: 1. Artery forceps-1 (2, for extensive or infected wounds).
2. Thumb forceps - 1.
3. Cotton swabs. 4. Gauze pieces.
5. Gallipot for cleansing solution.
6. Surgical pads.
7. Kidney tray.
8. Sterile scissors.
A clean tray containing
1. Clean gloves.
2. Sterile gloves.
3. Cleaning solution (normal saline).
4. Ordered medications. 5. Adhesive plaster.
6. Bandage scissors.
7. Plastic bag.
8. Waterproof pad or Mackintosh.
9. Culture tubes (optional).
*For major wound dressing, a larger dressing pack with additional articles may be required.
PROCEDURE
Nursing action
1. Identify the patient.
2 Inform patient of dressing change, explain procedure and have patient lie in bed.
3. Gather equipment and arrange at the bedside.
4. Wash hands.
5. Check physician's order for dressing change and any specific instruction.
6. Close door or curtains and place waterproof pad on bed beneath area of dressing.
Nursing action
Assist patient to comfortable position that provides easy access to wound area.
Place opened, cuffed plastic bag near working area.
Loosen tapes on dressing (if tape is soiled, don clean gloves before loosening the tape)
Don clean disposable gloves and remove solled dressings carefully from more clean to less clean area (If
dressing is adherent to the skin, moisten it by pouring small amount of normal saline).
Keep soiled side of dressing away from patient's view.
Assess the amount, color and odor of drainage. Discard dressing in disposal bag. Pull off gloves inside
out and
discard in appropriate receptacle. Using sterile technique, open sterile dressing tray and arrange
supplies on work area.
Open cleaning solution and pour into the sterile gallipot/cup over the cotton balls.
Don sterile gloves.
Pick up soaked cotton using artery forceps.
For a surgical wound, clean from top to bottom or from center outward [Figure 10.1(a)]. In
contaminated wound, clean from periphery to center
(circular motion for cleaning circular wound)
10.
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b. Use one cotton swab/gauze sponge for each wipe, discarding each by dropping into the plastic bag
after
wiing. Do not touch the plastic bag with forceps. c. If drain is present, clean around it, ettward in a
circular motion. moving from center
d. the wound using sponge in same motion.
18. App medication ordered (ointment) to the wound on a dry ste gauze. Apply a layer of sterile dressing
over wound. 19. Place a sterile gauze slit on side under and around the drain
(use pricut gauze or cut one using sterile scissors). 20. Apply a second layer of gauze to wound site and a
surgical pad as the outer most layer.
21.
Remove gloves from inside out and discard in plastic waste bag. Apply adhesive tape to secure the
dressing [Figures10.1(b and c)).
22. Wash reusable articles to be sent for sterilization.
23. Wash hands, remove all articles and make patient comfortable.
24. Record dressing change, appearance of wound and describe any drainage in the chart.
Rotionale
Encourages patient co-operation.
An organized approach will save time and energy. Reduces spread of microorganisms.
Clarifies type of dressing.
Provides privacy and prevents soiling of linen.
Rationale
Provides for comfort.
Reduces risk of contamination from soiled dressing and used cotton balls. Removal of tape is easier
before wearing gloves.
Protects nurse from contamination.
Cautious removal of dressing is less painful for the patient. Moistened dressing is easier to remove.
Reduces anxiety of patient.
Helps for identifying the wound healing process.
Prevents spread of microorganisms.
Keeps supplies within easy reach and maintains sterility.
Maintains asepsis.
Moisture provides medium for growth of microorganisms and drying the wound may retard the growth
of organisms and improve healing process.
Additional dressing serves as a wick for drainage.
Drainage is absorbed and surrounding skin area is protected.
Provides for absorption of wound drainage and protection from microorganisms.
Tape is easier to apply after gloves have been removed.
Prevents spread of infection.
Provides accurate documentation of procedure
SPECIAL CONSIDERATION
If culture swab is required, obtain it before cleansing the wound.
