Care of Wound

• 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
micro-organisms .
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 aesthetic
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 wounds 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 instructions .
6. Close door or curtains and place waterproof
pad on bed beneath area of dressing .
7. Assist patient to comfortable position that
provides easy access to wound area .
8.Place opened , cuffed plastic bag near working
area .
9. Loosen tapes on dressing (if tape is soiled , don
clean gloves before loosening the tape ).
10. Don clean disposable gloves and remove
soiled 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 ) .
11. Asses the amount , color and odor of drainage
.
12. Discard dressing in disposal bag . Pull off
gloves inside out and discard in appropriate
receptacle .
13. Using sterile technique , open sterile
dressing tray and arrange supplies on work
area .
14. Open cleaning solution and pour into the
sterile gallipor/cup over the cotton balls .
15. Don sterile gloves .
16. Pick up soaked cotton using artery forceps .
17. i. For a surgical wound , clean from top to
bottom or from centre outward (figure
10.1(a).
in contaminated wound , clean from periphery
to centre (circular motion for cleaning circular
wound)
ii. Use one cotton swab / gauze sponge for each wipe ,
discarding ch by dropping into the plastic bag after
wiping . Do not touch th plastic bag width forceps .
Iii. If a drain is present , clean around it , moving from
centre outward in a circular motion .
iv. Dry the wound using sponge in same motion.
18. Apply medications ordered( ointment to the
wound on a dry sterile gauze . Apply a layer of sterile
dressing over wound .
19. Place a sterile gauze slit on side under and
around the drain (use precut 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 outd and discard
in plastic waste bag . Apply adhesive tape to
secure the dressing (figure 10.1(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.
• Rationale
1...................
2. Encourage patient co-operation .
3. An organized approach will save time and
energy .
4. Reduces spread of micro-organisms.
5. Clarifies type of dressing .
6. Provides privacy and prevents soiling of linen.
7. Provides comfort .
8. Reduces risk of contamination from soiled dressing and used
cotton balls .
9. Removal of tape is easier before wearing gloves .
10. Protects nurse from contamination.
cautions removal of dressing is less painful for the patient.
Moistened dressing is easier to remove .
Reduces anxiety of patient.
11. Helps for identifying the wound healing
process.
12. Prevents spread of mocro-organisms.
13. Keeps supplies within easy reach and
maintains sterility .
14..................
15. Maintains asepsis .
16. ..................
17. Moving from least to most contaminated area
prevents spread of micro-organisms to less
infected area .
moisture provides medium for growth of micro-
organisms and drying the wound may retard the
growth of organisms and improve healing
process .
18. Additional dressing serves as a wick for
drainage .
19. Drainage is absorbed and surrounding skin
area is protected .
20. Provides for absorption of wound drainage
and protection from micro-organisms.
21. Tape is easier to apply after gloves have been
removed .
22...............
23. prevents spread of infection .
24. provides accurate documentation of
procedure .

SPECIAL CONSIDERATION
If culture swab is required , obtain it before
cleansing the wound .

Care of Wound

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• PERFORMING A WOUND DRESSING

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