WOUND DRESSING
A wound is any abnormal opening on the skin.
Wound dressing is the process by which a wound
is cleaned and a sterile dressing applied
The purpose is to render the wound free from
micro – organisms and enhance healing
Indications for Wound Dressing
Surgical Incisions
Septic Wounds
Pressure (decubitus) Ulcers
Removal of stitches/staples/clips/drains
CLASSIFICATION OF WOUNDS
Wounds are classified based on various factors:
a) According to Intension
Intentional Wounds: Occur out of will e.g.
surgical wounds
Accidental Wounds: Occur without will
b) According to Mechanism of Injury
Incised: Caused by a sharp object and have
sharp edges e.g. surgical wounds
Lacerated: Have rugged/uneven edges. They are
caused by things like barbed wire
Abrasion: Results from rubbing of the skin
against a surface
Contused: Result from a blunt force and are
characterized by excessive damage to soft tissue
Puncture: Wounds that are deep into a tissue but
with a small opening on a surface e.g. a bullet
wound
c) According to Degree of Contamination
Clean Wound: Made using aseptic technique. It
is usually sutured
Contaminated Wound: Occurred accidentally or
surgically but there was a break of asepsis or
spillage from GIT. Require cleaning with antiseptic
before suturing
Infected Wound: Contaminated by disease
causing micro - organisms
DRESSING
This is the covering applied on a wound. They are
made of three layers:
Contact Layer: Directly applied to the wound
Middle Layer: Absorbs secretion of the wound
Outer Layer: Holds/ secures the inner layers
properly
Types of Dressing
a) Dry – dry Dressing
Placed to protect the wound from contamination.
Placed when dry and removed when dry unless
the wound is oozing
b) Wet – dry Dressing
Dressing are soaked with normal saline solution and
placed on the wound. They are left to dry then they
are removed
Tissue debris or necrotic tissue and drainage that
sticks are removed with the dressing
c) Wet – wet Dressing
Dressings are soaked in solution and remain wet until
they are removed
They provide moisture and warmth conducive for
wound healing
Thick secretions can also be made loose and removed
Advantages of Dressings
Used to remove necrotic/ dead tissues
Prevent invasion by micro – organisms
Absorbs drainage
Control bleeding
Used to apply medication
Promote healing by providing warmth and moisture
Provide comfort
Protect wound from injury and trauma
Splint or immobilize the wound
Lesser scar tissue formation
Disadvantages
Provide warmth and moisture which is a
conducive environment for micro – organisms
multiplication
They hinder wound from direct observation
Hinder activities like bathing, mobility and comfort
of the patient
Some patients are hypersensitive to some
dressing materials e.g. adhesive tape
They are expensive
Wound Dressing Procedure
Assessment
Condition of patient
Patient’s understanding of the need for dressing
Patient’s possible risk/benefit associated with
wound dressing
Equipment and required assistance
Appropriateness of the working environment
Extent of skin impairment and the drainage from
wound
Client for history of allergies to dressing solution
and material
Need for analgesic
Planning
Self
Review knowledge on:
Management of wound
Procedure of wound dressing
Wash and dry hands and gloving
Client
Explain the procedure to the client and obtain
informed
Requirements
Clean trolley/cabinet with;
Top Shelf
Sterile dressing pack containing:
2 pairs of dressing forceps
2 pairs of dissecting forceps
3 gallipots
10 cotton wool swabs and 3 gauze swabs
1 kidney dish
1 hand towel/ 4 paper towels
Sterile gloves
Petri dish
Bottom Shelf
Pair of scissors
Adhesive tape/bandage
Antiseptic solutions as required
Kidney dish or jug with disinfectants (as per
institutional policy)
Topical drugs if required
Extra sterile swabs and gauze
Sterile gloves
Receiver for used swabs (with liner for clinical
waste)
Dressing mackintosh
Steps
Close windows, screen bed and offer bed pan
Wash hands, dry and glove
Ensure that the trolley is clean then disinfect it
with spirit. Allow the spirit to dry.
Place sterile dressing pack on Top Shelf. Wheel
trolley to bedside
Explain the procedure and position client
appropriately
Loosen the dressing
Wash hands socially, clean and dry
Open dressing pack to expose dissecting forceps
Using the dissecting forceps, arrange the
instruments
Use the same dissecting forceps to remove the
loosened dressing from the wound and discard
dressing into the clinical wastes receiver
Discard the forceps into the jug/kidney dish with
decontaminant
Pour dressing solutions into the gallipots and add
extra sterile materials required. Prepare the
strapping
Perform surgical hand scrub
Dry hands using sterile towels and do sterile
gloving
Drape the patient with a dressing towel
Note condition of wound, surrounding tissues and
Prepare the cotton wool swabs as follows:
Using the dissecting forceps, put enough cotton
wool balls in the dressing solution. (if using two
solutions, put swabs in both)
With the dressing forceps in the dominant hand,
squeeze excess solution from the swabs, and
place them on the extra gallipot/kidney dish/petri
dish
Using the dissecting forceps pick a wet swab and
transfer to the dressing forceps
Clean from inside outward rotating the forceps
using a swab only once and discard. Repeat until
the wound is clean. Then clean the skin around
the wound
Discard dressing forceps into the disinfectant
If using two solutions repeat procedure with second
solution
Transfer dissecting forceps to dominant hand and
pick the second dissecting forceps with non
dominant hand
Using the non dominant hand, pick dressing
material e.g. gauze of sofratulle and transfer to
the dominant hand. Cover wound with dressing
material. (Ensure wound is adequately covered)
Discard forceps into disinfectants
Secure dressing with strapping
Remove drape and place it on trolley. Use the
towel lining the trolley to cover used equipment
Tie disposal bag or cover bin and remove the
gloves
Make client comfortable, un screen bed and open
windows
When trolley to the door of the sluice room. Wear
non sterile gloves, decontaminate and discard
used equipment appropriately
Wheel the trolley to the treatment room. Clean
trolley and tray with soap and water then store
solutions, trolley, tray and unused dressing
materials in appropriate places
Documentation
Record:
The characteristics of the wound
Type and amount of dressing solution used
Tolerance of client to procedure any abnormality
detected during the procedure and action taken
REMOVING THE CLIPS
• Insert remover under clip by opening handles of remover
• Gently squeeze remover handles together to release the
clip from the patient’s skin.
Dispose of clip appropriately.
• Assess wound union, if gapping in incision line is evident .if
evident stop the procedure you may notify surgical team
If skin has healed proceed with clip removal
• Do not clean the incision line with normal saline if it is clean
and dry (this increases the risk of infection)
• Swab the incision line if it has evident debris using normal
saline soaked gauze, in one direction only. Use each piece of
gauze once only, then discard.
Allow skin to dry
• Apply steri-strips if required and document
• Do not cover incision line if dry and intact.
