Wound Dressing
Purposes :
1- To promote wound healing by primary intention .
2- To prevent infection .
3- To assess the healing process .
4- To protect the wound from mechanical trauma .
Mode of applying gauze dressings :
1-Dry - to – dry :
Layer of wide mesh cotton gauze lies next to the wound surface , second layer of dry absorbent cotton to protect the wound
2-Wet – to – dry :
Layer of wide mesh cotton gauze saturated with saline next to wound surface ,second layer of moist absorbent with same solution to debride the wound
3-Wet –to – damp :
Variation of wet to dry dressing .
4-Wet – to wet :
Layer of wide mesh gauze saturated with antibacterial solution next to the wound surface, second layer of absorbent material saturated with the same solution to dilutes viscous exudates .
Assessment :
1- Client allergies to wound cleaning agents.
2- The appearance and size of the wound .
3- The amount and character of exudates.
4- Client complaints of discomfort.
5- The time of last pain medication .
6- Signs of systemic infection ( e.g. .elevated in body temp , diaphoresis, malaise …) .
Equipment :
-Moisture proof bag .
-Mask .
-Acetone solution to loosen adhesive .
-Clean gloves.
-Sterile gloves .
-Sterile dressing set .
-Additional supplies ( extra gauze dressing , and ointment if ordered .
-Tie tapes, tape or binder .
Normal saline or antiseptic solution .-
-Bath blanket.
Implementation :
Before changing a dressing , determine any specific order about dressing or wound.
Preparation
- Acquire assistance for changing a dressing on restless or confused client .
- Put the client to comfortable position in which the wound can be readily exposed ( expose only wound area ).
- Make cuff on the moisture proof bag for disposal of the soiled dressings and place the bag within reach .
- Put on face mask .
Performance :
1- Explain procedure to the client .
2- Wash hands.
3- Provide for client privacy.
4- Remove binder and tape ( figure 1 )
-remove binder if used and place them aside .
- If adhesive tape used , remove it by holding down the skin and pulling the tape toward the wound .
- Use solvent to loose the tape if required .
Figure (1)
5- Remove and dispose of soiled dressing .( figure 2 )
- Put on clean gloves to remove outer dressing or surgipad .
- Place outer dressing away from client .
- Place the soiled dressing in moisture proof bag without touch the outside the bag .
- Remove the under dressing , taking care not to dislodge any drains , if the gauze sticks to the drains , support the drain with one hand and remove the gauze with other.
figure 2
-Assess the location , type and odor of the wound drainage and number of gauzes saturated .( figure 3 )
-Discard the soiled dressing in the bag as before .
Remove clean gloves .-
- Wash hands or clean with antiseptic solution .
Figure (3 )
6- Setup sterile supplies .( figure 4 )
- Open the sterile dressing set using aseptic technique .
- Place the sterile drape beside the wound .
- Open the sterile cleaning solution pour it over the gauze sponges .
- Put on sterile gloves . ( figure 5 )
Figure 4 Figure 5
7- Clean the wound .
- Clean the wound using your gloved hands or forceps and gauze swabs moisture with cleaning solutions.( figure 6)
Use the cleaning method ( clean from top to bottom or from centre outward . ( figure 7)-
-Use a separate swab for each stroke and discard each swab after use .
Figure 6 Figure 7
-If drain is present , clean the skin around the drain site by swabbing it half or circle . ( figure 8 )
Figure 8
--Support and hold the drain erect while cleaning around .
-Dry the surrounding skin with gauze swab as required .do not dry wound or incision itself .
8- Apply dressing to the drain site and incision.
-Place a precut 4 in 4 gauze around drain . ( figure 9 )
-Apply the sterile dressing one at a time over the drain and incision .( figure 10 )
-Apply surgipad , remove gloves and dispose of them . ( figure 11 )
-Secure the dressing with tape or tie.
-Document the procedure and all nursing assessment .
Figure 9 Figure 10 Figure 11