CENTRAL PHLIPPINE ADVENTIST COLLEGE

SCHOOL OF NURSING
“Committed to the development of the whole man”

RESOURCE UNIT: ADVANCED WOUND CARE AND WOUND DRESSING

DATE OBJECTIVES CONTENTS TEACHING EVALUATION
STRATEGIES
11/20/17 At the end of 1 hour RLE Definition of wound:  Power point 1. Define wound care.
Lecture, the students will A wound occurs when the integrity of any tissue is Presentation 2. Give (3) purposes of
be able to: compromised (e.g. skin breaks, muscle tears, burns, or bone  Lecture wound care.
fractures). A wound may be caused by an act, such as a gunshot,  Demonstration 3. Determine if it is
Cognitive Domain fall, or surgical procedure; by an infectious disease; or by an  Handouts open wound or close
 Define wound underlying condition wound:
 Activity
care. a. Laceration
 Discuss the
 Graded Return
Classifications of wound: Demonstration b. Crush
nursing  Open wound: Injury involving an external or internal injuries
management of
break in body tissue, usually involving the skin. c. Gunshot
patient with
wound. o Abrasion: when the skin rubs or scrapes against d. Contusions
 Enumerate the a rough or hard surface. e. Incision
steps of wound o Laceration: deep cut or tearing of the skin. 4. What are the (3)
care. o Incision: skin cut with a sharp object; like stages of wound
scalpels, knives and scissors. healing process?
Psychomotor Domain o Puncture: small hole caused by a long pointy 5. Give (3) important
 Perform proper object, such as nail, needle, or ice pick. things, the nurse
assessment to o Avulsion: partial or complete tearing away of must assess.
determine skin and the tissue beneath. 6. True or False
complications of o Penetrating: caused by any object or force that a. Clean the
wound.
breaks through the skin to the underlying organs wound from
 Demonstrate
or tissue. inner area
wound care
correctly. o Gunshot wounds: caused by bullets from even when
 Utilize aseptic firearms there is
technique when inflammation
performing wound Complications: Infections, Inflammation, Loss of and presence
dressing. function Scarring. of puss and
fowling odor
Affective Domain  Close wound: the skin is intact and the underlying tissue toward the
 Display active is not directly exposed. outer area
participation where there

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 CENTRAL PHLIPPINE ADVENTIST COLLEGE
SCHOOL OF NURSING
“Committed to the development of the whole man”

through active o Contusions: direct blunt trauma that damages the is no more
listening and small blood vessels and capillaries, muscles and presence of
interaction. underlying tissue, as well the internal organs puss.
 Reflect own and, in some cases, bone. Painful bruise with b. If any
feelings/experience reddish to bluish discoloration that spread over abnormality
while caring for a
patient with
the injured area of the skin. is observed,
wound/s. o Hematomas: painful, spongey rubbery lump-like refer it to the
lesion that results from blood collection and doctor after
 Reflect Christ
Character by being pooling in a limited space. 24 hours
understanding, o Crush injuries: minor bruise to a complete observation
tactful and destruction of the crushed area of the body and
supportive to depending on the site, size, duration and power assessment.
patient and of the trauma due to external high pressure force c. Provide fan
significant others. that squeezes part of the body between two for fast
surfaces. drying of
Complications: Severe bleeding, large bruises, nerve wound.
damage, bone fractures and internal organ damage. 7. Write a health
teaching to a client
A normal wound healing process can take place through three regarding wound
stages: dressing.
1. Reaction Phase – Upon the occurrence of injury,
constriction of blood vessels occur in order to control the
entrance of foreign bodies into the wound. Some tissues become
edematous as a form of combating the injury to the skin. The
neutrophils then surround the wound to eat the loosened tissues
and fight the infection. Once the neutrophils have served its
purpose they will die forming pus.

2. Regrowth Phase – After the debris has been taken out,

a thin covering or film of tissue is outline on the wound.
Collagen for instance gives strength to the scar. For pressure
ulcers, granulation tissue covered the hollow area during this

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 CENTRAL PHLIPPINE ADVENTIST COLLEGE
SCHOOL OF NURSING
“Committed to the development of the whole man”

stage. The reaction phase and the regrowth phase may actually
overlap.

3. Remodeling Phase – The new scar formation is

strengthened through time. The average maturation of the scar
may range from 6 months to 12 months depending on the
intensity of the wounds and its damaged area.

Definition of wound care:

A nursing intervention from the Nursing Intervention
Classification (NIC) defined as prevention of wound
complications and promotion of wound healing.

Purpose of wound care:

 Promote wound granulation and healing
 Prevent undue contamination of wound
 Decrease purulent wound drainage (dressing material
absorbs the drainage)
 Provide dry environment (prevent micro-organisms
multiplication)
 Immobilize and support the wound
 Apply medication to the wound
 Provide comfort
 Promote aesthetic sense

Wound Care involves:

1. Local care to the skin, with debridement and dressings
2. Careful positioning of the affected body part to avoid
excessive pressure on the wound
3. Application of the compression or medicated bandages
4. Treatment of edema or lymphedema
5. Treatment of infection
6. Optimization of nutrition and of blood glucose levels
7. The use of supports and cushions

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 CENTRAL PHLIPPINE ADVENTIST COLLEGE
SCHOOL OF NURSING
“Committed to the development of the whole man”

8. Maximization of blood flow and oxygen

Major Principles for wound dressing:

1. Obtain informed consent from the patient
2. Maintain patient comfort and dignity throughout
3. Clean the wound from cleaner area toward the dirtier area.
4. Clean the wound from inner area toward the outer area
5. Change swab or gauze after one stroke.
6. Decontaminate hands pre and post procedure
7. Keep exposure of wound to a minimum
8. Maintain Asepsis throughout

Assessment:
 v/s
 Allergy to tape and cleaning solution
 Bleeding tendencies
 Doctor’s order
 Bleeding or drainage from wound site
 Condition of the wound

Preparations:
 Ensure environment is clean
 Explain procedure to patient
 All materials
 Proper lighting
 Switch off fan
 Provide privacy
 Check protocol about using cleaning solutions
 Fix disposable plastic bags in holders in the trolley.
Place within reach.
 Check patient’s care notes

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 CENTRAL PHLIPPINE ADVENTIST COLLEGE
SCHOOL OF NURSING
“Committed to the development of the whole man”

Materials needed:
 K basin
 Cotton balls or Swab
 Sterile Gauze
Plaster
 Sterile Gloves
 Betadine
 NSS
 Plastic bag
 Scissor

Procedure:

(see next page)

REFERENCES
Farlex, (2017). Wounds. Retrieved from: MedicalDictionary.com
NSGMED, (2017). Nursing Journals. Retrieved from: Nsgmed.com
E Doctors, (2017). Close and open wound basics. Retrieved from: woundcarecenters.org
Rhajan, R. (2017). Wound Dressing: Nurses Responsibility. Retrieved from: Canestar.com

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 CENTRAL PHLIPPINE ADVENTIST COLLEGE
SCHOOL OF NURSING
“Committed to the development of the whole man”

PROCEDURE
1. Introduce yourself to the patient and explain the procedure
3. Assess the patient for possible need for nonpharmacological pain-reducing interventions or analgesic medication before wound care dressing change
4. Assist the patient to a comfortable position that provides easy access to the wound area. Use the bath blanket to cover any exposed area other than the wound.
5. Wash your hands and put on clean gloves (to protect yourself).
6. Loosen the existing dressing but do not remove it.
7. Open the waste bag and put your hand inside. Use this to remove the soiled dressing. If any part of the dressing sticks to the underlying skin, use small amounts of
sterile saline to help loosen and remove.
8. Complete a wound assessment. This includes a visual check and comparing and evaluating the smell, amount of blood or ooze (excretions) and their color, and the
size of the wound.
9. Turn the bag inside out so that the dressing is contained within it. Attach the waste bag use the self-adhesive strip to attach the bag to the side of the trolley or other
convenient place close to the wound.
9. Remove the clean gloves and put on the sterile gloves.
10. Use a gauze swab dipped in cleansing solution to clean around the wound to remove blood. Start from the clean area and then move out to the dirty area. Clean the
wound from top to bottom and from the center to the outside. Following this pattern, use new gauze for each wipe, placing the used gauze in the waste receptacle. If the
wound itself needs cleaning, use a syringe primed with NSS in one hand and a gauze swab on the skin below the wound in the other.
11. Use fresh gauze swabs to dry around the wound (not the wound itself) Use each swab once only and swabbing away from the wound.
12. Dress the wound. Apply 2 layers of gauze or depends on the type of wound.
13. Remove the gloves and discard it: gloves worn during the dressing will be highly contaminated.
14. Secure the dressings with bandage or adhesive tapes.
15. When the dressing is secure, make the patient comfortable and assist the patient as necessary into a comfortable position. Raise side rails if necessary
16. Wrap all used disposable items in the sterile field and place in the waste bag.
17. Wash hands. Return any unused items to the stock cupboard and clean the trolley according to local policy
18. Document the type of dressing, condition of the wound, type of exudate and patient’s response. Report immediately if any abnormality is observed

Team Leaders: Clinical Instructors:

Mendoza, Elidale Vicsel Rose Jore, RN, MN
Orbegoso, Greg Martin S. Clinical Coordinator, SON
Pinili, Precious Julienne L.
Puerta, Kyla Angela Omega Albao, RN, MSN
Salazar, Nap Jedaiah D. Academic Coordinator, SON

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