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Wound Dressing Procedure

(1) A wound dressing procedure involves assessing the wound, planning appropriate treatment, and implementing the treatment. (2) Types of wounds include abrasions, lacerations, punctures, and avulsions. (3) Objectives of wound dressing include applying compression, immobilizing injured body parts, protecting the wound, and promoting moist wound healing. (4) The APIED procedure involves assessing the wound, planning appropriate dressing, implementing the dressing change while maintaining asepsis, and evaluating the wound and documentation.

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80 views6 pages

Wound Dressing Procedure

(1) A wound dressing procedure involves assessing the wound, planning appropriate treatment, and implementing the treatment. (2) Types of wounds include abrasions, lacerations, punctures, and avulsions. (3) Objectives of wound dressing include applying compression, immobilizing injured body parts, protecting the wound, and promoting moist wound healing. (4) The APIED procedure involves assessing the wound, planning appropriate dressing, implementing the dressing change while maintaining asepsis, and evaluating the wound and documentation.

Uploaded by

wyclife akong'o
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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WOUND DRESSING

PROCEDURE

GROUP 3
INTRODUCTION
A dressing is a sterile pad or compress applied to a wound to promote
healing and protect the wound against futher harm.A dressing is
designed to be in direct contavt with the wound, as distinguished
from a bandage, which is most often used to hold a wound in
place.Many modern dressings are self- adhesive.

Types of wound

 Abrasion – occurs when the skin rubs or scrapes against a rough


or hard surface
 Laceration – A deep cut or tearing of your skin
 Puncture – Made by a pointed object such as a nail, knife or
sharp tooth
 Avulsion – a wound in which part of the body has been removed
or turned off through trauma or surgery.

Indications (objectives) of wound dressing

 Apply compression for hemorrhage or venous stasis


 Immobilize an injured body part
 Protect the wound against body tissues
 Promote moist wound healing

THE “APIED” PROCEDURE OF WOUND DRESSING

 Assessment

Assess for :

 Type of wound
 Amount of injury
 Color of wound
 Odor of exudate
 Signs of infection
 Pain
 Wound edges and periwound skin

 Planning

 Apply appropriate wound dressing.


 Non- adherent saline wraps and absorbent material are
effective to prevent wound infection and promote tissue re-
epithelialization
 Secure the dressing with soft gauze tape.
 Asepsis in wound care would prevent further contamination
of wound

 Implementation

 Explain the procedure to the client


 Organization facilitates accurate skill performance
 Perform hand hygiene  To prevent the spread of infection
 Check Dry’s order for dressing change. Note whether drain is present.  The order clarifies type
of dressing
 Close door and put screen or pull curtains.  To provide privacy
 Position waterproof pad or mackintosh under the client if desired  To prevent bed sheets from
wetting body substances and disinfectant
 Assist client to comfortable position that provides easy access to wound area.  Proper
positioning provides for comfort.
 Place opened, cuffed plastic bag near working area.  Soiled dressings may be placed in disposal
bag without contamination outside surfaces of bag.
 Loosen tape on dressing . Use adhesive remover if necessary. If tape is soiled, put on gloves. It
is easier to loosen tape before putting in gloves.
 1) Put on disposable gloves 2) Removed soiled dressings carefully in a clean to less clean
direction3) Do not reach over wound.
 Keep soiled side of dressing away from client’s view.  Using clean gloves protect the nurse
when handling contaminated dressings. not removed if it is present.  Sterile saline provides for
easier removal of dressing.
 Assess amount, type, and odor of drainage.  Wound healing process or presence of infection
should be documented.
 Discard dressings in plastic disposable bag.
 Pull off gloves inside out and drop it in the bag when your gloves were contaminated extremely
by drainage.  Proper disposal dressings prevent the spread of microorganisms by contaminated
dressings.

 Evaluation
 Identify the wound location
 Determine the cause of the wound
 Evaluate for foreign bodies or neoplastic processes
 Determine the sage of the wound
 Evaluate a measure the depth, length and width of
the wound
 To evaluate for an infection, the classic signs for an
infection are
 Heat
 Swelling
 Pain
 Increased exudate
 Delayed healing
 Contact bleeding
 Odor

Documentation

General documentation types:

 Type of exudate
 Pressure injuries
 Intervention methods
 Reports of pain
 Patient’s refusal of care
 Daily, weekly progress
 Referrals
 Implementation of new orders

Conclusion

Medical documentation and records serve multiple purposes. They


should plan and provide continuity of care for a patient’s medical
treatment. Clinicians must provide adequate and accurate
documentation of all relevant wound characteristics, interventions
and responses.

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