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Wound Dressing

Wound dressing involves cleaning a wound and applying a sterile dressing to prevent infection and promote healing. Wounds are classified by intention, mechanism of injury, and degree of contamination, with various dressing types available for different needs. The procedure includes assessment, planning, and specific steps for dressing application and removal, along with documentation of the process.

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32 views20 pages

Wound Dressing

Wound dressing involves cleaning a wound and applying a sterile dressing to prevent infection and promote healing. Wounds are classified by intention, mechanism of injury, and degree of contamination, with various dressing types available for different needs. The procedure includes assessment, planning, and specific steps for dressing application and removal, along with documentation of the process.

Uploaded by

isaacderi8
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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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.

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