WOUND DRESSING
Skin- is the largest organ in the body
and serves a variety of important
functions in maintaining health and
protecting the individual from injury.
Important nursing functions are
maintaining skin integrity and
promoting wound healing.
Intact skin - refers to the presence of
normal skin and skin layers
uninterrupted by wounds.
Wound- is a breakdown in the
protective function of the skin; the loss
of continuity of epithelium, with or
without loss of underlying connective
tissue (i.e. muscle, bone,
nerves) following injury to the skin or
underlying tissues/ organs caused by
surgery, a blow, a cut, chemicals, heat/
cold, friction/ shear force, pressure or
as a result of disease, such as leg ulcers
or carcinomas
They are either intentional or
unintentional. Intentional trauma
occurs during therapy. Examples are
operations or venipuncture. Although
removing a tumor, for example, is
therapeutic, the surgeon must cut into
body tissues, thus traumatizing them.
Unintentional wounds are accidental;
for example, a person may fracture an
arm in an automobile collision. If the
tissues are traumatized without a break
in the skin, the wound is closed. The
wound is open when the skin or
mucous membrane surface is broken.
Dressing- is a sterile pad or compress
applied to a wound to promote healing
and protect the wound from further
harm. A dressing is designed to be in
direct contact with the wound, as
distinguished from a bandage, which is
most often used to hold a dressing in
place.
Dressings are applied for the following
purposes:
• To protect the wound from
mechanical injury
• To protect the wound from microbial
contamination
• To provide or maintain moist wound
healing
• To provide thermal insulation
• To absorb drainage or debride a
wound or both
• To prevent hemorrhage (when
applied as a pressure dressing or with
elastic bandages)
• To splint or immobilize the wound site
and thereby facilitate healing and
prevent injury.
Types of Dressing depends on (a) the
location, size, and type of the wound;
(b) the amount of exudate; (c) whether
the wound requires debridement or is
infected; and (d) such considerations as
frequency of dressing change, ease or
difficulty of dressing application, and
cost.
PROCEDURE
Explain the procedure to the patient
Wash hands thoroughly with soap and
water.
Follow standard precautions for
personal protection. Wear gloves,
gown, goggles, and mask as indicated.
Use individually wrapped sterile
dressing and equipment for greatest
safety of wound.
Create a sterile field around the wound.
Use solutions such as isotonic saline or
wound cleansers to clean or irrigate
wounds. If antimicrobial solutions are
used, make sure they are well diluted.
Microwave heating of liquids to be used
on the wound is not recommended.
When possible, warm the solution to
body temperature before use.
This prevents lowering the wound
temperature, which slows the healing
process. Microwave heating could
cause the solution to become too hot.
Before doing the dressing inspect the
wound for any complications such as
dehiscence and evisceration
For Proper documentation for the
progress of wound healing.
If a wound is grossly contaminated by
foreign material, bacteria, slough, or
necrotic tissue, clean the wound at
every dressing change.
Foreign bodies and devitalized tissue
act as a focus for infection and can
delay healing.
If a wound is clean, has little exudate,
and reveals healthy granulation tissue,
avoid repeated cleaning.
Unnecessary cleaning can delay wound
healing by traumatizing newly
produced, delicate tissues, reducing the
surface temperature of the wound, and
removing exudate, which itself may
have bactericidal properties.
Use gauze squares or nonwoven swabs
that do not shed fibers. Avoid using
cotton balls and other products that
shed fibers onto the wound surface.
The fibers become embedded in
granulation tissue and can act as foci for
infection. They may also stimulate
“foreign body” reactions, pro-
longing the inflammatory phase of
healing and delaying the healing
process.
Clean superficial non-infected wounds
by irrigating them with normal saline.
The hydraulic pressure of an irrigating
stream of fluid dislodges contaminating
debris and reduces bacterial
colonization.
Avoid drying a wound after cleaning it.
This helps retain wound moisture.
Hold cleaning sponges with forceps or
with a sterile gloved hand.
Clean from the wound in an outward
direction to avoid transferring
organisms from the surrounding skin
into the wound.
Consider not cleaning the wound at all
if it appears to be clean
Frequent cleaning of clean wound may
disrupt or delay wound healing.
Apply sterile dressing and fasten it with
a bandage.
Wrap the soiled dressing and throw it in
a yellow garbage bag.
Collect and wash used instruments with
soap and water.
Removed PPE’s after dressing. Follow
the sequence on how to remove PPE.
Wash hands thoroughly after the procedure.