Module Title: Wound Care: Part A Sterile Dressing Change for Wounds over 48 Hours Old

Sterile Dressing ChangeTwo Main Types of Wounds:

Open

Closed

Sterile Dressing ChangeOpen Wounds:One in which the surface of the skin or mucus membrane

is no longer intact, usually from an accident or surgical incision

Types:Incision-clean separation of skin and tissue with smooth edgesLaceration-separation of skin and tissue with irregular edgesAbrasion-surface layers of the skin are scraped awayAvulsion-stripping away of a large area of skin and underlying tissue,

leaving bone and cartilage exposedUlceration-shallow crater in which skin or mucous membrane are

missingPuncture- opening of skin, underlying tissue, or mucous membrane

caused by a sharp pointed narrow object

Sterile Dressing ChangeClosed Wounds:Ones in which there is no opening in the skin

or mucous membrane usually caused by blunt trauma or pressure

Types of Closed Wounds:Contusion-injury to soft tissue underlying the skin from

the force of contact with a hard object

Sterile Dressing ChangeFactors Affecting Wound Healing:

Extent of injuryBlood supplyType of injury

Presence debris Presence of infection

Health of Patient

Sterile Dressing ChangeTypes of Dressings:

Cean DressingSterile DressingDressing a DrainWet-to-Dry DressingsTransparent Film and Hydrocolloid Dressings

Sterile Dressing Change Wound Care: Removing Old Dressing

Slowly remove tape or old bandagesRemove old dressingApply small amounts of Normal Saline to gauze if

sticking to wound and debridement is not the goal of the ordering MD.

Note color, odor and amount of drainage on dressingObserve wound for s/s of infection, granulation,

necrotic tissue, sloughNotify nurse to assess the patient before redressingCleanse the wound

Sterile Dressing Change Wound Care: Cleaning the woundClean wound using sterile gauze pads and ordered

cleaning solutionKnow the directions for use of the cleaning productCleanse linear/surgical wounds from top to bottom

from clean to less clean areasUse new gauze for each strokeWork outward in parallel lines/ Do not rub back and

forthCleanse open wounds in half circles or full circles. Begin at center and work outward to one inch

beyond the edge of the dressing. Use a new gauze for each circle

Sterile Dressing ChangeDressings and Bandages

Dressings protect the wound, preventing contamination. Increase comfort and prevent further injury

Some dressings are used to apply pressure to control bleeding

Dressings are usually gauze, film or other synthetic substances that cover a wound

Bandages are used to hold dressings in place and can be gauze, net or elastic wrappings

Some dressings have an adhesive backingSome are held on with tapeBe aware that some patients may be allergic to tape

Sterile Dressing ChangeWound Care: Redressing the Wound

Before applying the dressing, check the wound care orders

Gather your supplies, Select a dressing that will extend at least one inch

beyond the borders of the woundPlace the patient in a position that he or she can

maintain for the entire procedure without discomfortGloves may be removed once the wound is covered if

there is no drainage notedSecure the dressing with tape, bandage, binder or

Montgomery Straps

Sterile Dressing ChangeWound Care: Dressing a Drain

Use Sterile Technique when working with drainsHandle the drain as little as possibleCleanse using a circular motion from center outwardApply at least two layers of precut drain gauzeCover with two layers of uncut gauzeHandle Sterile Cover Dressing by the corners onlyTape securely in placeDuring procedure note: drain is not intact or not

patent, condition of peri skin, color and odor of drainage, change in amount of drainage, patient has fever.

Sterile Wound Dressing Wound Care: Wet-to-Dry Dressing

Used for wound healing or for debridementUse Sterile TechniqueNormal Saline is used to moisten gauzeAfter cleaning the wound area, pick up moist

gauze sponge one at a time and squeeze so it is damp not dripping.

Open and unfold the dressingPlace over woundPick up the Sterile Cover Dressing by the corner Cover the damp dressing and wound completelyTape securely in place

Sterile Wound Dressing Wound Care: Transparent Film and

Hydrocolloid DressingTransparent film dressings: adhesive

membranes of various sizes and thicknessesSelect one that will allow 1 ¼ inch of dressing Promote healing; protect from bacteria; never

used if infection is presentChange every 3 to 7 daysCan be used as a cover dressing instead of tape

Sterile Dressing ChangeHydrocolloid DressingsMade of materials such as gelatin and pectinSelf adhesive and come in various sizes and

thicknessesShould extend 1 ¼ inch beyond the edge of the

woundUsed for pressure ulcers and some other woundsChange ever 7 daysProvide a moist environment for wound healingNever use when infection is present, deep

wounds or when tendons and bones are exposed

Sterile Dressing ChangesWound Care: Applying Bandages

Most are conforming and some are self adhering gauze

Hold bandage in dominant handHold bandage against the skin approximately one

inch below the dressingWrap around extremity two or three times then wrap

from distal to proximal in overlapping spiral turnsShould be snug but not so tight it restricts blood flowWrap at least one inch above top of dressingWrap it twice then cut endTape the end to the bandage NOT to the skin

Module Title: Wound Care: Part B – Wound Irrigation

Wound Care: IrrigationPurpose: to remove bacteria and debris, drainage and

exudate from the wound

Materials:Strict sterile technique must be usedMD orders the solution to be used for irrigatingIrrigation is usually performed using a piston

syringeNurse will need to assess wound

Wound Care: IrrigationBeing too aggressive or not aggressive enough

with irrigation could lead to damage of the wound bed

Before irrigating the wound observe:Amount of drainage, condition of the wound,

stage of healingIf inflammation is present, a more aggressive

approach is necessaryIf the wound bed is mostly pink tissue with small

amounts of tissue debris use a more gentle approach