Wound Wound dressing dressing

Prepared by Miss Prepared by Miss Aisha Al-hofaianAisha Al-hofaianSupervised by Supervised by

Dr.Gehan Dr.Gehan

Purpose Purpose 1- To promote wound healing 1- To promote wound healing

by primary intention .by primary intention .2- To prevent infection .2- To prevent infection .3- To assess the healing 3- To assess the healing

process process 4- To protect the wound from 4- To protect the wound from

mechanical trauma .mechanical trauma .5- To absorb drainage.5- To absorb drainage.6- To prevent contamination 6- To prevent contamination

from bodily discharge.from bodily discharge.

Types of dressingsTypes of dressingsDry - to – dry :Dry - to – dry :Used primarily for wounds closing by Used primarily for wounds closing by

primary intention.primary intention.Layer of wide mesh cotton gauze lies Layer of wide mesh cotton gauze lies

next to the wound surface , second next to the wound surface , second layer of dry absorbent cotton to layer of dry absorbent cotton to protect the wound protect the wound

Types of dressingsTypes of dressings

Wet – to – dry :Wet – to – dry :These are particularly useful for untidy or These are particularly useful for untidy or

infected wounds that must be debrided infected wounds that must be debrided and closed by secondary intentionand closed by secondary intention

Layer of wide mesh cotton gauze Layer of wide mesh cotton gauze saturated with saline next to wound saturated with saline next to wound surface ,second layer of moist absorbent surface ,second layer of moist absorbent with same solution to debride the woundwith same solution to debride the wound

Cont..Cont..Wet –to – damp :Wet –to – damp :Variation of wet to dry dressing .Variation of wet to dry dressing .Wet – to wet :Wet – to wet :Used in clean open wounds.Used in clean open wounds.Layer of wide mesh gauze saturated with Layer of wide mesh gauze saturated with

antibacterial solution next to the wound antibacterial solution next to the wound surface, second layer of absorbent surface, second layer of absorbent material saturated with the same material saturated with the same solution to dilutes viscous exudates . solution to dilutes viscous exudates .

Assessment Assessment 1- Client allergies to wound 1- Client allergies to wound

cleaning agents.cleaning agents.2- The appearance and size of the 2- The appearance and size of the

wound .wound .3- The amount and character of 3- The amount and character of

exudates.exudates.4- Client complaints of discomfort.4- Client complaints of discomfort.5- The time of last pain 5- The time of last pain

medication .medication .6- Signs of systemic infection 6- Signs of systemic infection

( e.g. .elevated in body temp , ( e.g. .elevated in body temp , diaphoresis, malaise …) .diaphoresis, malaise …) .

Equipment Equipment -Moisture proof bag .-Moisture proof bag .-Mask .-Mask .-Acetone solution to loosen adhesive .-Acetone solution to loosen adhesive .-Clean gloves.-Clean gloves.-Sterile gloves .-Sterile gloves .-Sterile dressing set .-Sterile dressing set .-Additional supplies ( extra gauze -Additional supplies ( extra gauze

dressing , and ointment if ordered .dressing , and ointment if ordered .-Tie tapes, tape or binder .-Tie tapes, tape or binder .- Normal saline or antiseptic solution .- Normal saline or antiseptic solution .

Implementation Implementation Before changing a dressing , determine any specific order Before changing a dressing , determine any specific order

about dressing or wound.about dressing or wound. Preparation Preparation - Acquire assistance for changing a dressing - Acquire assistance for changing a dressing

on restless or confused client .on restless or confused client .- Put the client to comfortable position in - Put the client to comfortable position in

which the wound can be readily exposed which the wound can be readily exposed ( expose only wound area ).( expose only wound area ).

- Make cuff on the moisture proof bag for - Make cuff on the moisture proof bag for disposal of the soiled dressings and place disposal of the soiled dressings and place the bag within reach .the bag within reach .

- Put on face mask .- Put on face mask .

Performance Performance

1- Explain procedure to the 1- Explain procedure to the client .client .

2- wash hands.2- wash hands.

3- provide for client privacy .3- provide for client privacy .

4 -Remove binder and tape

-remove binder if used and place them aside.

-If adhesive tape used , remove it by holding down the skin and pulling the tape

toward the wound.

-Use solvent to loose the tape if required.

5 -Remove and dispose of soiled dressing.

-Put on clean gloves to remove outer dressing or surgipad.

-Place outer dressing away from client.

-Place the soiled dressing in moisture proof bag without touch the outside

the bag.

-Remove the under dressing , taking care not to dislodge any drains , if the gauze sticks to the drains , support the drain with one hand and remove the gauze with other.

-Assess the location , type and odor of the wound drainage and number of gauzes saturated .

-Discard the soiled dressing in the bag as before .

-Remove clean gloves .

- Wash hands or clean with antiseptic solution .

6 -Setup sterile supplies.

-Open the sterile dressing set using aseptic technique.

-Place the sterile drape beside the wound.

-Open the sterile cleaning solution pour it over the gauze

sponges.

-Put on sterile gloves.

7- Irrigate the wound :

-Instill a steady stream of irrigating solution into the wound .

- Position the basin below the wound to receive the irrigating

-Use either a syringe with a catheter attached or with irrigating tip to flush the wound

-Continue irrigating until the solution becomes clear.

-Dry the area around the wound.

8- Clean the wound .

- Clean the wound using your gloved hands or forceps and gauze swabs moisture with cleaning solutions.

-Use the cleaning method .

- Use a separate swab for each stroke and discard each swab after use .

-If drain is present , clean the skin around the drain site by swabbing it half or circle .

Cont…

-Support and hold the drain erect while cleaning around .

-Dry the surrounding skin with gauze swab as required .do not dry wound or incision itself .

9- Apply dressing to the drain site and incision.-Place a precut 4 in 4 gauze around drain .

-Apply the sterile dressing one at a time over the drain and incision .

-Apply surgipad , remove gloves and dispose of them .

-Secure the dressing with tape or tie.- Wash your hands.

-Document the procedure and all nursing assessment .