Introduction
A pressure ulcer is a localized injury to the skin and sometimes involves underlying tissues, usually over a bony prominence as a result of unrelieved pressure. Dressing a pressure ulcer involves cleaning with saline solution, applying an antiseptic agent and covering the wound with dressing pad or bandage following aseptic technique.
Maintaining a moist environment at the wound site and keeping the intact skin surrounding the wound dry is the goal of dressing. healing optimized by a moist rather than dry wound environment. Thus, a dressing that will keep the ulcer bed continuously moist should be used.
Purposes
- To promote healing of the wound.
- To protect the wound from infections and microorganisms (contamination),
- To support the wound site from further pressure/have mechanical protection.
- To provide physical and emotional support to patients
Articles
A tray containing
- Sterile gauze pieces of 4″ x 4″ size
- Sterile cotton swabs.
- Cotton pads for absorption of exudates, if needed for bigger wounds.
- A small cup for cleaning solution (normal saline).
- Antiseptic solution (as per prescription).
- A pair of gloves.
- Forceps (both artery and thumb types)
- Adhesive tape
- Bandage scissors.
- A small mackintosh and towel.
- A receptacle (plastic bag) for waste collection.
- Medication/ointment as prescribed.
Procedure
| Nursing action | Rationale | |
| 1 | Assemble articles at the beside | For effective management of time |
| 2 | Explain to patient and family with the patient what will be done. | To reduce anxiety and gain cooperation. |
| 3 | Position the patient for performing procedure | For making patient comfortable and visualization wound. |
| 4 | Place a mackintosh and towel under the patient or part to be dressed. | To prevent soiling of bed line. |
| 5 | Wash and dry hands | To prevent contamination |
| 6 | Remove and dispose of the dressing on the wound. If the dressing is dry and sticks to the wound, pour normal saline. | To expose the wound for inspection and cleaning |
| 7 | Assess the wound for its condition, drainage, color, and odor. | To get the baseline data of the wound. |
| 8 | Wash and dry hands. | Avoids contamination |
| 9 | Pour normal saline in the small cup and soak cotton swabs in it. | Using wet cotton swabs for cleaning hurts less and removes discharge better. |
| 10 | Put on sterile gloves. | Maintain sterility. |
| 11 | Clean the wound from inner to outer side in circular motion with saline soaked cotton swabs. Use one cotton swab for each stroke. | To prevent further infection/spread of infection. |
| 12 | Dry the wound using gauze and sponge pieces. | Using gauze and sponge places avoids cotton sticking to the wound surface. |
| 13 | Apply medication/ointment over the wound and cover it with gauze pieces and pad at the size of the wound requires. | Avoids cotton sticking to the wound surface. |
| 14 | Remove gloves | |
| 15 | Secure dressing with adhesive tape bandage. | Avoids chances of spreading infection |
| 16 | Position patient comfortably. | Wound remains covered and protected. |
| 17 | Dispose of waste. | To promote relaxation. |
| 18 | Wash the used articles and replace them in an appropriate place. | To prevent transmission of infection. |
| 19 | Wash and dry hands thoroughly. | |
| 20 | Document in patient’s chart, details of the procedure including appearance of wound, discharge if present and any other observations. | For communication among members of the health team. |
Special considerations
- Monitor wound healing by regular reviews for pain, size of wound, presence and absence of exudates and foul smell.
- For proper healing, wounds need to be free of damaged tissues and hence adequate flushing or debridement will be needed.
- To prevent further damage due to shear, friction, and pressure:
- Use draw sheets for positioning.
- Elevate the foot end of bed slightly if possible.
- To avoid pressure:
- Use pillow between legs for side lying position.
- Do not position directly on the trochanter
- Use a pillow or wedge to support hips.
- Perform timely positioning –every two hours for bed-ridden patients and every 3 hours for wheelchair patients.
- Apply barrier ointment to intact skin.
- Use disposable diapers for incontinent patients.
- Employ measures to improve nutritional status.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
Stories are the threads that bind us; through them, we understand each other, grow, and heal.
JOHN NOORD
Connect with “Nurses Lab Editorial Team”
I hope you found this information helpful. Do you have any questions or comments? Kindly write in comments section. Subscribe the Blog with your email so you can stay updated on upcoming events and the latest articles.
