Definition
Performing a wound dressing is a core nursing procedure aimed at promoting healing, preventing infection, and ensuring patient comfort.
Purposes
- To protect the wound from contamination with microorganisms.
- To promote wound granulation and healing.
- To support or splint the wound site.
- To promote thermal insulation to the wound surface.
- To provide for maintenance of high humidity between the wound and dressing
- To promote physical, psychological and esthetic comfort.
Articles
Sterile dressing tray containing:
- Artery forceps-1 (2, for extensive or infected wounds).
- Thumb forceps-1.
- Cotton swabs.
- Gauze pieces.
- Gallipot for cleansing solution.
- Surgical pads.
- Kidney tray.
- Sterile scissors.
A clean tray containing:
- Clean gloves.
- Sterile gloves.
- Cleaning solution (normal saline).
- Ordered medications.
- Adhesive plaster.
- Bandage scissors.
- Plastic bag.
- Waterproof pad or Mackintosh.
- Culture tubes (optional).
*For major wound dressing, a larger dressing pack with additional articles may be required.
- Procedure
| Nursing action | Rationale | |
| 1 | Before procedure Identify the patient. | |
| 2 | Inform patient about dressing change, explain procedure and have patient lie in bed. | Encourages patient cooperation. |
| 3 | Gather equipment and arrange at the bedside. | An organized approach will save time and energy. |
| 4 | During procedure Wash hands. | Reduces spread of microorganisms. |
| 5 | Check physician’s order for dressing change and any specific instruction. | Clarifies type of dressing. |
| 6 | Close door or best curtains and place waterproof pad on bed beneath area of dressing. | Provides privacy and prevents soiling of linen. |
| 7 | Assist patient to comfortable position that provides easy access to wound area. | Provides comfort |
| 8 | Place opened, cuffed plastic bag near working area. | Reduces the risk of contamination from soiled dressing and used cotton balls. |
| 9 | Losen tapes on dressing (if tape is soiled, don clean gloves before loosening the tape. | Removal of tape is easier before wearing gloves. |
| 10 | Don clean disposable gloves and remove soiled dressings carefully from more clean to less clean area (if dressing is adherent to the skin, moisten its by pouring small amount of normal saline. | Protects nurse from contamination. Cautious removal of dressing is less painful for the patient. Moistened dressing is easier to remove. Reduces anxiety of patient. |
| 11 | Assess the amount, color and odor of drainage. | Helps in identifying the wound healing process. |
| 12 | Discard dressing in disposable bag. Pull off gloves inside out and discard in appropriate receptacle. | Prevents spread of microorganisms. |
| 13 | using sterile technique, open sterile dressing tray and arrange supplies on work area. | Keeps supplies within easy reach and maintains sterility. |
| 14 | Open cleaning solution and pour into the sterile gallipot/cup over the cotton balls. | |
| 15 | Dan sterile gloves. | Maintain asepsis. |
| 16 | pick up soaked cotton using artery forceps | |
| 17 | For a surgical wound, clean from top to bottom or from center outward. In contaminated wound, clean from periphery to center (circular motion for cleaning circular wound.) | Moisture provides medium for growth of microorganisms and trying the wound may retard the growth of microorganisms and improv healing process. |
| User one cotton swab/gauze sponge for each wipe, discarding each by dropping into the plastic bag after wiping. Do not touch the plastic bag with forceps. | ||
| If a drain is present, clean around it, moving from center outward in a circular motion | ||
| Dry the wound using sponge in same motion. | ||
| 18 | Apply medication ordered (ointment) to the wound on a dry sterile gauze. Apply a layer of sterile dressing over the wound. | Additional dressing servers as a wick for drainage. |
| 19 | Place a sterile gauze slit on side under and around the drain, (use precut gauze or cut one using sterile scissors). | Drainage is absorbed and the surrounding skin area is protected. |
| 20 | Apply a second layer of gauze to wound site and a surgical pad as the outermost layer. | Provides absorption of wound drainage and protection from microorganisms. |
| 21 | After procedure Remove gloves from inside out and discard in plastic waste bag. Apply adhesive tape to secure the dressing. | Tape is easier to apply after gloves have been removed. |
| 22 | Wash reusable articles to be send for sterilization | |
| 23 | Wash hands, remove all articles and make patient comfortable | Prevent spreading of infection. |
| 24 | Record dressing change, appearance of wound and describe any drainage in the chart. | Provide accurate documentation of procedure. |
Special Consideration
If culture swab is required, obtain it before cleansing the wound.
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/
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