NURSE’S RESPONSIBILITY IN THE WOUND DRESSING

Preliminary Assessment

1. Check the diagnosis and the general condition of the patient.


2. Check the purpose for which the dressing is to be done.


3. Check the condition of the wound – the type of the wound, the types of suturing applied, the type of dressings to be applied etc.


4. Check the physician’s orders for the type of dressing to be applied and the specific instructions, if any, regarding the cleansing solutions, removal of sutures, drains and the application of medications etc.


5. Check the patient’s name, bed number and other identifications.


6. Check the nurse’s records to find out the general condition of wound.


7. Check the abilities and limitations of the patient.


8. Check the consciousness of the patient and the ability to follow instructions.


9. Check the articles available in the unit.

 

Preparation of the Articles

Articles

A sterile tray containing:


1. Artery forceps – 1

Purpose: to clean the wound

2. Dissecting forceps – 2


3. Scissors – 1

Purpose: for the debridement of the wound, if necessary or to cut the gauze pieces to fit around the drainage tubes etc.

4. Sinus forceps – 1

Purpose: to open the sinus tract or to pack the sinus tract, if necessary

5. Probe – 1

Purpose: to open the sinus tract or to pack the sinus tract, if necessary

6. Small bowl – 1

Purpose: to take the cleaning solutions

7. Safety pin – 1

Purpose: to fix the drain, in case the drains are cut short

8. Gloves, masks and gowns

Purpose: to use when large wounds are dressed

9. Cotton balls, gauze pieces cotton pads etc as necessary

Purpose: to clean and dress the wound

10. Slit or dressing towels

Purpose: to create a sterile field around the wound

 

An Unsterile Tray containing:

1. Cleaning solutions as necessary

Purpose: to clean the wound and the surrounding skin area

2. Ointment and powders as ordered

Purpose: to apply on the wound

3. Vaseline gauze in sterile containers

Purpose: to prevent the dressing adhering to the wound

4. Ribbon gauze in sterile containers

Purpose: to pack a sinus tract or penetrating wound

5. Swab sticks in a sterile container

Purpose: to apply the medications if necessary

6. Transfer forceps in a sterile container

Purpose: to handle the sterile supplies

7. Bandages, binders, pins, adhesive plaster, and scissors

Purpose: to fix the dressing in place

8. A large bowl with disinfectant solution

Purpose: to discard the used instruments

9. Kidney tray and paper bag

Purpose: to collect the wastes

10. Mackintosh and towel

Purpose: to protect the bed garments.

wound dressing - nursing procedure

AUTHOR: REJITHA RAJAN 

Wound Dressing – Nurse’s Responsibility, preparation, procedure and after care of patient. Nursing Procedure

Dressing

Definition

A dressing is a sterile pad or compress applied to wound to promote healing and protect the wound from further harm. Dressing is used to have direct contact with a wound but bandage is used to hold a dressing in place.

 

GENERAL INSTRUCTIONS FOR THE WOUND DRESSING

1. Practice strict aseptic technique to prevent cross infection to the wound and from the wound. Dressing a wound is surgical procedure which should be carried out with the precision and care of an operation. All materials touching the wound should be sterile.


2. All articles should be disinfected thoroughly to make sure that they are free from pathogens. Special care must be taken when there is any reason to suspect the presence of pathogenic spores particularly those causing the dreaded wound infections of gas gangrene and tetanus. These spores are destroyed only be the sterilization with steam under pressure.


3. Wash hands thoroughly before and after the procedure.


4. Instruments used for one dressing cannot be used for another until they have been re-sterilized.


5. Use masks, sterile gloves and gowns for large dressings to minimize the wound contamination.


6. Dressings are not changed for atleast 15 minutes after the room has been swept or cleaned. Sweeping and dusting of the room will raise the dust and the wound will be contaminated.


7. Use individually wrapped sterile dressings and equipments for the greatest safety of the wound. The practice of storing dressings and instruments in large trays and drums and opening them every now and then should be condemned.


8. Create a sterile field around the wound by spreading sterile towels.


9. Avoid talking, coughing and sneezing when the wound is opened.


10. During the procedure the nurse works carefully to avoid contaminating the patient’s skin, clothing and bed linen with soiled instruments and dressings. All the soiled dressings and contaminated instruments should be carefully collected and disposed safely.


11. Cleaning the wound should be done from the cleanest area to the less clean area. Consider the wound area cleaner than the skin area even if the wound is infected. Therefore clean the wound from its centre to the periphery. When cleaning a circular wound, start from the centre of the wound and go to the periphery. When cleaning a linear wound, the first swab cleanses the wound line; the subsequent swabs cleanse the skin on either side of the wound.


12. If the dressings are adherent to the wound due to the drying of the secretions or blood, wet it with physiologic saline before it is removed from the wound.


13. When dressing the wound, keep the wound edges are near as possible to promote healing.


14. When drains are in place, anticipate drainage and re-enforce the dressing accordingly. The dressings over the drains should not be combined with the dressings on the wound line. This enables the nurse to change the dressings over the drains without disturbing the wound dressings and thereby minimize the wound infections.


15. The amount of discharge from the wound should be accurately measured by recording the number and size of the dressings changed. Note the color, odor, amount and consistency of the drainage.


16. When the wound drainage is diminished the drains are to be shortened. This should be done in consultation with the doctor. Usually the doctor gives a written order.


17. Before doing the dressing, inspect the wound for any complications such as dehiscence and evisceration. If present, report it immediately to the surgeon and immediate steps are to be taken.


18. Avoid meal timings.


19. Give an analgesic prior to the painful dressings.

Preparation of the Patient and the Environment

1. Identify the patient and explain the procedure to win the confidence and co-operation. Explain the sequence of the procedure and tell the patient how he can co-operate in the procedure


2. Provide privacy with curtains and drapes.


3. Apply restraints, in case of children


4. As far as possible, avoid meal timings; the dressings may be done either one hour before the meals or after meals.


5. Offer bedpan or urinal prior to the dressing.


6. Give some analgesics if the patient is in pain; e.g., before dressing an extensive burned wound.


7. See that the cleaning of the room is done at least one hour before the expected time of the dressing.


8. Shave the area if necessary to  remove the hairs. Removal of the adhesive is more painful if the hair is present. So the shaving should be done before the first dressing is applied.


9. Place the patient in a comfortable and relaxed position depending on the area to be dressed.


10. Give proper support to the body parts if the patient has to raise and hold it in position for a considerable time.


11. See that the patient’s room is in order with no unnecessary articles. Clear the bedside table or the overbed table, so that there is sufficient space to set up a sterile field and to arrange needed supplies and equipments.


12. Close the doors and windows to prevent drafts. Put off fan.


13. Adjust the height of the bed for the comfortable working of the doctor or nurse so that they have neither to stoop nor overreach to do the dressing. Bring the patient to the edge of the bed.


14. Call for assistance if necessary e.g., to do the unsterile procedure, to transfer sterile supplies etc.


15. Protect the bed with a mackintosh and towel.


16. Fold back the upper bedding towards the foot end of the bed leaving a bath blanket or sheet over the patient. Expose the part as necessary.


17. Untie the bandage or adhesive and remove them. Make use that the dressing is not removed from its place until the nurse is ready to do dressing (after washing her hands)


18. Turn the head of the patient to one side, so that the patient may not see the wound and get worried about it.

 

PROCEDURE

 Steps of Procedure

1. Tie the mask

Reason/Explanations: to prevent wound contamination with droplets.

2. Wash hands thoroughly

Reason/Explanations: to prevent cross infection

3. Put on gown, gloves etc. as necessary

Reason/Explanations: to ensure asepsis

4. Open the sterile tray. Spread the sterile towel around the wound.

Purpose/Explanations: to create a sterile field around the wound.

5. Pick up a dissecting forceps and remove the dressings and put it in the paper bag. Discard the dissecting forceps in the bowl of lotion.

Purpose/Explanations: to prevent contamination of the hands, with the soiled dressings. (if the dressing is adherent to the wound, pour physiologic saline and wet it before removal).

6. Note the type and the amount of drainage present


7. Ask the assistant to pour small amount of cleansing solution into the bowl

Purpose/Explanations: to prevent contaminating the hands of the nurse by the outside of the bottle.

8. Clean the wound from the centre to periphery, discarding the used swabs after each stroke

Purpose/Explanations: cleaning should be done from the cleanest area to the less clean area. Wound line is considered cleaner than the surrounding area even if the wound is infected.

9. After thoroughly cleaning of the wound, dry the wound with dry swabs using the same precautions. Discard the forceps in the bowl of lotion

Reasons/Explanations: to keep the wound as dry as possible.

10. Apply medications if ordered.

Reasons/Explanations: to apply the ointment directly to the wound may be difficult. Apply a small portion on the dressing that goes directly over the wound.

11. Apply the sterile dressings. Apply the gauze pieces first and then the cotton pads. Reinforce the dressing on the dependent parts where the drainage may collect.

Reasons/Explanations: cotton placed directly onto the wound may stick on the wound, when the discharge dries. Reinforcing the dressing will prevent oozing of the drainage onto the bed of the patient.

12. Remove the gloves and discard it into the bowl with lotion

Reasons/Explanations: gloves worn during the dressing will be highly contaminated.

13. Secure the dressings with bandage or adhesive tapes.

 

After Care of the Patient and the Articles

1. Help the patient to dress up and to take a comfortable position in the bed.

 Change the garments if soiled with drainage.


2. Replace the bed linen.


3. Remove the mackintosh and towel.


4. Take all articles to the utility room. Discard the soiled dressings into a covered container and send for incineration. Remove the instruments and other articles from the disinfectant solution and clean them thoroughly. Dry them. Re-set the tray and send for autoclaving. Replace all other articles to their proper places. Send the soiled linen to the laundry bag for washing (remove the blood stains before sending them to washing).


5. Wash hands.


6.Record the procedure on the nurse’s record with date and time. Record the condition of the wound, the type and amount of drainage, condition of the sutures etc. on the nurse record. Report to the surgeon any abnormalities found.


7.Return to the bedside to assess the comfort of the patient. Special instruction in the care of the wound care to be communicated to the patient.
Tidy up the bed and the unit of the patient.