• Within few seconds after injury, inflammation begins and
lasts for about 3 days.
• Injured tissues and mast cells secrete histamine, resulting in
vasodilation of surrounding capillaries and exudation of
serum and while blood cells into damaged tissues.
• Leukocytes reach the wound within few hours. The neutrophil
begins to ingest bacteria and small debris. The neutrophil dies
in a few days.
• During this period the monocyte which transforms into
macrophages cells clean the wound bacteria, dead cells and
• This process continues for about 48 hours. Finally a thin layer
of epithelial tissue forms over the wound, which is later
This begins before the inflammatory phase ends and
lasts for about 2 to 5 days.
Macrophages continue its cleaning process and
stimulate the formation of fibroblast.
This phase begins with the appearance of the new
blood vessels and lasts from 3 to 24 days. Fibroblasts
appear alongside the capillaries. These two together
constitute the granulation tissue.
Subsequently there is epithelization. All the cells
forming the surface epithelium undergoes rapid
division and migrates as a thin film covering the
The wound appears pink owing to the new capillaries
in the granulation tissue and the area is soft and
This final phase may take more than one year there
is scar formation by the fibroblasts. The capillaries
and lymphatic endothelial buds in the new tissues
disappear and the scar then shrinks. The collagen
scar continues to regain strength over several
FACTORS AFFECTING HEALING PROCESS
Extent of the injury
Necrosis or Gangrene
Interference with organ function
DEFINITION OF WOUND DRESSING
It is a sterile protective covering applied to a
wound/incision with aseptic technique with or without
TYPES OF DRESSINGS
Dressings are vary by type of material and mode of
Non-adherent gauze dressings
Self-adhesive transparent film
PURPOSES OF WOUND DRESSINGS
To prevent infection.
To prevent further tissue damage.
To promote healing.
To absorb inflammatory exudate and to promote drainages.
To convert the contaminated wound into a clean wound.
To prevent hemorrhage.
To prevent skin excoriation.
To apply medication in place.
To restore the function of the part.
To provide physical and mental comfort to the patient.
To promote thermal insulation to the wound surface area.
To provide maintenance of high humidity between the wound and
PRINCIPLES INVOLVED IN WOUND
Micro-organisms are present in environment, on the
articles and on the skin. Pathogenic organisms are
transmitted from the source to the new host directly or
Bacteria travel along with the dust particles.
Cleaning the area where there is less number of
organisms, before cleaning an area where there is more
organisms. Minimize the spread of organisms to the clean
A break in the skin and mucus membrane acts as the
portal of entry for the pathogenic organisms.
Respiratory tract harbors micro-organisms that can enter
Nutrients and oxygen are carried to the wound via blood
stream and are essential for collagen formation.
Moisture facilitates growth and movement of micro-
Fluid moves downwards as a result of gravitational pull.
Fluids move through materials by capillary action.
Unfamiliar situations produce anxiety.
Systematic ways of working saves time, energy and
GENERAL INSTRUCTIONS FOR THE WOUND
Practice strict aseptic technique to prevent cross infection to the
wound and from the wound. All materials touching to the wound
should be sterile.
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 by the sterilization with
steam under pressure.
Wash hands thoroughly before and after procedure.
Instruments used for one dressing can not be used for another until
they have been re-sterilized.
Use masks, sterile gloves and gowns for large dressings to minimize
the wound contamination.
Dressings are not changed for at-least 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.
Use individually wrapped sterile dressings and equipment 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.
Create a sterile field around the wound by spreading sterile towels.
Avoid talking, coughing and sneezing when the wound is opened.
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.
Cleaning of the wound should be done from the most clean 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 center to the periphery.
When cleaning the circular wound, start from the center of the wound and go
to the periphery. When cleaning a linear wound, the first swab cleanses the
wound line and the subsequent swabs cleanse the skin on either side of the
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.
When dressing the wound, keep the wound edges as near as possible to
When drains are in place, anticipate drainage and re-enforce the dressings
accordingly. The dressings over the drains should not combined with the
dressings on the wound line. This enables a nurse to change the dressings over
the drains without disturbing the wound dressings and thereby minimizing the
The amount of discharge from the wound should be accurately
measured by recording the number and size of the dressings
changed. Note the colour, odour, amount and consistency of
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.
Before doing the dressings, inspect the wound for any
complications such as dehiscence and evisceration. If present,
report it immediately to the surgeon and immediate steps are to
Avoid meal timing.
Give an analgesics prior to the painful dressings.
PREPARATION OF ARTICLES
A sterile tray containing
Artery forceps - 1 To clean the wound
Dissecting forceps – 2
Scissors - 1 For the debridement of the wound if
necessary or to cut the gauze pieces to fit
around the drainage tubes etc.
Sinus forceps - 1 To open the sinus tract or to pack the sinus
tract if necessary.
Small bowl - 1 To take the cleaning solution.
Safety pins - 1 To fix the drain in case the drains are cut
Gloves, mask and gown To use when large wounds are dressed.
Cotton balls, gauze pieces, cotton pads etc.
To clean and dress the wound.
Slit or dressing towel To create a sterile field around the wound.
An unsterile tray containing
Cleaning solution as necessary To clean the wound and surrounding skin
Ointment and powders as ordered To apply on the wound.
Vaseline gauze in sterile containers To prevent the dressing adhering to the
Ribbon gauze in sterile containers To pack the sinus tract or a penetrating
Swab stick in a sterile containers To apply the medication if necessary.
Transfer forceps in a sterile containers To handle the sterile supplies.
Bandages, binders, pins, adhesive
plaster and scissors
To fix the dressing in place.
A large bowl with disinfectant solution To discard the used instruments.
Kidney tray and paper bag To collect the wastes.
Mackintosh and towel To protect the bed linens.
TOPICALAGENTS FOR CLEANSING WOUND
Mercurochrome 1 to 2.5% Skin antiseptic
Tr. Iodine 1 – 2%
Normal saline/ Eusol solution
0.5 to 1%
Non irritating antiseptics used for
cleaning of wounds
Hydrogen peroxide 1.5 to 3% It is an oxidizing agent useful for
softening and removing crusted
exudate and debris.
Acetone, ether, turpentine Used for removing adhesive
marks from the skin
Check the diagnosis and the general condition of the patient.
Check the purpose for which the dressing is to be done.
Check the condition of the wound- the type of the wound, the types of suturing
applied, the type of dressing to be applied etc.
Check the physician’s order for the type of dressing to be applied and the
specific instructions, if any, regarding the cleaning solutions, removal of
sutures, drains and the application of the medications etc.
Check the patient’s name, bed number and other identification.
Check the nurse’s records to find out the general condition of the wound.
Check the abilities and limitations of the patient.
Check the consciousness of the patient and the ability to follow instructions.
Check the articles available in the unit.
PREPARATION OF THE PATIENT AND
Identify the patient and explain the procedure to win his
confidence and co-operation.
Provide privacy with curtains and drapes.
Apply restraints in case of children.
As far as possible avoid meal timings. The dressings may
be done either one hour before of the meals or after meals.
Offer bedpan or urinal prior to the dressing.
Give some analgesics if the patient is in pain.
See the cleaning of the room is done at least one hour
before the expected time of the dressing.
Shave the areas if necessary. Removal of adhesive is more painful
if hair is present.
Placed the patient in a comfortable position and relaxed position
depending on the area to be dressed.
Give proper support to the body parts to the body parts if the
patient has to raise and hold it in position for considerable time.
See that patient’s room is in order with no unnecessary articles.
Clear the bedside table, so that there is sufficient space to set up a
sterile field and to arrange needed supplies and equipment.
Close the doors and windows to prevent drafts. Put off fan.
Adjust the height of the bed for the comfortable working of the
doctors and nurses so that they have neither to stop nor over
reach to do the dressing. Bring the patient to the edge to the
bed. Call for assistance if necessary.
Protect the bed with a mackintosh and towel.
Fold back the upper bedding towards the foot end of the bed
leaving a bath blanket or sheet over the patient. Expose the part
Untie the bandage or adhesive and remove them. Make sure
that the dressing is not removed from it place until the nurse is
ready to do dressing.
Turn the head of the patient to one side, so that the patient may
not see the wound and get worried about it.
STEPS OF THE PROCEDURE
Steps of the procedure Reason
Tie the mask To prevent wound contamination with
Wash hands thoroughly To prevent cross infection
Put on gown (if necessary), gloves To ensure asepsis
Open the sterile tray. Spread the sterile
towel around the wound
To create a sterile field around the wound
Pick up a dissecting forceps and remove
the dressings and put into kidney. Discard
the dissecting forceps in the bowl of
To prevent contamination of the hands with
soiled dressings. If the dressing is adherent
to the wound, pour physiologic saline and
wet it before removal.
Note the type and amount of drainage
Ask the assistant to pour small amount of
cleansing solution into the bowl.
To prevent contaminating the hands of the
nurse by the outside of the bottle.
Clean the wound from center to
periphery discarding each swab after
Cleaning the wound 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
After thoroughly cleaning of the wound,
dry the wound with dry swabs using the
same precautions. Discard the forceps in
the bowl of lotion.
To keep the wound as dry as possible.
Apply medications if ordered. To apply the ointment directly to the wound
may be difficult. Apply a small portion on
the dressing that goes directly over the
Apply the sterile dressings. Apply the
gauze pieces first and then the cotton
pads. Reinforce the dressing on the
dependent parts where the drainage
Cotton placed directly onto the wound
may stick on the wound, when the
Reinforcing the dressing will prevent
oozing of the drainage onto the bed of
Remove the gloves and discard it into
the bowl with lotion.
Gloves worn during the dressing will be
Secure the dressings with bandage or
AFTER CARE OF THE PATIENT AND ARTICLES
Help the patient to dress up and to take comfortable
position in the bed. Change the garments if soiled with
Replace the bed linen.
Remove the mackintosh and towel.
Take all articles to the utility room. Discard the soiled
dressing 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 them for
autoclaving. Replace all other articles to their proper
places. Send the soiled linen to the laundry bag for the
washing (remove blood stains before sending them).
Record the procedure on nurse’s record with date
and time. Record the condition of the wound, type
and amount of drainage, condition of the sutures etc.
on the nurse’s record. Report to the surgeon if any
Return to the bedside to assess the comfort of the
patient. Special instruction in the care of the wound
are to be communicated to the patient.
Tidy up the bed and unit of the patient.