The objective of dressing wounds is to promote healing. The procedure includes cleaning, disinfection and protection of the wound while respecting the rules of hygiene.

1. Chapter-22
Dressing procedure for nursing officer working in health care
setting
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

2. 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.
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.

3. 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

4. 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

5. Purpose: to collect the wastes
10. Mackintosh and towel
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.

6. 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

7. 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.Return to the bedside to assess the comfort of the patient. Special instruction in the care of the

8. wound care to be communicated to the patient.
Tidy up the bed and the unit of the patient.
Documentation :
Recording and reporting :
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.
SURGICAL DRESSING –
1. Purpose,
2. Type of Dressing,
3. General Instructions,
4. Procedure,
5. Cleaning the Surgical Wound,
6. Dressing the Wound and After Care (Follow-up Care)
Surgical Dressing
Surgical dressing is a sterile technique used to promote wound healing. It is a protective covering
placed on the wound.
Factors Influences in Surgical Dressing
 Patient acceptance
 Ease of application/removal
 Bleeding control
 Exudate control
 Pain management
 Prevent allergic reaction/blistering
 Conformable
 Comfortable
 Cost effective
Purpose
1. To protect the wound from mechanical injury
2. To splint or immobilize the wound
3. To absorbs drainage
4. To prevent contamination from bodily discharges (feces, urine)
5. To debride the wound by combining capillary action and the end wining of necrotic tissue
and in its mesh

9. 6. To inhibit or kill microorganism by using dressings with antiseptics, antimicrobial
properties
7. To provide a physiologic environment conductive to healing
8. To provide mental and physical comfort for the patient
Type Of Dressing
Dry-to-dry Dressing
 It is used primarily for wounds closing by 1 degree intention
 Offers good wound protection, absorption of drainage and esthetics, e.g. patient provides
pressure for homeostasis
 Disadvantage – they adhere to wound surface when drainage dries, removal can cause
pain and disruption of granulation tissue
Wet-to-dry Dressing
 They are particularly useful for untidy or infected wounds that must be debride and
closed by 2-degree intension
 Gauze saturated with sterile saline or an antimicrobial solution in packed into the wound,
eliminating dead space
 The wet dressings are then covered by dry dressings
 As drying occurs, wound debris and necrotic tissue are absorbed into the gauze dressing
by capillary action
 The dressing is charged when it became dry
Wet-to-wet Dressings
 Used on clean open wounds as on granulating surfaces. Sterile saline as an antimicrobial
agent may be read to saturate the dressings
 Provide a more physiologic environment, which can enhance the local healing process as
well as ensure greater patient comfort
 Disadvantage: surrounding tissues can become macerated, the risk of infection may rise
and bed linens become damp
GENERAL INSTRUCTIONS
 The procedure of changing dressings, examining and closing the wound, use principles of
asepsis
 The initial dressing change in frequently done by the physician especially for craniotomy
orthopedic or thoracotomy procedure; subsequent dressing changes are the nurse’s
responsibility
Equipment need for dressing procedure
Sterile
 Gloves – disposable
 Scissors, forceps
 Appropriate dressing materials
 Sterile saline

10.  Cotton dipped swabs
 Culture tubes (infection)
 For draining wound add extra-gauze and packing material absorbent and pad and
irrigation set
Unsterile
 Gloves
 Plastic bag for discarded dressings
 Tape proper size and type
 Pads to protect patient bed
 Gown for nurse, if wound is infected
Procedure
Pre-preparation
 Inform the patient of dressing change. Explain procedure and have patient lie in bed
 Avoid changing dressing at mealtime
 Ensure privacy by drawing the curtains on closing the door. Expose dressing site
 Respect patient modesty and prevent patient from being chilled
 Wash hands thoroughly
 Place dressing supplies on a clean, flat surface
 Place clean towel or plastic bag under part of the body where wound is located
 Cut off pieces of tape to be. Used in dressing change
 Place disposable bag nearby to collect soiled dressings
 Determine what types of dressing are necessary
Cleaning The Surgical Wound
 Use aseptic technique
 Open package of sterile gloves; open sterile cleaning sterile supplies
 Wear sterile gloves
 Clean along wound edges using a small circular motion from one end of incision to the
other do not scrub back and forth across the incision line
 Sterile saline in the cleansing agent of choice. Topical antiseptics (alcohol, basic a may
be used on intact skin surrounding the wound but should never be used within the wound)
 Repeat same process with drain site separately
 Discard used cleaning supplies in disposable
 Pad the incision site and drain site dry with sterile dressing sponge
Dressing The Wound
 Maintain asepsis with use of sterile gloves
 After wound in dry apply appropriate dressing
 Tape dressing, using only the amount of tape required for secure attachment of dressing
Use premade drain sponge (can be prepared by making 5 cm slit with sterile scissors in 4
multiply 4 inches gauzes sponge)

11. Dressing the drainage tube insertion tube:
Dressing the drainage tube insertion tube: be sure that one sponge in place at a right angle to the
second sponge. So the slits are going in different direction if drainage in heavy, a sterile
absorbent pad or extra gauze may be placed overall
 When dressing an excessive draining wound.Consider need for extra dressings and
packing materials
 Use Montgomery straps if frequent dressing are required
 Protect skin surrounding wound from copious on irritating drainage by applying some
type of skin barriers
After Care (Follow-Up Care)
 Assess patient’s tolerance to the procedure and help patient more comfortable
 Discard disposable items according to hospital protocol and clean equipment that is to be
recessed
 Wash hands
 Record nature of procedure and condition of wound, as well as patient reaction
WOUND CARE – NURSING PROCEDURE
WOUND CARE –
Content of the subjects:
1. Definition,
2. Types,
3. Wound Healing,
4. Wound Dressing,
5. Equipment and
6. Procedure
INTRODUCTION :
A wound is a break in the continuity of an external or internal surface caused by physical means.
Wounds can be accidental or intentional (as when the physician makes an incision during a
surgical operation). There are two basic types of wounds: closed and open.
DEFINITION
Wound care: wound care is defined as cleaning, monitoring and promoting healing in a wound
that is closed with sutures, clips or staples.

12. Wound: an injury to living tissue caused by a cut, blow, or other impact, typically one in which
the skin is cut or broken
Surgical or wound dressing: sterile dressing covering applied to a wound or incision using
aseptic technique with or without medication.
WOUND TYPES
A closed wound involves an injury to the underlying tissues of the body without a break in the
skin surface or mucous membrane; an example is a contusion, or bruise.
A contusion results when the tissues under the skin are injured and is often caused by a blunt
object. Blood vessels rupture, allowing blood to seep into the tissues, which results in a bluish
discoloration of the skin. After several days, the color of the contusion turns greenish yellow as a
result of oxidation of blood pigments
Bruising commonly occurs with injuries such as fractures, sprains, strains and black eyes. Open
wounds involve a break in the skin surface or mucous membrane that exposes the underlying
tissues; examples include incisions, lacerations, punctures, and abrasions.
An incision is a clean, smooth cut caused by a sharp instrument, such as a knife, razor, or piece
of glass. Deep incisions are accompanied by profuse bleeding; in addition, damage to muscles,
tendons, and nerves may occur.
A laceration is a wound in which the tissues are torn apart, rather than cut, leaving ragged and
irregular edges. Lacerations are caused by dull knives, large objects that have been driven into
the skin, and heavy machinery. Deep lacerations result in profuse bleeding and a scar often
results from the jagged tearing of the tissues.
A puncture is a wound made by a sharp-pointed object piercing the skin layers, for example, a
nail, splinter, needle, wire, knife, bullet, or animal bite. A puncture wound has a very small
external skin opening, and for this reason bleeding is usually minor. A tetanus booster may be
administered with this type of wound because the tetanus bacteria growth best in a warm
anaerobic environment, such as the one in a puncture.
An abrasion or scrape is a wound in which the outer layers of the skin are scraped or rubbed off,
resulting in oozing of blood from ruptured capillaries. Abrasions are often caused by falling on
gravel and floors (floor burn). These falls can result in skinned knees and elbows.
WOUND HEALING
The skin is a protective barrier for the body and is considered its first line of defense. When the
surface of the skin has been broken, it is easy for microorganisms to enter and cause infection.
The body has a natural healing process that works to destroy invading microorganisms and to
restore the structure and function of damaged tissues.

13. PHASES OF WOUND HEALING
Phase 1: Phase 1, is also called the inflammatory phase, begins as soon as the body is injured.
This phase lasts approximately 3 to 4 days. During this phase, a fibrin network forms, resulting
in a blood clot that “plugs” up the opening of the wound and stops the flow of blood.
The blood clot eventually becomes the scab. The inflammatory process also occurs during this
phase. Inflammation is the protective response of the body to trauma, such as cuts and abrasions,
and to the entrance of foreign matter, such as microorganisms. During inflammation, the blood
supply to the wound increases, which brings white blood cells and nutrients to the site to assist in
the healing process.
The four local signs of inflammation are redness, swelling, pain and warmth. The purpose of
inflammation is to destroy invading microorganisms and to remove damaged tissue debris from
the area so that proper healing can occur.
Phase 2: Phase 2 is also called the granulation phase and typically last 4 to 20 days. During this
phase, fibroblasts migrate to the wound and begin to synthesize collagen. Collagen is a white
protein that provides strength to the wound. As the amount of collagen increases, the wound
becomes stronger, and the chance that the wound will open decreases. There also is a growth of
new capillaries during this phase to provide the damaged tissue with an abundant supply of
blood. As the capillary network develops, the tissue becomes a translucent red color. This tissue
is known as granulation tissue. Granulation tissue consists primarily of collagen and is fragile
and shiny and bleeds easily.
Phase 3: Phase 3, is also known as the maturation phase, begins as soon as granulation tissue
forms and can last for 2 years. During this phase, collagen continues to be synthesized, and the
granulation tissue eventually hardens to white scar tissue. Scar tissue is not true skin and does
not contain nerves or have a blood supply. The medical assistant should always inspect the
wound when providing wound care. The wound should be observed for signs of inflammation
and the amount of healing that has occurred. This information should be charted in the patient’s
record.
WOUND DRESSING
Purpose of Dressing
 Provide physical, psychological and aesthetic comfort
 Remove necrotic tissue
 Prevent, eliminate or control infection
 Absorb drainage
 Maintain a moist wound environment
 Protect the wound from further injury
 Protect the skin surrounding the wound
 Promote homeostasis as in a pressure dressing

14.  Prevent contamination from feces, urine, vomitus, etc
 For splinting or immobilization of wound
Major Principles for Wound Dressing
 Uses standard precautions at all times
 When using a swab or gauze to cleanse a wound, work from the clean area out toward the
dirtier area. (Example: when cleaning a surgical incision, start over the incision line, and
swab downward from top to bottom). Change the swab and proceed again on either side
of the incision, using a new swab each time.
 When irrigating a wound, warm the solution to room temperature, preferably to body
temperature, to prevent lowering of the tissue temperature. Be sure to allow the irrigant to
flow from the cleanest area to the contaminated area to avoid spreading pathogens.
TYPES OF DRESSING
 Dry dressing: clean wounds are dressed by the application of 4 to 8 layers of gauze folded
into suitable size and shape. The surrounding of the wound is cleansed by some antiseptic
and dried and dry dressing is applied after the application of medicine to the wound.
 Wet dressings: it is used if wounds are infected and if there is pus. The wet dressing
compresses the hot, it stimulated the supportive process. The dressing is made of many
layers of gauze or cotton pad covered with gauze.
 Pressure dressing: it is done when there is bleeding or oozing from the wound. The
dressing consists thick pad of sterile gauze applied over the wound with a firm bandage
and binder
GENERAL INSTRUCTIONS
1. Maintain aseptic technique to prevent cross infection to the wound and to the ward
2. All the material touching the wound should be sterile
3. Wash hands before and after each dressing top avoid cross infection
4. All articles should be disinfected thoroughly, so that they will be free from pathogens
5. Use masks, sterile gloves and gown for large dressing to minimize the wound
contamination
6. Dressing is changed at least 15 minutes after the room has been cleaned and avoid meal
timings
7. Clean wound should be dressed before infected or discharging wounds
8. Wounds that are draining freely should be dressed frequently, according to the doctor’s
order
9. Avoid coughing, sneezing and talking when the wound is opened
10. While dressing avoid contamination with patients skin. Clothing and bed linen with
soiled instruments and dressings
11. Clean the wound from cleanest area to the less clean area, e.g. clean the wound from its
center to the periphery
12. If the dressings are adherent to the wound due to drying of the secretions or blood, wet it
with normal saline before it is removed from the wound
13. While dressing, keep the wound edges as near as possible to promote healing
14. Measure the amount of discharge from the wound. Note the color, amount and
consistency of the drainage

15. 15. Before doing the dressing, inspect the wound for any complication and if it is present,
report immediately to avoid further complications
PRELIMINARY ASSESSMENT
 Check the doctor’s order for specific instructions
 Identify the correct patient, bed number and general condition
 Check the nurse’s record to note the condition of the wound in previous dressing
 Check the abilities of the patient for self-help understanding and limitation
 Check the availabilities of the articles
EQUIPMENT
A sterile tray containing:
 Artery forceps: 1
 Dissecting forceps: 2
 Scissors: 1
 Sinus forceps: 1
 Probe: 1
 Small bowl: 1
 Safety pin: 1
Gloves, masks and gowns, cotton balls, gauze pieces, cotton pads, and site or dressing towels.
A trolley containing: cleaning solutions as necessary, ointments and powders as ordered,
Vaseline gauze in sterile containers, roller gauze in sterile container, chittle forceps in a solution,
sterile gauze, cotton and pad drum, bandages, adhesive plaster, pins and scissors, mackintosh and
draw sheet, kidney tray and covered bucket to put soiled dressing.
PROCEDURE
 Explain the procedure to the patient, using sensory preparation
 Inspect the wound for redness, swelling or signs of dehiscence or evisceration
 Observe the characteristics of any drainage
 Clean the area around the wound with an appropriate cleansing solution
 Swab from clean area towards the less clean area (clean the wound from the center to
periphery)
 Apply medications if ordered
 Apply sterile dressing – apply gauze pieces first and then the cotton pads
 Remove the gloves and discard it into the bowel with lotion
 Secure the dressing with bandage or adhesive tapes
DRESSING TECHNIQUES

16. The following dressing techniques are easy to do and require on sophisticated equipment. Clean
technique is usually sufficient. Pain medication may be required as dressing changes can be
painful. Gently cleanse the wound at the time of dressing change
Wet-to-Dry
 Indication: to clean a dirty or infected wound
 Technique: moisten a piece of gauze with solution and squeeze out the excess fluid. The
gauze should be damp, not soaking wet. Open the gauze and place it over top of the
wound to cover. You do not need many layers of wet gauze. Place a dry dressing over
top. The dressing is allowed to dry out and when it is removed it pulls off the debris. It’s
ok to moisten the dressing if it is too stuck.
 How often: ideally, 3-4 times per day, more often on a wound in need of debridement,
less often on a cleaner wound. When the wound is clean, change to a wet-to-wet dressing
or an antibiotic ointment
Wet-to-Wet
 Indication: to keep a wound clean and prevent buildup of exudates
 Technique: moisten a piece of gauze with solution and just barely squeeze out the excess
fluid so it is not soaking wet. Open the gauze and place it over top of the wound to cover
it. Place a dry dressing over top. The gauze should not be allowed to dry or stick to the
wound
 How often: ideally, 2-3 times a day. If the dressing gets too dry, pour saline over the
gauze to keep it moist
 Antibiotic ointment: antibiotic ointment is used to keep a wound clean and promote
healing
 Technique: apply ointment to the wound – not a thick layer; just a thin layer is enough.
Cover with dry gauze
 How often: 1-2 times per day
PROCEDURE OF WOUND/SURGICAL DRESSING
 Position the patient comfortably
 Expose the dressing site
 Instruct not to touch wound, equipment or dressing

17.  Wash hands
 Open dressing pack
 Transfer extra cotton balls and gauze pieces into the dressing pack if the wound is large
 Pour cleaning solution into the dressing cup
 Cover the pack without contaminating the inner layer
 Place dressing mackintosh and towel under the part and place clean K-basin over
mackintosh
 Remove outer dressing
 Use ether to remove adherent adhesive
 Leave the inner dressing if it does not come out with outer dressing
 If wound drain is present, remove one layer at a time
 Do surgical hand washing
 Wear gloves if the wound is contaminated
 Flip open the dressing pack cover by inserting fingers in the inner layer of the wrapper
 Using thumb forceps, pick up cotton ball and wet it in saline
 Using artery clamp and thumb forceps, soak adherent gauze squeezing the cotton ball
over the gauze
 Using the same artery clamp, remove the gauze and dispose in the plastic bag
 Discard the artery clamp
 Observe the character and amount of drain and assess the condition of the wound
 Use only thumb forceps to pick up cotton balls
 Pick up cotton balls every time using only the thumb forceps and soak in cleaning
solution
 Squeeze out excess solution from the cotton balls into the kidney basin (sterile)
 Clean the wound (clean to dirty) with firm stroke using the artery clamp
 Discard used cotton balls into the clean K-basin
 Use only one cotton ball for each stroke
 Ensure wound is thoroughly cleaned
 Finally, clean the skin is proximity to the wound edge, with strokes away from the wound
 Soak gauze piece in the dressing solution, squeeze out excess solution, spread it keeping
it over the sterile field
 Apply over the wound, fully covering the wound with medicated gauze pieces
 Apply dry gauze pieces over the medicated gauze pieces
 Apply pad if the wound is large or lot of exudates is present in the wound
 Discard gloves if used
 Discard the used artery clamp and thumb forceps into the clean K-basin
 Secure dressing with adhesive/bandage
AFTER CARE
 Assist the patient to dress up and to take a comfortable position
 Change the garments if soiled with drainage
 Remove the mackintosh and towel. Replace the bed linen
 Take all articles to the utility room. Discard the soiled dressing into a covered container
and send for incineration
 Wash hands and record the procedure on the nurse’s record with date and time
 Teach the patient/family about wound care and signs and symptoms of infection

18. PATIENT EDUCATION
Explain the following to the patient regarding wounds:
 The type of wound that the patient has: incision, laceration, puncture, or abrasion
 The purpose of suturing the wound: to close the skin and protect against further
contamination, to facilitate healing, and to leave a smaller scar
 If a tetanus toxoid has been administered, explain the purpose of this immunization: to
protect against tetanus (lockjaw)
 Teach the patient how to care for the wound, as follows:
 Keep the dressing clean and dry. If it becomes wet, contact the medical office to schedule
a sterile dressing change
 Apply an ice bag for swelling (if prescribed by the physician)
 Report immediately any signs that the wound is infected. These signs include the
following:
 Fever
 Persistent or increased pain, swelling or drainage
 Red streaks radiating away from the wound
Increased redness or warmth
 Notify the doctor’s office if the sutures become loose or break
 Return as instructed by the physician for the removal of sutures
 Teach the patient how to apply an ice bag (if prescribed by the physician)