SMTC Wound dressing

1. WOUND
DRESSING
Abdinasir Muhidin Abdulle
DR Sumait Hospital ICU Supervisor

2. Purpose of wound dressing
1- To promote wound healing
2- To prevent infection
3- To assess the healing process
4- To protect the wound from mechanical
trauma .
5- To absorb drainage.
6- To prevent contamination from bodily
discharge.

3. Types of dressings
Dry - to – dry :
Used primarily for wounds closing by primary
intention.
consist of dry, absorbent, gauze applied to the wound
and removed after the primary layer has absorbed
fluid and debris.

4. Types of dressings
Wet – to – dry :
Layer of gauze
saturated with
saline, second
layer of moist
absorbent with
same solution to
debride the wound.

5. Wet – to wet :
Layer of wide mesh gauze saturated with
antibacterial solution next to the wound
surface, second layer of absorbent material
saturated with the same solution to dilutes
viscous exudates .
Types of dressings

6. Assessment
1- Client allergies to wound cleaning
agents.
2- The appearance and size of the
wound .
3- The amount and character of
exudates.
4- Client complaints of discomfort.
5- The time of last pain medication .
6- Signs of systemic infection ( e.g.
.elevated in body temp , diaphoresis,
malaise …) .

7. Equipment
-Moisture proof bag (underpad) .
-Mask .
-Acetone solution to loosen adhesive .
-Clean gloves.
-Sterile gloves .
-Sterile dressing set .
-Additional supplies ( extra gauze dressing ,
and ointment if ordered .
-Tie tape.
- Normal saline or antiseptic solution .

8. Implementation
Before changing a dressing , determine any specific order
about dressing or wound.
Preparation
- Acquire assistance for changing a dressing on
restless or confused client .
- Put the client to comfortable position in which
the wound can be readily exposed ( expose
only wound area ).
- Make cuff on the moisture proof bag for
disposal of the soiled dressings and place the
bag within reach .
- Put on face mask .

9. Performance
1- Explain procedure to the client .
2- wash hands.
3- provide for client privacy .

10. - Remove tape
- If adhesive tape used
, remove it by holding
down the skin and
pulling the tape toward
the wound .
- Use solvent to loose
the tape if required .

11. 5- Remove and dispose of soiled
dressing .
- Put on clean gloves to remove outer
dressing or surgipad .
- Place outer dressing away from
client .
- Place the soiled dressing in moisture
bag without touch the outside the bag
.
- Remove the under dressing , taking
care not to dislodge any drains , if the
gauze sticks to the drains , support
the drain with one hand and remove
the gauze with other.

12. -Assess the location , type and
odor of the wound drainage and
number of gauzes saturated .
-Discard the soiled dressing in
the bag as before .
-Remove clean gloves .
- Wash hands or clean with
antiseptic solution .

13. 6- Setup sterile supplies .
- Open the sterile dressing
set using aseptic
technique .
- Place the sterile drape
beside the wound .
- Open the sterile cleaning
solution pour it over the
gauze sponges .
- Put on sterile gloves .

14. 7- Irrigate the wound :
-Instill a steady stream of irrigating
solution into the wound .
- Position the basin below the wound
to receive the irrigating
-Use either a syringe with a catheter
attached or with irrigating tip to flush
the wound
-Continue irrigating until the solution
becomes clear.
-Dry the area around the wound.

15. 8- Clean the wound .
- Clean the wound using
your gloved hands or
forceps and gauze swabs
moisture with cleaning
solutions.
-Use the cleaning method .
- Use a separate swab for
each stroke and discard
each swab after use .

16. -If drain is present , clean the skin around the drain site by swabbing
it half or circle .

17. Cont…
-Support and hold the drain erect while cleaning around .
-Dry the surrounding skin with gauze swab as required .do not dry
wound or incision itself .

18. 9- Apply dressing to the drain site and
incision.
-Place a precut 4 in 4 gauze around
drain .
-Apply the sterile dressing one at a
time over the drain and incision .
-Apply surgipad , remove gloves and
dispose of them .
-Secure the dressing with tape or tie.
- Wash your hands.
-Document the procedure and all
nursing assessment .