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 type 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 cleaning 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 record to find out the general condition of the wound.
7.
Check the consciousness of the patient and the ability to follow instructions
8.
Check the articles available in the unit
Preparation of the articles
Articles:
A
sterile tray containing
1.
Artery forceps-1
2.
Dissecting forceps-2
3.
Scissors-1
4.
Sinus fcrceps-1
5.
Probe-1
6.
Small bowl-1
7.
Safety pin-1
8.
Gloves , masks and growns
9.
cotton balls, gauze pieces , cotton
pads etc as necessary
Clean tray
containing
1.
Cleaning solutions as necessary.
2.
Ointment and powders as ordered.
3.
Vaseline gauze in sterile containers
4.
Ribbon gauze in sterile containers
5.
Swab sticks in a sterile container
6.
transfer forceps in a sterile
container
7.
Bandages, binders, pins adhesive
plaster and scissors.
8.
A large bowl with disinfectant
solution.
9.
Kidney tray
and paper bag
10.
Mackintosh and towel.
Purpose:
1.
To clean the wound and the
surrounding skin area.
2.
For the debridement of the wound, if
necessary or to cut the gauze pieces to fit around the gauze etc.
3.
To open the sinus tract or to pack
the sinus tract if necessary.
4.
To take the cleaning solutions.
5.
To fix the drain in case the drains
are cut short.
6.
To use when large wounds are
dressed.
7.
To create a sterile field around the
wound.
8.
To clean the wound and the
surrounding skin area.
9.
To apply on the wound.
10.
To prevent the dressing adhering to
the wound.
11.
To pack a sinus tract or a
penetrating wound.
12.
To apply the medications if
necessary.
13.
To handle the sterile supplies.
14.
To fix the dressing in place
15.
To discard the used instruments.
16.
To collect the waste.
17.
To protect the bed garments.
Preparation of the patient:
1.
Identify the patient and explain the
procedure to get his confidence and co-operation.
2.
Explain the sequence of the
procedure and tell the patient how he can co-operate during the procedure.
3.
Provide privacy with curtains and
drapes.
4.
Apply restraints, in case of
children.
5.
As far as possible, avoid -meal
timings; the dressings may be done either one-hour before the meal or after
meal.
6.
Offer bedpan or urinal prior to the
dressing.
7.
Give some analgesics if the patient
is in pain e.g., before dressing an extensive burned wound.
8.
See that the cleaning of the room is
done at least one hour before the expected time of the dressing.
9.
Shave the area if necessary.
10.
Removal of the adhesive is more
painful if the hair is present. So the shaving should be done before the first
dressing is applied.
11.
Place the patient in a comfortable
and relaxed position depending on the area to be dressed.
12.
Give proper support to the body
parts, if the patient has to raise and hold it in a position for a considerable
time.
13.
See that the 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
equipments.
14.
Close the doors and windows to
prevent drafts. Put off the fan.
15.
Bring the patient to the edge of
file bed.
16.
Call for assistance if necessary
e.g., to do the unsterile procedures, to transfer sterile supplies etc.
17.
Protect the bed with a mackintosh
and towel.
18.
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.
19.
Untie the bandage or adhesive and
remove them. Make sure that the dressing is not removed from its place until
the nurse is ready to do the dressing (after washing her hands).
20.
Turn the head of the patient to one
side, so that the patient may not see the wound and get worried about it.
Procedure:
1.
Wear the mask to prevent wound
contamination with droplets.
2.
Wash hands thoroughly to prevent
cross infection
3.
Put on gown, gloves etc as necessary
to ensure asepsis.
4.
Open the sterile tray. Spread the
sterile towel around the wound to create a sterile field around the wound.
5.
Pick up a dressing forceps and
remove the dressings and put it in the paper bag. Discard the dissecting
forceps in the bowl of lotion to prevent contamination of the hands with the
soiled dressings. (if the dressing is adherent to the wound, pour 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 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. Cleaning should be done
from 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
wounds dry the wound with dry swabs using the same precautions.
10.
Discard the forceps in the bowl of
lotion to keep the wound as dry as possible.
11.
Apply medications if ordered and to
apply the ointment directly to the wound may be difficult. Apply a small
portion on the dressing that goes directly over the wound.
12.
Apply the sterile dressings. Apply
the gauze pieces first and then the cotton pads. Cotton placed onto the wound
may stick on to the wound when the discharge dries.
13.
Reinforce the dressings on the
dependent parts where the drainage may collect. Reinforcing the dressing will
prevent oozing of the drainage onto the bed of the patient.
14.
Remove the gloves and discard it
into the bowl with lotion. Gloves worn during the dressing will be highly
contaminated.
15.
Secure the dressings with bandage or
adhesive tapes.
16.
Removal of the drains or sutures
should be done after the cleaning of the wound area.
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.
5.
Discard the soiled dressings into a
covered container and send for incineration.
6.
Remove the instruments and other
articles from the disinfectant solution and dean them thoroughly.
7.
Dry them.
8.
Re-set the tray and send for
autoclaving. Replace all other articles to their proper places.
9.
Send the soiled linen to the laundry
bag for washing (Remove the blood stains before sending them to dhobi).
10.
Wash hands.
11.
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' s record. Report
to the surgeon any abnormalities.
12.
Return to the bedside to assess the
comfort of the patient. Special instructions in the care of the wound are to be
communicated to the patient.
13.
Clean the bed and the unit of the
patient
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