Home | Nursing Practical Guideline Procedure : Wound dressing

Chapter: 11th 12th std standard Class Nursing Health Care Hospital Hygiene Higher secondary school College Notes

Nursing Practical Guideline Procedure : Wound dressing

Check the diagnosis and the general condition of the patient.

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




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.




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.




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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11th 12th std standard Class Nursing Health Care Hospital Hygiene Higher secondary school College Notes : Nursing Practical Guideline Procedure : Wound dressing |

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