Prepared by Miss Aisha Al-hofaian Supervised by Dr.Gehan Wound dressing Prepared by Miss Aisha Al-hofaian Supervised by Dr.Gehan

Purpose 1- To promote wound healing by primary intention . 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.

Types of dressings Dry - to – dry : Used primarily for wounds closing by primary intention. Layer of wide mesh cotton gauze lies next to the wound surface , second layer of dry absorbent cotton to protect the wound

Types of dressings Wet – to – dry : These are particularly useful for untidy or infected wounds that must be debrided and closed by secondary intention Layer of wide mesh cotton gauze saturated with saline next to wound surface ,second layer of moist absorbent with same solution to debride the wound

Cont.. Wet –to – damp : Variation of wet to dry dressing . Wet – to wet : Used in clean open wounds. 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 .

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 …) .

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

Implementation Preparation 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 .

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

4- Remove binder and tape -remove binder if used and place them aside . - 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 .

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 proof 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.

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 .

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 .

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.

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 .

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

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 .

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 .