Krystal Gail Consumo Llanora

Victoria Healthcare Clinic

March 2, 2011

INTRODUCTION
Wound care is very important part of
Nursing procedure in any health care
setting. Wound come in all sizes and
forms, and each one offers unique
challenges to infection prevention.
Wound is a type of injury in which a skin
is torn, cut or punctured (open wound)
or where blunt force trauma causes
contusion (closed wound).

INTRODUCTION
Dressing is an adjunct used by a person for
application to a wound to promote
healing and/or prevent further harm. A
dressing is designed to be in direct
contact with wound, which makes it
different from a bandage, which is
primarily used to hold a dressing in place.

CORE PURPOSES OF A DRESSING:

A dressing can have a number of
purposes, depending on the type,
severity and position of the wound,
although all purposes are focused
towards promoting recovery and
preventing further harm from the wound.

KEY PURPOSES OF DRESSING ARE:

1. Stem Bleeding helps seal the wound
to expedite the clotting process.
2. Absorb exudates soak up blood,
plasma and other fluids exuded from
the wound, containing it in one place.
3. Ease pain some dressing may have a
pain relieving effect, and others may
have placebo effect.

KEY PURPOSES OF DRESSING ARE:

4. Debride the wound removal of
slough and foreign objects from the
wound
5. Protection from infection and
mechanical damage
6. Promote healing through granulation
and epithelialization.

CLASSIFICATION OF A WOUND:
Size of the Wound
Large wounds are more serious than
small ones, they usually involve more
severe bleeding, more damage to the
underlying organs or tissues, and
greater degree of shock.
Small wounds are sometimes more
dangerous than large ones; they may
become infected more readily due to
neglect

CLASSIFICATION OF A WOUND:
Location of the Wound since the wound
may involve serious damage to the
deeper structures, as well as to the skin
and the tissue immediately below it,
the location of the wound is important

CLASSIFICATION OF A WOUND:
Types of wounds:
Abrasions made when skin is rubbed or
scraped off. Rope burns, floor burns and
skinned knees or elbows are common
examples of abrasions. It can be infected
easily because dirt and germs may be
embedded in the tissues.
Incisions commonly called CUTS, are wounds
made by sharp cutting instruments such as
knives, razors and broken glass. It tends to
bleed freely because the blood vessels are
cut cleanly and without ragged edges.

CLASSIFICATION OF A WOUND:
Types of wounds:
Lacerations wounds are torn rather than cut.
They have ragged, irregular edges and
masses of torn tissue underneath. Usually
made by blunt, rather than sharp objects.
Punctures caused by objects that penetrates
into the tissues while leaving a small surface
opening. Wounds made by nails, needles,
wire and bullets are usually punctures.

CLASSIFICATION OF A WOUND:
Types of wounds:
Avulsions is the tearing away of tissue from a
body part. Bleeding usually heavy. In certain
situations, the torn tissue may be surgically
reattached.
Amputations is a nonsurgical removal of the
limb from the body. Bleeding is heavy and
requires a tourniquet to stop the flow. Shock
is certain to develop in these cases.

THINGS USUALLY USED WHEN DOING

WOUND DRESSING:
Sterile tray (small cup, forceps, Kelly, scissors
and etc)
Sterile gauze (melolin, urgosterile)
Vaseline gauze (urgotul)
Adhesive tape (urgosyval, urgoderm)
NaCl and Betadine
Lidocaine spray (if necessary)
Clean gloves, waste bin, under pad
Syringe (for irrigation)

STEPS TO FOLLOW FOR A WOUND

DRESSING:
(if the patient comes after an accident, call the doctor first
to assess the wound before doing wound dressing)

Check the severity and type of wound

Do the medical hand washing and put on a pair
of non-sterile gloves
Explain procedure and prepare equipments
Prepare the patient and position carefully
Clean the wound with hydrogen peroxide (you
can pour the hydrogen peroxide directly but
make sure that the tip of the container doesnt
touch the wound

STEPS TO FOLLOW FOR A WOUND

DRESSING:
(if the patient comes after an accident, call the doctor
first to assess the wound before doing wound
dressing)

Wipe the wound with sterile gauze (inside

outside direction / circular motion)
Discard the gauze in the waste bin and
continue pouring hydrogen peroxide until
you can see few bubbles from the wound.
Soak the gauze in the cup of Sodium
Chloride and wipe the wound. Remove some
blood surrounding it.

STEPS TO FOLLOW FOR A WOUND

DRESSING:
(if the patient comes after an accident, call the doctor first
to assess the wound before doing wound dressing)

After it, clean the wound with Betadine solution

Cover it with sterile gauze (if the wound is
deep, you can use compress for the blood to be
absorb well) Ex.: melolin, urgotul, urgosterile
Tape and secure the wound, make sure that the
tape is not too tight to create circulation in the
blood.
Advise patient to change dressing everyday or
depends on Doctors order.

STEPS TO FOLLOW FOR A WOUND

DRESSING:
(if the patient comes after an accident, call the doctor first
to assess the wound before doing wound dressing)

Check the order of the doctor before let the

patient go outside the room
Send the file to the cashier for payment and
make an appointment if there is a schedule for
follow up
Note the procedure youve done in the Nurses
Note (PMSI)
If the patient wants to buy some gauze or
dressing materials, inform the pharmacist

STEPS TO FOLLOW FOR A WOUND

DRESSING:
(if the patient comes after an accident, call the doctor
first to assess the wound before doing wound
dressing)

Clean the area after the procedure, return all

the equipments in the proper place, arrange
it properly and inform the housekeeper to
take the tray you used during the procedure
Make sure that all instruments inside the
tray are complete.
Wash your hands again

STEPS TO FOLLOW FOR A WOUND

DRESSING:
(wet to dry dressing, if patient return for dressing change)

Wash hand and put on a pair of non-sterile

gloves
Prepare all the equipments needed
Prepare the patient and position carefully
Carefully remove the tape
Remove the old dressing. If it is sticking to the
skin, wet it with sterile water or NaCl to loosen it
Remove the gauze pads or packing tape from
inside the wound
Throw the old dressing in the waste bin and
gloves and wash hands again

STEPS TO FOLLOW FOR A WOUND

DRESSING:
(wet to dry dressing, if patient return for dressing
change)

Put on a new pair of non-sterile gloves

Check the wound for signs of infection
(redness, swelling, pus, warm to touch, bad
odor, drainage that is darker or thicker) if
you suspect infection call Doctor first to
recheck the wound before cleaning it
You should not bleed much when cleaning it,
but small amount of blood is okay.
Pour saline into a clean bowl

STEPS TO FOLLOW FOR A WOUND

DRESSING:
(wet to dry dressing, if patient return for dressing change)

Place gauze pads into the bowl, squeeze the

saline from the gauze pads until it is no longer
dripping.
Gently clean the wound using aseptic technique.
Put betadine after and cover the wound using
gauze pack and tape
Put all used supplies in the waste bin and clean
the area, return all the equipments thats being
used, removed gloves and wash hand

STEPS TO FOLLOW FOR A WOUND

DRESSING:
(wet to dry dressing, if patient return for dressing
change)

Order dressing change (simple/complicated)

in the PMSI
Send patient file to the cashier for payment
and record the procedure youve done in
PMSI (Nurses Notes)
(if the patient has surgical incision, inform the
patient when to come back for removal of
suture)

STEPS TO FOLLOW FOR A WOUND

DRESSING:
(when to call the Doctor)
More redness
More pain
Swelling
Bleeding
The wound is larger or deeper
The wound looks dried out or dark
Temperature above 100F for more than 4 hours
Drainage coming from or around the incision or wound
and it: is not decreasing after 3 to 5 days, increasing
and becomes thick, tan or yellow or smells bad.