PROCEDURE

ON
SURGICAL DRESSING

SUBMITTED TO:
Mr. EKE Lama Tamang
HOD of Medical Surgical Nursing
Rufaida College of Nursing
SUBMITTED BY :
Sneha Sehrawat
M.Ṣc. Nursing
Ist Year
Rufaida College of Nursing
WOUND & WOUND HEALING:-

A wound is any type of injury to the skin. Wounds can be open wounds, in which
the skin is broken or torn or closed wounds. Although open wounds can bleed
and run the risk of infections, closed wounds can also be dangerous depending on
the extent of tissue damage.
Wound healing is an intricate process where the skin or other body tissue repairs
itself after injury. In normal skin, the epidermis (surface layer)
and dermis (deeper layer) form a protective barrier against the external
environment. When the barrier is broken, an orchestrated cascade of biochemical
events is quickly set into motion to repair the damage. This process is divided
into predictable phases: blood clotting (haemostasis), inflammation, the growth
of new tissue (proliferation), and the remodelling of tissue (maturation).
Sometimes blood clotting is considered to be part of the inflammation stage
instead of its own stage.

 Haemostasis (blood clotting): Within the first few minutes of

injury, platelets in the blood begin to stick to the injured site. This activates
the platelets, causing a few things to happen. They change into an amorphous
shape, more suitable for clotting, and they release chemical signals to promote
clotting. This results in the activation of fibrin, which forms a mesh and acts
as "glue" to bind platelets to each other. This makes a clot that serves to plug
the break in the blood vessel, slowing/preventing further bleeding.
 Inflammation: During this phase, damaged and dead cells are cleared out,
along with bacteria and other pathogens or debris. This happens through the
process of phagocytosis, where white blood cells "eat" debris by engulfing
it. Platelet-derived growth factors are released into the wound that cause the
migration and division of cells during the proliferative phase.
 Proliferation (growth of new tissue): In this
phase, angiogenesis, collagen deposition, granulation tissue formation,
epithelialisation, and wound contraction occur. In angiogenesis, vascular
endothelial cells form new blood vessels. In fibroplasia and granulation tissue
formation, fibroblasts grow and form a new, provisional extracellular
matrix (ECM) by excreting collagen and fibronectin. Concurrently, re-
epithelialization of the epidermis occurs, in which epithelial cells proliferate
and 'crawl' atop the wound bed, providing cover for the new tissue. In wound
contraction, myofibroblasts decrease the size of the wound by gripping the
 wound edges and contracting using a mechanism that resembles that in
smooth muscle cells. When the cells' roles are close to complete, unneeded
cells undergo apoptosis.
 Maturation (remodeling): During maturation and remodeling, collagen is
realigned along tension lines, and cells that are no longer needed are removed
by programmed cell death, or apoptosis.
The wound healing process is not only complex but also fragile, and it is
susceptible to interruption or failure leading to the formation of non-
healing chronic wounds. Factors that contribute to non-healing chronic wounds
are diabetes, venous or arterial disease, infection, and metabolic deficiencies of
old age.
Wound care encourages and speeds wound healing via cleaning and protection
from reinjury or infection.
TYPES OF HEALING
There are three types of healing, distinguished by just how much skin and tissue
has been lost:
1. Primary Intention Healing – This occurs where the tissue surfaces have
been approximated (closed). This can be with stitches, or staples, or skin
glue (like Derma bond), or even with tapes (like steri-strips). This kind of
closure is used when there has been very little tissue loss. It is also called
“primary union” or “first intention healing.” An example of wound
healing by primary intention is a surgical incision.
2. Second Intention Healing – A wound that is extensive and involves
considerable tissue loss, and in which the edges cannot be brought
together heals in this manner. This is how pressure ulcers heal. Secondary
intention healing differs from primary intention healing in three ways:
o The repair time is longer.
o The scarring is greater.
o The chances of infection are far greater.
3. Tertiary Intention Healing – This type of wound healing is also known
as “delayed” or “secondary closure” and is indicated where there is a
reason to delay suturing or closing a wound some other way, for example
when there is poor circulation to the injured area. These wounds are
closed later.
Wounds that heal by tertiary intention require more connective tissue (scar
tissue) than wounds that heal by secondary intention. An example of a wound
healing by tertiary intention is an abdominal wound that is initially left open to
allow for drainage but is later closed.
SURGICAL DRESSING
It is the process of cleansing an incision and applying sterile protective covering
using aseptic technique.
DRESSING
A dressing is a sterile pad or compress applied to a wound to
promote healing and/or prevent further harm. A dressing is designed to be in
direct contact with the wound, as distinguished from a bandage, which is most
often used to hold a dressing in place.
DRESSING MATERIALS

TOPICAL AGENTS FOR CLEANSING WOUNDS

 Skin antiseptic: mercurochrome 1- 2.5%
 Non-irritating antiseptics : savlon 5%, normal saline, eusol 0.5-1 %
 Oxidising agent for softening and removing crusted exudates and debris :
hydrogen peroxide 1.5-3 %
 Agents to remove adhesive marks from the skin : acetone, ether
MATERIALS FOR SECURING DRESSINGS
Dressings are secured by adhesive tapes, bandages, binders etc. The choice of the
material depends on the wound size, location, presence of drainage, frequency of
dressing changes and the client’s level of activity. The main purpose of these
materials is to keep the dressing in place. It also helps to keep the edges of the
wound together and relieves strain on the sutures.
TYPES OF DRESSING
Dressings vary by type of material and mode of application. They should be easy
to apply, comfortable and made of materials that promote wound healing.
1. GAUZE DRESSING: are the commonest. Gauze is available in different
textures and shapes e.g., in squares, rectangles and rolls of various lengths.
 2. NON-ANTISEPTIC DRESSINGS : are sterile un-medicated dressings
applied to a fresh wound to protect it from infection.
3. ANTISEPTIC DRESSINGS : are impregnated with some medication and are
applied to wounds already infected to limit the septic process.
4. WET DRESSINGS: are used in infected wounds to soften the discharge,
promote drainage and also in wounds that require debridement. It is also
used to supply heat to the tissues. Moist heat is more penetrating than dry
heat. Therefore moist heat is more beneficial in localizing the infection in
an area.
5. PRESSURE DRESSINGS: when there is danger of bleeding or when there
is oozing from the wounds, a pressure dressing may be applied. This is a
thick sterile pad made of gauze or gauze and cellulose, applied with a firm
bandage, binder.
6. NON-ADHERANT GAUZE DRESSINGS : these are used to cover clean
wounds. Telfa gauze has a shiny, non-adherant surface that does not stick to
incisions or one opening but allow drainage to pass through to the softened
gauze above.
7. SELF-ADHESIVE TRANSPARENT FILM : it acts as a temporary second
skin. This is ideal for small superficial wounds and wounds which do not
require debridement.
PURPOSES OF DRESSING
There are several purpose of dressing :
 To protect the wounds from contamination with microorganisms.
 To aid in homeostasis.
 To promote healing by absorbing drainage and debriding a wound.
 To support or splint the wound site.
 To prevent the client from visualising the wound.
 To promote thermal insulation to the wound surface.
 To provide maintenance of high humidity between the wound and dressing.
 To provide mental and physical comfort for the patient.
 ARTICLES REQUIRED
STERILE DRESSING TRAY CONTAINING:
i. Artery forceps-1 (2, for extensive or infected wounds)
ii. Thumb forcep-1
iii. Cotton swabs
iv. Gauze pieces
v. Gallipot for cleansing solution
vi. Surgical pad
vii. Kidney tray
viii. Sterile scissors

A CLEAN TRAY CONTAINING:

i. Clean gloves
ii. Sterile gloves
iii. Cleaning solution (normal saline)
iv. Ordered medications
v. Adhesive plaster
vi. Bandage scissors
vii. Plastic bag
viii. Mackintosh
ix. Culture tube (optional)

NOTE- for major wound dressing, a larger dressing pack with additional articles
may be required.
PROCEDURE

S. Nursing action Rationale

no
1. Identify the patient.

2. Inform patient of dressing Encourages patient co-

change, explain procedure operation.
and have patient lie in
bed.
3. Gather equipment and An organized approach will
arrange at the bedside. save time and energy.

4. Check physician’s order Clarifies type of dressing.

for dressing change and
any specific instruction.
5. Close door or curtains and Provide privacy and prevent
place waterproof pad on soiling of linen.
bed beneath area of
dressing.
6. Assist patient to Provides for comfort.
comfortable position that
provides easy access to
wound area.
7. Place opened, cuffed Reduces risk of contamination
plastic bag near working from soiled dressing and used
area. cotton balls.
8. Wash hands Reduces spread of
microorganism.
9. Loosen tape on dressing Removal of tape is easier
(if tape is soiled, don before wearing gloves
clean gloves before
loosening the tape)

10. Don clean disposable Protects nurse from

gloves and remove soiled contamination.
dressings carefully from
more clean to less clean
 area, (if dressing is Cautious removal of dressing
adherent to the skin, is less painful for the patient.
moisten it by pouring Moistened dressing is easier to
small amount of normal remove.
saline)
Reduces anxiety of patient.

Keep soiled side of

dressing away from
patient’s view.
11. Assess the amount, colour Helps for identifying the
and odour of drainage. wound healing process.
12. Discard dressing in Prevents spread of
disposal bag. Pull off microorganism.
gloves inside out and
discard in appropriate
receptacle
13. Using sterile technique, Keep supplies within easy
open sterile dressing tray reach and maintains sterility.
and arrange supplies on
work area.
14. Open cleaning solution
and pour into the sterile
gallipot/cup over the
cotton balls.
15. Don sterile gloves. Maintains asepsis.

16. Pick up soaked cotton

using artery forceps.
17. i. For a surgical wound, Moving from least to most
clean from top to bottom contaminated area prevents
or from center to outward. spread of microorganism to
less infected area.
ii. Use one cotton swab
/gauze sponge for each
wipe, discarding each by
dropping into the plastic
bag after wiping. Do not
touch the plastic bag with
forceps.
 iii. If a drain is present,
clean around it, moving
from center outward in a
circular motion.
iv. Dry the wound using
sponge in same motion
Moisture provides medium for
growth of microorganism and
drying the wound may retard
the growth of organisms and
improve healing process.

18. Apply medication ordered Additional dressing serves as a

(ointment) to the wound wick for drainage.
on a dry sterile gauze.
Apply a layer of sterile
dressing over wound.
19. Place a sterile gauze slit Drainage is absorbed and
on side under and around surrounding skin area is
the drain (use precut protected.
gauze or cut one using
sterile scissors)
20. Apply a second layer of Provides for absorption of
gauze to wound site and a wound drainage and protection
surgical pad as the outer from microorganism.
most layer.
21. Remove gloves from Tape is easier to apply after
inside out and discard in gloves have been removed.
plastic waste bag.

22. Apply adhesive tape to Medical tapes can cause

secure the dressing. injuries if used incorrectly.
 Place the tape so that
the dressing cannot
be folded back to
 expose the wound.
Place strips at the
ends of the dressing,
and space tapes
evenly in the middle.
 Ensure that the tape
is long and wide
enough to adhere to
several inches of
skin on each side of
the dressing, but not
so long or wide that
the tape loosens with
activity.
 Place the tape in the
opposite direction
from the body
action, for example,
across a body joint
or crease, not length-
wise.
23. Wash reusable articles to
be sent for sterilization
24. Wash hands, remove all Prevents spread of infection.
articles and make patient
comfortable.
25. Record and Report Provides accurate
 Report brisk, bright documentation of procedure.
red bleeding or
evidence of wound
dehiscence or
evisceration to
physician
immediately.
 Report wound and
peri-wound tissue
appearance, colour,
and tissue type and
presence and
characterist-ics of
exudates, type and
 amount of dressings
used, and tolerance
of client to
procedure.
 Record client’s level
of comfort.
 Write date and time
of dressing applied,
on tape.

CLIENT TEACHING (HOME CARE CONSIDERATIONS)

Appropriate client teaching is essential for promoting wound healing and
maintenance of healthy skin.
i. Emphasise on hygiene and medical asepsis; hand cleansing before and after
dressing changes; and using a clean area for storage of dressing supplies.
ii. Teach the client and family about proper disposal of contaminated
dressings. Advice them to dispose off contaminated items in double-
bagged moisture – proof bags.
iii. Teach, how the client may bathe with the wound ( that is, does the wound
need to be covered with a water-proof barrier or should it be cleansed in the
shower)
iv. Suggest client to use tap water instead of normal saline.
v. Teach the client and family members about the signs of complications and
to report to the physician immediately, if any, occur.
DECUBITUS ULCER / PRESSURE SORE / BED SORE
Decubitus ulcers, also known as pressure sores, are ulcerated or sloughed areas
of tissue subjected to pressure from lying on mattress or sitting on a chair for a
prolonged period of time resulting in the slowing of circulation and finally death
(necrosis) of tissues.

COMMON SITES OF BED SORE

The sites depend up on the position of the client in bed.
The pressure points in the supine position are back of the head, scapula, sacral
region, elbow and heels.
In a side lying position the pressure points are the ears, acromion process of the
shoulder, ribs, greater trochanter of the hip and ankle joint.
In a prone position, the pressure points are ears, cheek, acromion process, breast
(females), genitalia(males), knees and toes.

PREVENTION OF PRESSURE SORE

1. Identification of clients who are particularly prone to the development of
decubitus ulcer.
2. Daily examination of the decubitus prone clients for redness, discolouration
or blister on the pressure points and they should be reported and treated
immediately.
3. Keep the clients clean and dry.
4. Change the position of the client every 2 hours so that another body surface
bears weight.
5. Use a bed cradle to take off the weight of the bed linen of the client, so as
to enable him to move in bed with ease.
6. Keep the client’s skin well lubricated to prevent cracking by using powder.
7. Protect the damaged skin. Damaged skin can be further irritated and
macerated by urine, faeces, sweat etc.
 8. Provide the client with adequate fluids and with a nourishing diet that is
high in protein and vitamins.
9. Attend to the pressure points as often as necessary to stimulate circulation.
The client who are liable to bed sores must have their back treated two
hourly or more often. The back is washed with soap and warm water, dried
and massaged with powder. Avoid using excess alcohol for back rub
because it dries the skin and cause tissue damage. Attending to the back
alone is not sufficient but should include the pressure areas at the iliac
crests, ankles, heels, elbows and other pressure points.
10. Call assistance and lift the client before giving and taking bedpans. If
the bedpan is chipped, care should be taken to pad the bedpan to avoid
friction.
11. Provide a smooth, firm and wrinkle free bed on which the client can
take rest.
12. Use special mattresses and beds to decrease the pressure on body
parts, e.g. air mattresses, water mattresses etc.
13. Cut short the finger nails of the client to avoid scratching on the skin.
14. Use adequate amount of cotton under splints and plaster casts to
prevent friction.
15. Use the comfort devices to take off the pressure from the pressure
points, e.g. air cushions, cotton rings etc. Avoid using rubber rings since
they compress the area of the skin beneath them, decreasing blood supply
around the pressure points.
16. Encourage the clients to move in bed as far as it is allowed.
17. Change the linen as soon as they become wet. The back and buttocks
also must be washed, dried and rubbed with powder. After each urination
and defecation the back must be attended.
18. Teach the clients and their relatives the hygienic care of the skin.
TREATMENT OF THE DECUBITUS ULCER
The following steps are taken by the nurses.
1. Report to the sister in-charge and the physician the early symptoms of a
bedsore so that the steps may be taken as early as possible to prevent
further damage.
 2. Whenever possible, take off the pressure from the decubitus ulcers by
placing the client on pillows or foam cushions or change the position of the
client (prevent the development of a pressure sore in the new area).
3. Prevent the ulcerated area from becoming infected. Inflection will retard
healing of an ulcer. Follow strict aseptic technique.
4. A cleaning agent is used to clean the ulcerated area e.g., normal saline.
5. Apply all the possible measures for the healing of the wound.
- Heat is applied by an electric bulb (100 watt). This is placed from 45 to
60 cm away from the wound and is left in place for 10 min.
- Application of a few drops of insulin dropped from a syringe has a
healing effect on the wound. The wound is then exposed to air dry.
6. Application of waterproof ointment e.g., zinc oxide on the surface of the
wound will prevent infection of the underlying tissues. It will be of much
value in clients with incontinence of urine.
7. For Pressure Ulcers with minimal exudate, transparent films or hydrogels,
which are cross-linked polymer dressings that come in sheets or gels, are
used to protect the wound from infection and create a moist environment.
Hydrocolloids, which combine gelatin, pectin, and carboxymethylcellulose
in the form of wafers and powders, are indicated for PUs with light-to-
moderate exudates.
8. If slough is present, clean the area thoroughly twice a day with hydrogen
peroxide diluted with distilled water. If the slough is loose, the physician
may cut off the slough.
If there is delay in healing of the wound, the surgeon may debride the ulcer and a
skin graft may be applied over the ulcerated site.