Nursing Care of Wounds

Purposes of Wound Care

• To prevent infection
• To prevent further tissue damage
• To promote healing
• To absorb inflammatory exudate
• To convert the contaminated wound into clean wound
• To prevent haemorrhage
• To apply medications
• To restore the functions of the part

Principles  of Wound Care

1.      Microorganisms are present in the environment, on the articles and on the skin.
2.      Bacteria travel along with the dust partricles
3.      Cleaning an area where there are less no. of organisms, before cleaning an area where there are more organisms, minimize the spread of organisms to the clean area.
4.      A break in the skin and mucus membrane acts as a portal of entry for the pathogenic organisms.
5.      Respiratory tract harbours micro organisms that can enter the wound
6.      Nutrients and oxygen are carried to the wound via blood stream and are essential for collagen formation
7.      Moisture facilitates growth and movement of microorganisms
8.      Fluid moves downwards as a result of gravitational pull
9.      Fluid move through materials by capillary action.
10.  Unfamiliar situations produce anxeity.
11.  Systematic ways of working saves time, energy and material.

Dressing materials

• Topical agents for cleansing wounds
• Mercurochrome 1-2.5%
• Tincture Iodine
• Savlon  5%
• Betadine solution
• Normal saline
• Hydrogen peroxide   1.5- 3%
• Acetone/ Ether –Used to remove the adhesive marks from the skin

Types of dressings

• Guaze dressings
• Nonantiseptic dressings
• Antiseptic dressings
• Wet dressings
• Pressure dressings
• Nonadherent  guaze dressings
• Self adhesive transparent film
• Hydrocolloid and hydrogen dressing

General instructions for the wound dressing

• Practice strict aseptic technique
• Use sterile articles
• Wash hands
• Use masks, gloves  and gown
• Dressings are not changed for at least 15min. after the room have been swept or cleaned
• Use individually wrapped sterile dressings
• Create a sterile field around the wound by spreading sterile towels
• Avoid talking, coughing and sneezing when the wound is opened
• All the soiled dressings and contaminated instruments should be carefully collected and disposed
• Cleaning the wound should be done from the cleanest area to the less clean area
• If the dressings are adherent to the wound due to the drying of the secretions, wet it with physiologic saline before it is removed from the wound
• When drains are in place anticipate the drainage and reinforce the dressing accordingly
• The amount of discharge from the wound is accurately measured by recording the number and size of dressing changed
• Before doing the dressing inspect wound for any complications
• Avoid meal timings
• Give an analgesic prior to the painful dressings
• Check the diagnosis and general condition of the patient
• Check the condition of the wound, physicians order, patients name, abilities and limitations of the patient and articles available in the unit

Preparation of the articles

• A sterile tray containing
• Artery forceps-1
• Dissecting forceps-2
• Scissors
• Small bowl
• Gloves, mask and gown
• Cotton balls, guaze pieces, cotton pads
• Slit or dressing towel
• Unsterile tray containing
• Cleaning solutions as necessary
• Ointments and powders as ordered
• Vaseline gauze, ribbon guaze, swab stick in sterile containers
• Transfer forceps in a sterile container
• Bandages, binders, adhesive plaster and scissors
•  A large bowl with disinfectant solution
• Kidney tray and paper bag
• Mackintosh and towel

Preparation of the patient and the environment

• Identify patient
• Apply restrains in case of children
• Shave the area if necessary
• Comfortable position to the patient
• Put off fan
• Untie the bandage or adhesive or remove them

Procedure

• Wear mask  and wash hands, put on gown & gloves as necessary
• Open the sterile tray and spread the sterile towel around the wound
• Control the haemorrhage
• Prepare to anaesthetise the wound edges
• Clean the wound thoroughly with normal Saline
• Using a sharp scissors cut off the dead tissues
• Put on fresh sterile gloves
• Pick up the dissecting forceps and remove the dressings and put it in the paper bag and discard the forceps in the bowl of lotion
• Ask the assistant to pour small amount of cleansing solution into the bowl
• Clean the wound from the center to periphery
• After cleaning dry the wound with dry swabs
• Apply medications and sterile dressings
• Remove the gloves and secure the dressings with bandage
• After care of the patient and the articles
• Remove the mackintosh and towels
• Replace all articles
• Wash hands
• Record the procedure on the nurses record