Component Task: Dressing of Simple Wound (Without Assistant)

It is the process of aseptically caring for an injury to body tissues or break in the continuity of the skin or mucous membrane.

Aims

·         Remove exudates

·         Support injured part and hold the skin tissue in place

·         Prevent further injury and infection

·         Obtain wound swab for laboratory investigation

·         Promote healing

Requirements

A trolley containing the following:

a.      Top shelf (a Sterile field with the following sterile items)

·         Two (2) or three (3) gallipots for lotions

·         Two (2) kidney dish

·         Two (2) pairs of dressing forceps

·         Two (2) pairs of dissecting forceps

·         Sinus forceps

·         Probe

b.      Bottom shelf with the following:

·         Dressing lotion

·         Sterile cotton and gauze swab in a drum/ pack

·         Mackintosh and dressing towel

·         Adhesive tape/strip

·         Bandage

·         Scissors

·         Apron

·         Disposable gloves

·         Sterile gloves

·         Receiver for used dressings

Steps

1.        Establish rapport (Refer to steps)

2.      Explain procedure to patient (Refer to steps)

3.      Ensure privacy

4.      Put on mask perform hand hygiene

5.      Prepare and send trolley aseptically to the patient’s bedside

6.      Assist patient into a desirable position

7.       Protect bed clothes with mackintosh and dressing towel

8.      Assembly instruments and pours lotions into gallipots

9.      Perform hand hygiene

10.    Wear disposable gloves

11.      Expose area of wound and removes plaster or bandage

12.    Remove soiled dressing with dissecting forceps or disposable gloves, assess for the type of exudate and discard

13.    Perform hand hygiene

14.    Dab or clean wound with sterile forceps/gloves using prescribed lotion from within outwards

15.    Where necessary gently irrigates wound with syringe and saline

16.    Clean or dab wound with series of swabs until wound is clean

17.    Clean the surrounding skin

18.    Apply sterile dressing using prescribed dressing lotion

19.    Add enough sterile dressing and secures into position or leaves exposed where necessary

20.  Apply adhesive tape or bandage to the site where necessary

21.    Remove mackintosh and dressing towel

22.  Reposition patient in bed

23.  Inform patient about the state of the wound

24.  Dispose off used items, decontaminate used instruments and trolley

25.  Perform hand hygiene

26.  Documents and reports state of the wound in the nurse notes (manually or electronically)