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STANDARD OPERATING PROCEDURE ON WOUND DRESSING

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

Wound Care Training Module

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  1. Introduction
  2. Wound Dressing Procedures

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Content

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Content

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INTRODUCTION

  • Wound dressing is a core nursing responsibility which utilizes aseptic technique.
  • The goal technique is to minimize the risk of introducing pathogenic organisms into a wound and to prevent the transfer of pathogens from the wound to other patients or staff.
  • It is also employed to maximize and maintain asepsis and is applicable in any clinical setting.
  • The need for dressing or wound care depends on the type of wound which includes incision, abrasions, pressure ulcers, ulcers, wound at site of drains and others.

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  • The attending health care personnel may require different wound technique for each type of wounds.
  • However, the choice of wound dressing should be large enough to cover and protect the wound site and tissue around it. It should allow air circulation, safely secured to prevent slippage and is comfortable to patient.

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STANDARD :

The nurses observe principles of medical asepsis during wound dressing to minimize introduction of potential infection and or its spread.

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WOUND DRESSING PROCEDURE

  • Great/ acknowledge patient
  • Provide privacy
  • Explain the procedure
  • Identify type of wound dressing required. Infected or dirty wound dressing should be done last
  • Perform pain assessment
  • Administer analgesic if indicated

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  • Perform hand hygiene using soap and water OR alcohol based hand rub
  • Wear mask
  • Prepare trolley for dressing
  • Provide privacy
  • Place patient in a comfortable position

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OR

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  • Loose dressing:
    • Perform hand hygiene. Wear gloves (unsterile)
    • Loosen the existing dressing but do not remove it
    • Use saline or water for irrigation to further loosen the dressing if necessary
    • Remove gloves

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  • Perform hand hygiene. Prepare dressing requirements:
    • Clean dressing trolley
    • Sterile dressing set - top trolley
    • Dressing materials - bottom trolley
    • Cleansing solution - bottom trolley
    • Plaster/ bandage, scissor
    • Clinical waste bin
    • General waste bin
    • Check expiry date

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  • A complete dressing set should consists of:
    • Kidney dish (1)
    • Galipots (2)
    • Non-tooth dissecting forceps (2)
    • Bryant’s dressing forceps (2)

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  • Perform hand hygiene
    • Open dressing set
    • Add the right quantity of sterile dressing material
    • Pour cleansing agent
    • Maintain sterile field:-
    • Non sterile person should not reach across sterile areas or touch sterile item
    • Non sterile person should not contaminate sterile items when opening, disposing or transferring them to the sterile area
    • Place only sterile items within the sterile area
    • The sterile person should not reach across unsterile areas or touch unsterile items

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  • Perform hand hygiene
    • Wear sterile gloves
    • Remove loosen soiled dressing with a pair of forceps
    • Discard used forceps into receiver (bottom trolley)
    • Perform wound assessment. Inform attending doctor if there is any concern

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  • Prepare swabs for dressing
    • Dip swabs into cleansing solution and squeeze excessive cleansing solution

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  • Keep forceps facing downward and above waist line when performing dressing
  • Avoid the soiled forceps (forceps in contact with the wound) from touching the field

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  • Perform dressing as according to the sequence below:
    • Swab from clean area to dirty area. Use 1 swab for each stroke
    • Remove debris, scabs, slough, biofilm when necessary
    • Irrigate with non antiseptic solution if required
    • Clean the peri-wound area thoroughly

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  • Choice of dressings:
    • Apply non-allergenic dressing. To promote healing
    • Use to appropriate off-loading device if required
    • Ensure the wound is completely covered with appropriate dressing
    • Secure dressing appropriately so as not to impair blood circulation

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  • Label dressing done:
    • Date dressing done
    • Date due for next dressing

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  • Clear trolley. Used dressing set to be sent to Central Sterile Supply Unit (CSSU) for re-sterilization
  • Perform hand hygiene

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  • Health education
    • Inform patient wound progress
    • Maintain a well-balanced diet
    • Compliance medication and follow up treatment
    • Personal hygiene

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  • Document wound findings and care rendered in wound care chart.

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TAKE HOME MESSAGES

  • Ensure healthcare personnel perform wound dressing using principles of aseptic technique to prevent or minimize transmission of microorganisms during wound care procedures.

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REFERENCES

  • Nicol, M. (2008).Aseptic Dressing
  • Technique.www.cetl.org.uk/learning
  • Ministry Of Health Malaysia, Policies and Procedures on Infection Control”, 2nd edition (2010)
  • Nursing Division, Ministry Of Health. National Nursing Audit, Version 4(2011)

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THANK YOU

Wound Care Training Module - National Wound Care Committee