Ministry of Higher Education and Scientific Research Anesthesia department
Sulaimani Polytechnic University – technical college of health & medical technology 1st Stage
Date: April 30, 2025 Nursing / practice 11
Wound and Medical Dressing
Wound: is defined as a disruption in the continuity of the epithelial lining of the
skin or mucosa resulting from physical damage.
According to the duration and nature of healing process, the wound is
categorized as acute and chronic.
1. An acute wound is an injury to the skin that occurs suddenly due to
accident or surgical injury. It heals at a predictable and expected time frame
usually less than 12 weeks depending on the size, depth and the extent of
damage in the epidermis and dermis layer of the skin.
2. Chronic wounds on the other hand fail to progress through the normal
stages of healing and cannot be repaired in an orderly and timely manner.
Chronic wounds generally result from burns.
Wound healing is a complex process of tissue regeneration and growth progress
through four different phases:
(i) The coagulation and haemostasis phase (immediately after injury);
(ii) The inflammatory phase, (shortly after injury to tissue) during which swelling
takes place;
(iii) The proliferation period, where new tissues are formed and
(iv) The maturation phase, in which remodeling of new tissues takes place.
What is Medical dressing?
A dressing is process which is a sterile pad or compress applied to a wound to
promote healing and protect the wound from 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. Many modern dressings are self -
adhesive.
When applying or changing dressings, an aseptic technique is used in order to
avoid introducing infections into the wound. Even if the wound is already infected,
an aseptic technique should be used as it is important that no further infection is
introduced. This technique should be used when the patient has a surgical or non-
surgical wound.
Purposes:
1. To promote wound healing.
2. To prevent micro-organisms from entering into the wound.
4. To absorb fluid and provide dry environment.
5. To immobilize and support the wound.
6. To assist in removal of necrotic tissue.
7. To apply medication to the wound.
8. To provide comfort.
9. Reduce psychological stress.
10. To help to seal the wound to expedite the clotting process.
Equipment:
1. Sterile gloves.
2. Gauze dressing set containing scissors and forceps.
3. Cleaning disposable gloves.
4. Cleaning basin.
5. Adhesive tape and/ gauze bandage.
6. Normal saline.
Safety considerations:
• Perform hand hygiene.
• Check room for additional precaution.
• Introduce yourself to patient.
• Confirm patient ID using two patient identifiers (e.g., name and date of
birth).
• Explain procedure to patient; offer analgesia.
• Ensure patient’s privacy and dignity.
• Assess ABCCS (airway, breathing, circulation, consciousness, safety)
Preparation and procedure:
• Gather necessary Equipments.
• Prepare environment, position patient, adjust height of bed, and turn on
lights.
• Prepare sterile field.
• Prepare patient and expose dressed wound.
• Assess the wound.
• Cleanse the wound using one 2 x 2 gauze per stroke. Strokes should be:
1. From clean to dirty (incision, then outer edges).
2. From top to bottom.
• Dry wound or surgical incision using gauze sponge (Moisture provides
medium for growth of microorganisms).
• Apply antiseptic ointment by forceps if ordered.
• Apply a layer of dry, sterile dressing over wound using sterile forceps
• Place surgical pad over wound as outer most layer if available. (Wound is
protected from microorganisms in environment)
• Discard non-sterile gloves if they were used.
• Apply outer dressing, keeping the inside of the sterile dressing touching the
wound and Apply tape or existing tape to secure dressings (Tape is easier to
apply after gloves have been removed.
• Perform hand hygiene.
• Remove all Equipments and disinfect them as needed.
Document the following:
1) Record the dressing change.
2) Note appearance of wound or surgical incision including drainage, odor,
redness, and presence of pus and any complication.
3) Sign the chart.
4) Check dressing and wound site every shift.
