Dressings


– The objective of dressing wounds is to promote healing. The procedure includes cleaning, disinfection and protection of the wound while respecting the rules of hygiene.
– Not all wounds need to be covered by a dressing (e.g. a clean wound that has been sutured for several days; a small dry wound not requiring sutures).

Material

– Sterile instruments
• one Kocher or Pean forceps
• one dissecting forceps
• one pair of surgical scissors or one scalpel to excise necrotic tissue and to cut gauze or sutures
Instruments for one dressing for one patient must be wrapped together in paper or fabric (or can be placed in a metallic box) and sterilised together to limit handling and breaks in asepsis. 5 to 10 compresses may be included in this set.
If there are no sterile instruments, a dressing can be done using sterile gloves.

– Renewable supplies
• sterile compresses
• non-sterile disposable gloves
• adhesive tape and/or crepe or gauze bandage
• sterile 0.9% sodium chloride or sterile water
• depending on the wound: antiseptic (polyvidone iodine scrub solution, polyvidone iodine dermal solution), paraffin compresses, analgesics

Organisation of care

Proper organization of care helps maintain the rules of asepsis and decreases the risk of contamination of the wound or transmission of organisms from one patient to another:
– Assign one room for dressings. It must be cleaned and the waste removed every day. The dressing table must be disinfected after each patient.
– Dressings may be applied at the bedside if the patient’s condition requires. Use a clean, disinfected dressing trolley with: on the upper tray, sterile and/or clean material (dressing set, extra compresses, etc.) and on the lower tray, septic material (container for contaminated instruments, sharps disposal container and a container or garbage bag for waste).
– Prepare all the necessary material in a well lit area. If necessary, arrange for an assistant to be present.
– Wear protective glasses if there is a risk of projection from an oozing wound.
– Always proceed from clean to dirty: start with patients with uninfected wounds. If there are multiple dressings for one patient, start with the cleanest wound.

Technique

– If the procedure may be painful, give an analgesic and wait the necessary time for the drug to take effect before starting the procedure.
– Settle the patient comfortably in an area where his privacy is respected throughout the procedure.
– Explain the procedure to the patient and obtain his co-operation.
– Instruments (or sterile gloves) must be changed between patients.
– To prevent drug interactions, use the same antiseptic for all care of one patient.

Removal of an old dressing

– Wash hands (ordinary soap) or disinfect them with an alcohol-based hand rub.
– Put on non-sterile gloves and remove the adhesive tape, bandage and superficial compresses.
– Proceed gently with the last compresses. If they stick to the wound, loosen them with 0.9% sodium chloride or sterile water before removal.
– Observe the soiled compresses. If there is significant discharge, a greenish colour or a foul odour, a wound infection is likely.
– Discard the dressing and the non-sterile gloves in the waste container.

Observe the wound

– In the case of an open wound, loss of cutaneous tissue or ulcer, the colour is an indicator of the stage in the healing process:
• black area = necrosis, wet or dry infected eschar
• yellow or greenish area = infected tissue and presence of pus
• red area = granulation, usually a sign of healing (unless there is hypertrophy), however, red edges indicate inflammation or infection
• pink area = process of epithelisation, the final stage of healing that begins at the edges of the wound

– In the case of a sutured wound, the existence of local signs of suppuration and pain requires the removal of one or more sutures to avoid the infection spreading. Local signs include:
• red, indurated and painful edges
• drainage of pus between the sutures, either spontaneously or when pressure is applied on either side of the wound
• lymphangitis
• sub-cutaneous crepitations around the wound

In any case, if local signs of infection are observed, look for general signs of infection (fever, chills, changes in the overall condition).

Technique for cleaning and dressing of the wound

– Wash hands again or disinfect them with an alcohol-based hand rub.

– Open the dressing set or box after checking the date of sterilisation and that the wrapping is intact.

– Pick up one of the sterile forceps being careful not to touch anything else.

– Pick up the second forceps with the help of the first one.

– Make a swab by folding a compress in 4 using the forceps.

– Clean sutured wound or clean open wound with red granulation:
• clean with 0.9% sodium chloride or sterile water to remove any organic residue; work from the cleanest to the dirtiest area (use a clean swab for each stroke);
• dab dry with a sterile compress;
• re-cover a sutured wound with sterile compresses or an open wound with paraffin compresses; the dressing should extend a few cm beyond the edges of the wound;
• keep the dressing in place with adhesive tape or a bandage.

– Necrotic or infected open wounds:
• clean with polyvidone iodine (7.5% scrub solution, 1 part of solution + 4 parts of sterile 0.9% sodium chloride or sterile water). Rinse thoroughly then dab dry with a sterile compress; or if not available, sterile 0.9% sodium chloride or sterile water and apply an antiseptic (10% polyvidone iodine dermal solution).
• apply sterile vaseline and remove all necrotic tissue at each dressing change until the wound is clean.

– Discard any sharp materials used in an appropriate sharps container and the rest of the waste in a waste container.

– As quickly as possible, soak the instruments in disinfectant.

– Wash hands again or disinfect them with an alcohol-based hand rub.

The principles remain the same if the dressing is done using instruments or sterile gloves.

Subsequent dressings

– Clean, sutured wound: remove the initial dressing after 5 days if the wound remains painless and odourless, and if the dressing remains clean. The decision to re-cover or to leave the wound uncovered (if it is dry) often depends on the context and local practices.

– Infected, sutured wound: remove one or more sutures and evacuate the pus. Change the dressing at least once daily.

– Open, dirty wound: daily cleaning and dressing change.

– Open granulating wound: change the dressing every 2 to 3 days, except if the granulation is hypertrophic (in this case, apply local corticosteroids).