NUR 113: SKILL 39-1: APPLYING A DRESSING (DRY & MOIST-TO-DRY)

1. NUR 113: SKILL 39-1: APPLYING A DRESSING (DRY & MOIST-TO-DRY)

2. Applying a Dressing (Dry & Moist-to-Dry) Introduction • Dry gauze dressings are for wound healing by primary intention with little drainage. • The dressing protects the wound from injury, reduces discomfort, and speed healing (when used correctly). • Dry gauze dressings do not interact with wound tissue and cause little wound irritation. • However, gauze does not maintain a moist wound environment unless a wound is highly exudative. • In addition, gauze dressings have the disadvantage of moisture evaporating quickly, causing a dressing to dry out.

3. PRINCIPLES FOR PACKING A WOUND • Use the wound characteristics to decide which type of packing is appropriate. • Make sure that the packing material can be safely used to pack a wound. • Moisten the packing material with a non-cytotoxic solution such as normal saline. Never use cytotoxic solutions (e.g., povidone-iodine) to pack a wound. • If using woven gauze, fluff it before packing it into the wound. • Loosely pack the wound. • Do not let the packing material drag or touch the surrounding wound tissue before you put it into the wound. • Fill all the wound dead space with the packing material. • Pack the wound until you reach the wound surface; never pack the wound higher than the wound surface.

4. ASSESSMENT Ask patient to rate their level of pain using a pain scale of 0 to 10 and assess character of pain. Administer prescribed analgesic as needed 30 minutes before dressing change. Assess size, location, and condition of wound. Review previous nurses’ notes and electronic health record (EHR). Assess patient for allergies, especially antiseptics, tape, or latex. Assess patient’s and family caregiver’s knowledge of purpose of dressing change. Assess need, readiness, and willingness for patient or family caregiver to participate in dressing wound. Review medical orders for dressing change procedure.

5. ASSESSMENT – CONT’D 7. Identify patients at risk for wound-healing problems including aging, premature infant, obesity, diabetes mellitus, circulation disorders, nutritional deficit, immunosuppression, radiation therapy, high levels of stress, and use of steroids.

6. PLANNING • 1. Expected outcomes following completion of the procedure: • Patient’s wound shows evidence of healing by decrease in size and less drainage, redness, or swelling. • Patient reports pain less than previous assessment after dressing change. • Dressing remains clean, dry, and intact. • Patient or family explains purpose of dressing and method of dressing application. • 2. Explain procedure to the patient.

7. IMPLEMENTATION • 1. Identify patient using two identifiers. • 2. Close room or cubicle curtains. Perform hand hygiene. • 3. Position patient comfortably and drape to expose only wound site. Instruct patient not to touch wound or sterile supplies. • 4. Place disposable waterproof bag within reach of work area. Fold top of bag to make cuff. Perform hand hygiene and apply clean gloves. Apply gown, goggles, and mask if risk for splashing exists. • 5. Gently remove tape, bandages, or ties; use non-dominant hand to support dressing and, with your dominant hand, pull tape parallel to skin and toward dressing. If dressing is over hair area, remove in direction of hair growth. Get patient permission to clip or shave area (check agency policy). Remove any adhesive from skin.

8. IMPLEMENTATION – CONT’D • 6. With gloved hand or forceps remove dressing one layer at a time, observing appearance and drainage of dressing. Carefully remove outer secondary dressing first; then remove inner primary dressing that is in contact with wound bed. If drains are present, slowly and carefully remove dressings and avoid tension on any drainage devices. Keep soiled undersurface from patient’s sight. • A. If moist-to-dry dressing adheres to wound, gently free dressing and alert patient of discomfort. • B. If dry dressing adheres to wound that is not to be debrided, moisten with normal saline and remove.

9. IMPLEMENTATION – CONT’D • 7. Inspect wound and peri-wound for appearance, color, size (length, width, and depth), drainage, edema, presence and condition of drains, approximation (wound edges are together), granulation tissue, or odor. Use measuring guide or ruler to measure size of wound. Gently palpate wound edges fro bogginess or patient report of increased pain. • 8. Fold dressings with drainage contained inside and remove gloves inside out. With small dressings remove gloves inside out over dressing. Dispose of gloves and soiled dressing according to agency policy. Cover wound lightly with sterile gauze pad and perform hand hygiene. • 9. Describe appearance of wound and any indicators of wound healing to patient. • 10. Create sterile field with sterile dressing tray or individually wrapped sterile supplies on over-bed table. Pour any prescribed solution into sterile basin.

10. IMPLEMENTATION – CONT’D • 11. Cleanse wound (see Chapter 38); • A. Perform hand hygiene and apply clean gloves. Use gauze or cotton ball moistened in saline or antiseptic swab (per health care provider order) for each cleansing stroke or spray wound surface with wound cleanser. • B. Clean from least to most contaminated area (see Chapter 38). • C. Clean around any drain (if present), using circular strokes starting near drain and moving outward and away from insertion site.

11. IMPLEMENTATION – CONT’D • 12. Use sterile gauze to blot in same manner as in Step 11 to dry wound – Drying reduces excess moisture, which could eventually harbor microorganisms. • 13. Apply antiseptic ointment (if ordered) with sterile Q-tip or gauze, using same technique to apply as for cleaning. Dispose of gloves. Perform hand hygiene. • 14. Apply dressing (see agency policy) • A. Dry sterile dressing: • 1. Apply clean gloves (see agency policy). • 2. Apply loose woven gauze as contact layer. • 3. If drain is present, apply precut, split 4 x 4 inch gauze around drain. • 4. Apply additional layers of gauze as needed. • 5. Apply thicker woven pad (e.g., Surgipad, abdominal {ABD} pad)

12. IMPLEMENTATION – CONT’D • B. Moist-to-dry dressing: • 1. Apply sterile gloves (see agency policy). • 2. Place fine-mesh or loose 4 X 4 inch gauze in container of prescribed sterile solution. Wring out excess solution. • 3. Apply moist fine-mesh or open-weave gauze as single layer directly onto wound surface. If wound is deep, gently pack gauze into wound with sterile gloved hand or forceps until all wound surfaces are in contact with moist gauze, including dead spaces from sinus tracts, tunnels, and undermining. Be sure that gauze does not touch peri-wound skin. • 4. Apply dry sterile 4 x 4 inch gauze over moist gauze. • 5. Cover with ABD pad, Surgipad, or gauze

13. IMPLEMENTATION – CONT’D • 15. Secure dressing. • A. Tape: Apply tape 1 to 2 inches (2.3 to 5 cm) beyond dressing. Use non-allergenic tape when necessary. • B. Montgomery ties. – ties allow for repeated dressing changes without removal of tape. • 1. Be sure that skin is clean. Application of skin barrier is recommended (see Chapter 18). • 2. Expose adhesive surface of tape ends. • 3. Place ties on opposite sides of dressing over skin or skin barrier. • 4. Secure dressing by lacing ties across dressing snugly enough to hold it secure but without placing pressure on the skin. • C. For dressing an extremity, secure with roller gauze or elastic net.

14. IMPLEMENTATION – CONT’D • 16. Dispose of all dressing supplies. Remove cover gown and goggles and remove gloves inside out; dispose of them according to agency policy. • 17. Label tape over dressing with your initials and date dressing is changed. • 18. Help patient to a comfortable position. • 19. Perform hand hygiene.

15. EVALUATION • 1. Observe appearance of wound for healing; measure size of wound; observe amount, color, and type of drainage and peri-wound erythema or swelling. • 2. Ask patient to rate pain using a scale of 0 to 10. • 3. Inspect condition of dressing at least every shift. • 4. Ask patient and/or family caregiver to describe steps and techniques of dressing change.

16. UNEXPECTED OUTCOMES • 1. Wound appears inflamed and tender, drainage is evident, and/or odor is present. • Monitor patient for signs of infection (e.g., fever, increased white blood cell count) • Obtain wound cultures, as ordered. • If there is yellow, tan, or brown necrotic tissue, refer to health care provider to determine the need for debridement. • 2. Wound bleeds during dressing change. • Observe color and amount of drainage. If excessive, may need to apply direct dressing. • Inspect area along dressing and directly underneath patient to determine amount of bleeding. • Obtain vital signs, as needed. • Notify health care provider.

17. UNEXPECTED OUTCOMES – CONT’D • 3. Patient reports sensation that “something has given way under the dressing.” • Observe wound for increased drainage or dehiscence (partial or total separation of wound layers) or evisceration (total separation of wound layers and protrusion of viscera through wound opening). • Protect wound. Cover with sterile moist dressing. • Instruct patient to lie still. • Stay with patient to monitor vital signs. • Notify health care provider.

18. RECORDING AND REPORTING • Record appearance and size of wound, characteristics of drainage, presence of necrotic tissue, type of dressing applied, patient’s response to dressing change, and level of comfort in nurses’ notes and EHR. • Report any unexpected appearance of wound drainage, accidental removal of drain, bright red bleeding, or evidence of wound dehiscence or evisceration.

19. PROBLEMS ASSOCIATED WITH WOUNDS REQUIRING DEBRIDEMENT

20. PROBLEMS ASSOCIATED WITH WOUNDS REQUIRING DEBRIDEMENT – CONT’D

21. END OF SKILL This is the end of the skill Your book has not provided a video for this skill. In order to pass this skill, you will need to go into the skills lab to practice it! Good Luck

22. PROCEDURE GUIDELINE 38-1: APPLYING GAUZE & ELASTIC BANDAGE

23. INTRODUCTION INTRODUCTION: Gauze and elastic bandages secure or wrap hard-to-cover areas of the body such as dressing on extremities, amputation stumps, and the hand. Bandages are a secondary dressing, providing protection, pressure, immobilization, and anchoring of underlying dressings or splints. There are numerous types of and applications for bandages. Bandages are available in rolls of various widths and materials, including gauze, elastic, webbing, elasticized knit, and muslin. Gauze bandages are lightweight and inexpensive, mold easily around body contours, and permit air circulation to prevent skin maceration. Elastic bandages apply compression to a body part. Elastic compression to a lower extremity prevents edema by promoting the return of blood from the peripheral to the central circulation. Compression also supports varicosities. Many patients use elastic bandages in the form of stockings to reduce dependent edema in the extremities.

24. PROCEDURAL STEPS • 1. Review patient’s medical record for specific orders related to application of gauze or elastic bandage. Note area to be covered, type of bandage required, frequency of change and previous response to treatment. • 2. Identify patient using two identifiers (i.e., name & birthday or name and account number) according to agency policy. • 3. Observe adequacy of circulation by palpating temperature or skin and pulses, presence of edema, and sensation (distal to area to be bandaged). Observe skin color and movement of body part to be wrapped. • Note: Impaired circulation may result in pain, coolness to touch when compared with the opposite side of the body, cyanosis or pallor of skin, diminished or absent pulses, edema or localized pooling, and numbness and/or tingling of body part.

25. PROCEDURAL STEPS – CONT’D • 4. Assess patient’s level of comfort (pain scale of 0 to 10). Administer prescribed analgesic as needed before dressing change. • 5. Apply clean gloves (if drainage or break in skin is present). Inspect skin of area to be bandaged for altercations in integrity as indicated by the presence of abrasion, discoloration, or chafing. Pay close attention to areas over bony prominences. • 6. Inspect the condition of any wound for appearance, size and presence and character of drainage and be sure that it is covered with a proper dressing. If not, reapply dressing (check agency policy for type of gloves to use). Remove clean gloves and perform hand hygiene.

26. PROCEDURAL STEPS – CONT’D • 7. Assess for size of bandage: • A. Gauze or basic elastic bandage to secure a dressing: Assess size of area to be covered. Each successive roll of gauze/elastic should overlap previous layer. Use smaller widths for upper extremities, larger widths for lower extremities. • B. Elastic bandage to provide simple compression: Assess circumference of lower extremity before or shortly after patient gets out of bed in the morning or after patient has been in bed for at least 15 minutes. Select width that will cover and overlap without bulkiness.

27. PROCEDURAL STEPS – CONT’D • 9. Close room door or curtains. Position patient comfortably in an anatomically correct supine position in bed. • 10. Perform hand hygiene and apply clean gloves if drainage is present.

28. PROCEDURAL STEPS – CONT’D • 11. Apply gauze or elastic bandage to secure dressings: • A. Elevate dependent extremity for 15 minutes before applying elastic bandage to promote venous return. • B. Make sure that the primary dressing over the wound is securely in place. • C. Hold roll of bandage in your dominant hand and use other hand to lightly hold beginning layer of bandage at distal body part. • D. Begin with two circular turns to anchor bandage. Continue transferring roll to dominant hand as you wrap bandage. • E. Apply bandage from distal point toward proximal boundary, using appropriate turns to cover various shapes of body parts. Roll gauze, overlapping each layer by one half to two thirds the width of the bandage. • F. Alternate ascending and descending turns if you are wrapping a joint. • G. Ensure that bandage is snug but not tight and that the primary dressing or splint is positioned correctly. A tight bandage dressing or splint is position

29. PROCEDURAL STEPS – CONT’D H. While unrolling an elastic bandage, stretch bandage slightly. Explain to patient that smooth, even pressure will be applied to improve circulation, reduce swelling, immobilize body part, and provide pressure. I. End bandage with two circular turns; secure end of gauze or elastic bandage to outside layer of bandage, not skin, with tape or clips.

30. PROCEDURAL STEPS – CONT’D • 12. Apply elastic bandage over stump • A. Elevate stump with pillow or support it with the assistance of another person. • B. Secure bandage by wrapping it twice around proximal end of stump or person’s waist (depending on size of the stump). • C. Make half turn with bandage perpendicular to its edge. • D. Bring body of bandage over distal end of stump. • E. Continue to fold bandage over stump, wrapping from distal to proximal points. • F. Secure with metal clips, Velcro if provided or tape.

31. PROCEDURAL STEPS – CONT’D • 13. Remove gloves if worn and perform hand hygiene. • 14. Remove and reapply elastic bandage, securing the dressing once very 8 hours unless otherwise directed by health care provider. • 15. Evaluate degree of tightness of bandage. • 16. Evaluate distal circulation when bandage application is complete, at least twice during next 8 hours, and then at least every shift. • A. Observe skin color for pallor cyanosis. • B. Palpate skin for warmth. • C. Palpate distal pulses and compare bilaterally. • D. Ask patient to rate any pain on scale of 0 to 10 and to describe any numbness, tingling, or other discomfort to evaluate for neurologic and vascular changes.

32. PROCEDURAL STEPS – CONT’D • 17. Observe mobility of extremity. • 18. Evaluate bandage for wrinkles, looseness, and presence of drainage. • 19. Have patient or family caregiver demonstrate bandage application. • 20. Record patient’s baseline and post-bandage application, including level of comfort, circulation, type of bandage applied, presence of any swelling, and range of motion.

33. PROCEDURAL STEPS – CONT’D • 21. Record condition of wound or skin integrity if dressing is present and type of bandage applied. • 22. Report any changes in neurologic or circulatory status to nurse in charge or health care provider immediately.

34. END OF SKILL This is the end of the skill. Your book has not provided a video for this skill You will need to go into the skills lab and practice this skill in order to pass it!