Dressing.pptx

Fundamental of Nursing
B.Sc. Nursing First Year
Kathmandu University

1. Dressing Wound Irrigation Bandaging Prepared by: Geeta Rai, Lecturer

2. Content Dressing: Definition, purpose, types, principles and procedure Wound irrigation: Definition, purposes, principles and procedures

3. Definition A piece of material used to cover and protect a wound to aid in healing.

4. Principles of dressing Use sterile or very clean materials as dressings. ... Cover the entire wound and its immediate surrounding areas. Control bleeding. ... Do not remove dressing once it has been applied to a wound However, if bleeding persists despite bulky dressing, the bulky blood-soaked dressings may be removed to allow reestablishing of pressure.

5. Purposes To protect the wound from mechanical injury To protect the wound from microbial contamination To provide or maintain moist wound healing To provide thermal insulation

6. Contd… To absorb drainage or debride a wound or both To prevent hemorrhage (when applied as a pressure dressing or with elastic bandages) To splint or immobilize the wound site and thereby facilitate healing and prevent injury

7. Types of Dressings Various dressing materials are available to cover wounds. The type of dressing used depends on (a) the location, size, and type of the wound; (b) the amount of exudate;

8. Contd… (c) whether the wound requires debridement or is infected; and (d) such considerations as frequency of dressing change, ease or difficulty of dressing application, and cost

9. Transparent Dressings Transparent dressings are often applied to wounds including ulcerated or burned skin areas.

10. Hydrocolloid Dressings Hydrocolloid dressings are frequently used over pressure ulcers.

11. Securing Dressings The nurse tapes the dressing over the wound, ensuring that the dressing covers the entire wound and does not become dislodged. The correct type of tape must be selected for the purpose.

12. Dressing Technique

13. Wound irrigation Definition: An irrigation (lavage) is the washing or flushing out of an area. Sterile technique is required for a wound irrigation because there is a break in the skin integrity.

14. Purposes To clean the area To apply heat and hasten the healing process To apply an antimicrobial solution

15. Principles of wound irrigation Provide easy access to the wound. Move the patient in order to gain better access if necessary. Remove dressing. Irrigate the wound with the right equipment and pressure. Let the liquid flow from the cleanest to the dirtiest area. Cover open areas with a sterile bandage or towels.

16. Contd… Equipment Sterile dressing equipment and dressing materials Sterile irrigation set or individual supplies, including: Sterile syringe (e.g., a 30- to 60-mL syringe) with a catheter of an appropriate size (e.g., #18 or #19) or an irrigating (catheter) tip syringe

17. Contd… Basin for collecting the used irrigating solution Sterile graduated container for irrigating solution Moisture-proof sterile drape Moisture-proof bag

18. Contd… Irrigating solution, usually 200 mL (6.5 oz) of solution warmed to body temperature, according to the agency’s or primary care provider’s choice • Goggles, gown, and mask Clean gloves Sterile gloves

19. Procedures Preparation Check that the irrigating fluid is at the proper temperature. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments.

20. Contd… Perform hand hygiene and observe other appropriate infection prevention procedures. Provide for client privacy. Prepare the client. Assist the client to a position in which the irrigating solution will flow by gravity from the upper end of the wound to the lower end and then into the basin.

21. Contd… Place the waterproof drape under the wound and over the bed. Apply clean gloves and remove and discard the old dressing. If indicated, clean the wound from the cleanest area toward the least clean. If the wound is circular, this would be from the center of the wound outward. For a linear wound, cleanse from top to bottom, beginning in the middle and moving progressively laterally.

22. Contd… Use a separate swab for each stroke, and discard each swab after use. Rationale: This prevents the introduction of microorganisms to other wound areas.Assess the wound and drainage. Remove and discard clean gloves. Perform hand hygiene.

23. Contd… Prepare the equipment. Open the sterile dressing set and supplies. Pour the ordered solution into the solution container. Position the basin below the wound to receive the irrigating fluid

24. Contd… Irrigate the wound. Apply clean gloves. Instill a steady stream of irrigating solution into the wound. Make sure all areas of the wound are irrigated. Use either a syringe with a catheter attached or with an irrigating tip to flush the wound.

25. Contd… If you are using a catheter to reach tracks or crevices, insert the catheter into the wound until resistance is met. Do not force the catheter. Rationale: Forcing the catheter can cause tissue damage. Continue irrigating until the solution becomes clear (no exudate is present).

26. Contd… Dry the area around the wound. Rationale: Moisture left on the skin promotes the growth of microorganisms and can cause skin irritation and breakdown. Remove and discard clean gloves. Perform hand hygiene.

27. Contd… Assess and dress the wound. Assess the appearance of the wound again, noting in particular the type and amount of exudate still present and the presence and extent of granulation tissue. Using sterile technique, apply a dressing to the wound based on the amount of drainage expected

28. Contd… Remove and discard gloves. Perform hand hygiene.

29. Contd… Document the irrigation and the client’s response in the client record using forms or checklists supplemented by narrative notes when appropriate.

30. BANDAGING

31. Bandage Bandage is a strip of material used mainly to support and immobilize a part of the body.

32. Contd… Bandage is a strip or roll of cloth or other materials that may be bound around a part of the body in variety of ways to secure a dressing maintain pressure over a body part or immobilize a limb or other part of the body.

33. Contd… Bandage are available in rolls of various widths and materials, including gauze, elasticized knit, elastic webbing, flannel, and muslin.

34. Bandaging Bandaging is the process of covering a wound or injured part using various materials such as gauze, cotton, elasticized knit, flannel.

35. Contd… A simple gauze dressing is often not enough to immobilize or provide support to a wound so that binder and bandages applied over around dressing provide extra protection and therapeutic benefits by creating pressure, supporting wound, and immobilizing a body part.

36. Purposes To support wound To immobilize a fracture or dislocation and an injured part so as to relieve pain To maintain direct pressure over a body part or dressing to control bleeding To secure dressing To maintain splints in position

37. Contd… To retain warmth e.g., a flannel bandage on a rheumatoid joint To prevent or reduce swelling To assist the patient in lifting and moving To prevent contamination of a wound To improve venous blood flow from lower extremities by applying pressure

38. Principles Always inspect the skin for abrasions, edema, discoloration or exposed wound edges Use a tightly rolled bandage of the correct width Support the part to be bandage throughout the procedure Cover exposed wounds with a sterile dressing Hold the end of the bandage in the right hand when bandaging a left limb and vice versa

39. Contd… Apply the bandage from the inner side to the outer side, from below to upwards, maintaining even pressure throughout Held the bandage with the head of roll uppermost and apply the outer surface of the bandage to the part. Unroll the bandage just a length at a time. Do not cover the tips of the fingers or toes. These must be observable.

40. Contd… Bandage should not be too tight or too loose Generally each turn should cover two thirds of the previous one Assess the condition of underlying dressings and change if soiled Pad the axilla or groin when bandaging these parts so that two surfaces of the skin do not touch each other beneath the bandage

41. Contd…. Finish off with a straight turn above the part. Hold the end and fasten with the safety pin Always stand in front of the patient, except when applying a capeline bandage Finish off with a strait turn above the part, hold the end and fasten with the safety pin or tape.

42. Types of bandage Roller bandage Triangular bandage T bandage Many tailed bandage Abdominal binder/ Large rectangular

43. Articles Bandages Padding Scissors Safety pins/ adhesive tape

44. Techniques of bandaging Roller bandage Circular turn Simple spiral turn Reverse spiral Figure of eight (Spica)

45. END

46. REFERENCE Berman, Audrey T., Synder, S. and Frandsen, G. 2016. Kozier and Erb’s Fundamentals for Nursing: concepts and practice 10th Edition.USA: Pearson Potter , P., Perry, A. Stockert P. and Hall, A. 2013. Fundamentals of Nursing . 8th edition. Canada : Mosby Elsevier Devkota R., Pathak S., A textbook of fundamentals of nursing; 2018, Page: 403-413