Simple Wound Dressing

Clinical Skills
Simple Wound Dressing

Clinical Skills and Simulation Team

PowerPoint content last updated 17/08/2016 14:46:23

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 Simple Wound Dressing
Introduction ?

Introduction
The aim of this module is to facilitate student learning regarding aseptic technique and how to
dress a simple wound. It has been produced using guidance from the Aseptic Non Touch
Technique (ANTT) guidelines designed by The Association for Safe Aseptic Practice (ASAP) along
with The Royal Marsden Hospital Manual of Clinical Nursing Procedures and video and
photography from local sources.

Learning Outcomes
At the end of the session the student should be able to:

 Discuss the steps required to prepare the patient and environment when dressing a wound.
 Describe the equipment required for carrying out a simple wound dressing.
 Demonstrate in a practical procedure session how to apply a simple wound dressing,
employing the principles of ANTT.
 Evaluate own knowledge of the principles of asepsis and wound management and
formulate an action plan to compensate for any deficits.

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 Simple Wound Dressing
Introduction ?

Introduction
There are many different wounds and a plentiful variety of dressings to choose from.
The decision of which dressing to use on each wound is directly influenced by the type of wound and clinical
judgment along with guidelines and local policies.

This module will provide you with the basic standard principles of applying a simple wound dressing.
These standard principles are transferable to any type of wound dressing. However, clinical judgment and
common sense need to be utilized in practice to alter the procedure dependent on the given circumstances.

The standard principles of using an ANTT approach will always remain the same regardless of what procedure
you are carrying out.

Access the Aseptic Technique – ANTT e-learning module if needed.

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 Simple Wound Dressing
ANTT Risk Assessment ?

ANTT Risk Assessment

The choice of Surgical ANTT is the approach required for a Wound Dressing application or change.

STANDARD ANTT
Yes Non-sterilised gloves
- General Aseptic Field
No - Micro Critical Aseptic Fields (MCAF)
- Non-touch technique (NTT)
‘To maintain - Hand Cleansing
asepsis of Key- - Infective precautions ‘Can I perform No Sterilised gloves
Parts and Key- this procedure
Sites, does the without
main aseptic touching Key-
field require Parts or Key-
Critical - Critical Aseptic Field Sites directly?’
Yes No

SURGICAL ANTT
Management?’ - Critical Aseptic Field Management
- Surgical hand scrub Sterilised gloves
- MCAFs & NTT desirable
- Infective precautions

Aseptic field management Glove choice

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 Simple Wound Dressing
4 Steps of Dressing a Wound

4 Steps of Dressing a Wound

IRRIGATE
Optional 1 (only if required, use clinical judgement)

CLEAN
2 (outer edges of wound only)

SWAB
Optional 3 (only if required, use clinical judgement)

Dress
4 (Apply appropriate dressing)

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 Simple Wound Dressing
Principles of Aseptic Wound Dressing Technique ?

Principles of Aseptic Wound Dressing Technique

Obtain informed consent from patient

Maintain patient comfort and dignity throughout

Decontaminate hands pre and post procedure

Keep exposure of wound to a minimum

Choose correct type of ANTT and use efficiently

Maintain Asepsis throughout

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 Simple Wound Dressing
Preparing to use Aseptic Technique for a Wound Dressing ?

Preparing to use Aseptic Technique for a Wound Dressing

Four main steps to follow – the 4 P’s:

P Preparation of AREA

P Preparation of EQUIPMENT

P Preparation of PATIENT

P Preparation of SELF

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 Simple Wound Dressing
Preparing to use Aseptic Technique for a Wound Dressing ?

P Preparation of AREA

Prior to commencement of any aseptic procedure:

 Ensure the surrounding area is tidy and free of any clutter

 The procedure environment must be visibly clean and free from dust and visible dirt

 Where possible, avoid performing aseptic procedures for a minimum of 30 minutes after bed making or
domestic cleaning has concluded.

 Pull screens/curtains around the bed area

 Turn off any fans and close windows

 Ensure adequate lighting is available

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 Simple Wound Dressing
Preparing to use Aseptic Technique for a Wound Dressing ?

P Preparation of EQUIPMENT

You will require:

 A suitable and appropriate surface or dressing trolley to use as your aseptic/sterile field

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 Simple Wound Dressing
Preparing to use Aseptic Technique for a Wound Dressing ?

P Preparation of EQUIPMENT

You will also require:

 A sterile procedure pack

Sterile Field

Front Back

Sterile Sheet
Sterile Gauze Swabs

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 Simple Wound Dressing
Preparing to use Aseptic Technique for a Wound Dressing ?

P Preparation of EQUIPMENT

 All equipment and items specific to the procedure to be carried out, e.g. the dressing to be used and
cleaning solution for the wound (usually sterile normal saline)

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 Simple Wound Dressing
Preparing to use Aseptic Technique for a Wound Dressing ?

P Preparation of EQUIPMENT

You will need to:

 Clean the surface/trolley to be used following local policy and guidelines (usually with detergent and water
or detergent wipes – start at top back of surface/trolley and work your way forward and then down,
ensuring every area of the surface/trolley is cleaned thoroughly.
 Ensure the surface is completely dry
 Check expiry dates, sterility and that all packaging is intact on all equipment and solutions to be used.
Always discard equipment which has damaged packaging.

Egg timer symbol indicates

expiry date on some equipment

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 Simple Wound Dressing
Preparing to use Aseptic Technique for a Wound Dressing ?

P Preparation of EQUIPMENT

You will need to:

 Place all equipment on the bottom of the trolley or clean convenient area close to where you will be
performing the procedure

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 Simple Wound Dressing
Preparing to use Aseptic Technique for a Wound Dressing ?

P Preparation of EQUIPMENT

 Gather all personal protective equipment (PPE) that you will require, e.g. apron, gloves and mask if
required

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 Simple Wound Dressing
Preparing to use Aseptic Technique for a Wound Dressing ?

P Preparation of PATIENT

 Explain the procedure and gain consent from the patient

 If necessary, administer analgesia and allow sufficient time to take effect

 Check comfort of patient, such as their position and whether they require the toilet

 Adjust bed clothes and/or personal clothing to allow easy access to the wound

 Ensure that warmth, comfort and dignity of the patient is maintained throughout

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 Simple Wound Dressing
Preparing to use Aseptic Technique for a Wound Dressing ?

P Preparation of SELF

 Adhere to local uniform and work wear policy ensuring hair is tied back and no items of clothing or jewellery
(apart from a wedding band) are worn below the elbow

 Perform hand hygiene in accordance with the hand hygiene policy depending on whether preparing for a
standard or surgical aseptic procedure

 Put on apron, gloves and any other PPE that may be required as indicated by the patients condition

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 Simple Wound Dressing
Preparing to use Aseptic Technique for a Wound Dressing ?

P Preparation of SELF

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 Simple Wound Dressing
Aseptic Technique and Dressing a Wound Video ?

Aseptic Technique and Dressing a Wound Video

On clicking Play, you will be re-directed to the Cardiff Player Media Library where you may need to log in using
your usual credentials (as you would for Learning Central for example).

Or type the following URL

into your browser:
https://hml.cardiff.ac.uk/
Play.aspx?VideoId=1655

Play

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 Simple Wound Dressing
Indications for Wound Swabbing ?

Indications for Wound Swabbing

Clinical infection my be indicated when the following symptoms are observed:

Heat Purulent Discharge, or Increase in Level of Exudate

Swelling Redness Systemic Temperature

Change in Appearance of Tissue, e.g. normal granulation

Wound Deterioration
becomes dark and bleeds easily

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 Simple Wound Dressing
4 Steps of Dressing a Wound

4 Steps of Dressing a Wound

If a wound requires cleaning and dressing (which wounds displaying signs of infection usually
would), then the swab can be taken during the Surgical ANTT procedure of cleaning and dressing
the wound. (see previous slides and video)

However, if the wound does not require cleaning and dressing follow the procedure guidelines
for taking a Nose, Throat or Skin Swab.

IRRIGATE
Optional 1 (only if required, use clinical judgement)

CLEAN
2 (outer edges of wound only)

SWAB
Optional 3 (only if required, use clinical judgement)

Dress
4 (Apply appropriate dressing)
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 Simple Wound Dressing
Taking a Wound Swab ?

Taking a Wound Swab - Procedure

Verbally confirm the identity of the patient and explain the full
procedure. This explanation should include any investigations to
be undertaken and any follow up advice and care required.
For example:
‘‘Hello, my name is Joe Bloggs and I am a medical student. I
have been asked to clean and dress your wound. May I confirm
your name and date of birth please?’
This procedure will involve me removing the current dressing as
gently as possible then cleaning the wound with sterile water.
We need to check if there is an infection so I will need to take a
swab of your wound. This is done by gently rubbing a swab,
similar to a cotton bud, within the wound.
I will then apply a clean dressing.
The swab will be sent to the laboratory to be processed and the
results will help us to ensure you receive the correct antibiotics,
if needed, and treatment. The results of the swab usually take 3
to 5 days so we will need to see you again then to reassess your
wound and check you are receiving the correct treatment.
Is that all OK?’’

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 Simple Wound Dressing
Taking a Wound Swab ?

Taking a Wound Swab - Procedure

All wounds should have exudate, necrotic tissue or excess blood removed prior to swabbing regardless of what
the swab is for. This removes spurious bacteria associated with non-pathogenic bacteria.
If necrotic tissue, dirt, excess exudate or blood are not present, irrigation/cleansing prior to swabbing is not
necessary.

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 Simple Wound Dressing
Taking a Wound Swab ?

Taking a Wound Swab - Procedure

Moisten the swab with sterile saline before taking sample if the wound bed is
dry. (In dry wounds a moistened swab will attach bacteria more effectively).

Use a “zig-zag” motion whilst simultaneously rotating the swab between the
fingers to ensure all the swab will contain sufficient amounts of bacteria.

Sample the whole wound surface.

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 Simple Wound Dressing
Taking a Wound Swab ?

Taking a Wound Swab - Procedure

Carefully place the specimen straight into the transport medium.

Continue to redress the wound as per care plan using a clean or aseptic non touch technique where
appropriate.

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 Simple Wound Dressing
Summary ?

Summary

Minimal exposure Maintain patient

Gain Consent
of Wound comfort and dignity

Prepare Area Clean area and

Prepare Self
reusable equipment

Document
Prepare Equipment Prepare Patient procedure in patient
notes

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 Simple Wound Dressing
Web Resources ?

Web Resources
ANTT (2013) Aseptic Non Touch Technique. The Association for Safe Aseptic Practice (ASAP).
http://www.antt.org/ANTT_Site/theory.html

NICE (2012) Infection: Prevention and control of healthcare-associated infections in primary and
community care (NICE guideline). National Institute for Health and Clinical Excellence.
http://publications.nice.org.uk/infection-cg139

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 Simple Wound Dressing
References ?

References
Dougherty, L. and Lister, S. (2011) The Royal Marsden Hospital Manual of Clinical Nursing
Procedures (8th edn.). Oxford, UK. John Wiley & Sons Ltd

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