WOUND CARE, DRESSING AND BANDAGING

OBJECTIVES
To learn the principles of wound care in terms of assessment and management
To learn bandaging techniques

Wound Care and Dressing
OBJECTIVES
To identify the optimal wound healing environment
To learn the different types of wounds
To identify the most appropriate type of wound dressings to promote wound healing of
different types of wounds
To learn how to do a conservative surgical debridement for necrotic tissues
To learn how to do simple wound irrigation

Wound Care
Wound care is more than a dressing.
It is a total approach to the assessment and management of the person with a wound.
Wound management consideration
Prevent further trauma to wound
Correct nutritional and fluid status
Promote comfort and reduce pain
Prevent maceration of skin
Treat systemic illness
Promote optimal wound healing environment
Optimal wound healing environment
Remove necrotic tissue
Eliminate wound infection and protect from bacterial invasion
Prevent irritation to wound and surrounding skin
Maintain wound temperature at 37C
Choose appropriate wound dressing materials, maintain moist wound surface to promote
granulation
It is important that necrotic tissue and slough are removed as it provides an ideal breeding
ground for bacteria
Debridement of Devitalized Tissue
Bacterial Reduction
Moisture Balance
Dry wounds
Wounds in which the skin is intact or in which the skin edges are approximated
Wide mesh gauze is most commonly used; protects the wound and allows free circulation
of air through the dressing. Moisture from the skin can evaporate and the dressing
remains dry.
Raw wounds
Chronically draining wounds
Wounds left open due to infection or contamination
Definition of Terms
Drainage/exudates the fluid produced by a wound, which may contain serum, cellular
debris, bacteria, leukocytes, pus or blood
Erythema an inflammatory redness of the skin caused by engorged capillaries
Eschar non viable wound tissue that is characterized by a dry, leathery, black crust
Fistula an abnormal passage between two organs or between organs and skin
Granulation the formation of soft, red, fleshy projections during the healing process in a
wound not healing by primary intention, consisting of capillarie ssurrounded by fibrous
collagen.
Maceration softening of a tissue as it is soaked in fluid
Necrosis cell or tissue death; non viable tissue easily recognizable as black or brownish in
appearance
Pressure ulcer wounds that are the clinical manifestation of localized tissue death due to
lack of blood flow in areas under pressure.
Stage I
Persistent redness on intact skin even after relief of pressure
Stage II
Superficial loss of skin or blister formation
Stage III
Loss of subcutaneous tissue with shallow cavity
Stage IV
Loss of subcutaneous tissue with deep cavity, may expose muscle, bone or tendon
Undermining a tunneling effect or pocket under the edges of a wound that is caused by the
pressure gradient transmitted from the body surface to the bone.
Wound assessment chart a written record of the wound and its progress
Wound care and assessment
Obtain patients consent before the treatment/ procedure.
Obtain patients profile and history relevant to the wound
Medications used
Medical condition
Social history
Mobility
Nutritional status
Incontinence
Allergies
Obtain latest laboratory results if any
Identify location of wound. Mark in the chart.
Identify type of wound
Pressure sore Stage I IV Malignancy
Traumatic Others
Leg ulcer
Surgical
Burn
Sinus/fistula
For leg ulcers assess as to
Presence of paresthesia
Presence of claudication
Monofilament assessment
Presence of lesser toe deformities
Presence of charcot joints
Presence or absence of peripheral pulses
Presence of atrophic skin
Presence of atrophic/dystophic nails
Absence of hair
Capillary refill
Presence of varicose veins
Temperature gradient on affected foot/leg
Take wound photo after obtaining patients consent or sketch wound in chart.
Measure the wound bed using wound measurement system. Use the unit centimeter. Take
the length and width. For burns, use the Rule of Nines.
Measure the depth using cotton applicator. Use the unit centimeter. If there is necrotic
tissue, wound depth cannot be measured.
Assess tissue status using percentage system.
Assess for the presence of undermining or sinus. If present, locate using the clock system of
measurement.
Assess the peri - wound skin as to:
Presence of maceration Presence of blisters
Presence of hyperpigmentation Presence of edema
Presence of eczema Others
Dryness/ friability
Presence of erythema/cellulitis
Describe amount of exudates
None
Minimal 5ml/24hours, minimal strikethrough marking on the surface of the inner
dressing approximately <2cm in diameter
Moderate 5 10ml/24hrs, strikethrough marking on the surface of the inner dressing
approximately .2cm in diameter but not outside the dressing edge
Heavy 10ml/24hrs, strikethrough marking on the surface of the inner dressing and
outside the dressing edges
Note the presence of odor as this can be caused by infection, necrotic tissue or the use of
certain dressing materials
None
Only present when dressing is removed (dressing may be the cause of the odor)
Fills the room often indicates the presence of anaerobic bacteria
Assess for wound pain. Location, frequency and severity of pain can help determine the
presence of underlying disease, effectiveness of analgesia and efficacy of local wound care i.e.
dressing/cleansing methods
None
Only at dressing change - may indicate inappropriate choice of dressing or method of
cleansing
Assess for wound pain. Location, frequency and severity of pain can help determine the
presence of underlying disease, effectiveness of analgesia and efficacy of local wound care i.e.
dressing/cleansing methods
Intermittent pain may be influenced by position (e.g. arterial ulceration of lower leg)
Continuous - dressing regime and analgesia should be reviewed
Assess for clinical signs of infection
Assess need for wound debridement
Autolytic selective as only necrotic tissue is liquefied achieved with hydrocolloids,
hydrogels and transparent films
Enzymatic - chemical enzymes are fast acting products that produce slough of necrotic
tissue. Can be selective or non - selective.
Assess need for wound debridement
Mechanical - allowing a dressing to proceed from moist to wet, then manually removing
the dressing causes a form of non - selective debridement.
Surgical - sharp surgical debridement and laser debridement under anesthesia are the
fastest methods of debridement. It is very selective since the surgeon has complete
control over which tissue is removed and left behind. Can be done at the OR or bedside
depending upon the extent of the necrotic material.
Wound home instructions should be explained and given to patient and/or caregiver. Includes
the ff:
Type of wound cleansing and dressing and how it should be applied
Frequency of changing
Compression therapy if applicable
Follow up care with the wound care clinic
Wound management
Debridement
Decreases potential for infection
Optimizes odor management
Enhances wound assessment
Debridement types
Surgical debridement fastest way to remove necrotic debris
Enzymatic debridement uses topically applied proteolytic enzymes to selectively degrade
necrotic tissue
Debridement types
Autolytic debridement slowest alternative
Mechanical debridement non selective

Surgical Debridement
Surgical debridement
Holding The Forceps: Hold the tissue forceps so that the 'blades' function as an extension to
the thumb and index finger (the pencil grip).
Using the scalpel for debridement: The scalpel should also be held in the pencil grip. This
allows the index finger/thumb joint to control the movements.
Using the scissors (Iris): If the scissors are curved, the concavity should face upwards. Rest
the index finger at the joint to gain maximum control.
Bacterial reduction
Use of antiseptic lotions hypochlorite solution, Povidone Iodine, hydrogen peroxide
Most antiseptic lotions are toxic to fibroblasts, thus delay healing
Some lose their antiseptic effect in the presence of blood and pus
Some irritate surrounding skin
Antiseptics need to be in contact with bacteria for about 20 minutes to have killing
effect
Ideal wound dressing
Keeps wound moist
Removes and debrides necrotic tissue
Prevents surrounding skin from maceration
Absorbs excessive wound exudates
Allows removal without causing trauma or pain
Protects from bacterial invasion
Maintains thermal insulation at 37C
Wound dressing selection
Wound dressings any material applied to cover a lesion or wound
Alginate derived from seaweed which becomes a hydrophilic gel when in contact with
wound secretions, providing a moist wound environment
Film dressing vapour permeable, allow the passage of water vapor and oxygen but not
water or microorganisms
Hydrogels made of silicone and water, rehydrates wounds and provide moist wound
environment
Hydrocolloids interactive when in contact with wound exudates. Absorbs fluid and
becomes a gel
Foam dressing absorbent polyurethane foam
Antimicrobial dressing reduces bacterial burden and prevent further development of
infection, maintains moist wound environment
Retention bandages and elastic stockinet used to secure dressing in place
Micropore tape used to secure dressing in place
Compression bandages used in the management of venous ulceration
Hydrofiber soft, sterile, hydrophilic non woven sheets composed entirely of
hydrocolloid fibers. It is used for management of exuding wounds.
After assessment of wound, choose a product ideal for wound healing
For necrotic tissues hydrogel, semi permeable film or low/non adherent dressing or
hydrocolloid for none to low exudates level. Alginate or hydrofiber for moderate to high
exudate level.

For necrotic digit Cadexomer iodine to prevent increase in bacterial contamination and to
control exudates or alginate to control moderate to high exudates.
For sloughy tissues hydrogel and semi permeable film/low non adherent dressing or
hydrocolloid for non to low exudates. Alginate with secondary absorbent dressing for
moderate to high exudates.
For granulating tissues low/ non adherent dressing or hydrocolloid for none to low
exudates. Alginate or hydrofiber with secondary absorbent dressing for moderate to high
exudates.
For epithilializing tissues low/ non adherent dressing or hydrocolloid for none to low
exudates. Alginate or hydrofiber with secondary absorbent dressing for moderate to high
exudates.
For cavity wounds hydrogel and semi permeable film for non to low exudates.
Alginate or hydrofiber with secondary absorbent dressing for moderate to high exudates.
For macerated wound edges alginate or hydrofiber with secondary absorbent dressing.
Gauze dressing
Characteristics: cotton fibers
Usage
Wet to dry mechanical debridement
Dry gauze absorb exudates
Wet gauze provide moist environment
Examples: Gauze, Melolin, Mesalt (hypertonic saline gauze)
ADV
Moderately absorbent
Economic
Autolytic effect if applied moist
DISADV
Adhere to wound and cause trauma when removed dry
Allow bacterial invasion
Unable to absorb excessive exudates
May macerate surrounding skin
Delay epithilialization
Transparent film
Characteristics: allow oxygen and water vapour to pass through but not bacteria or foreign
body
Usage: For minimally exudating wounds; used as secondary dressing to maintain moisture
and promote autolytic debridement effect
Examples: OpSite, Optiskin, Tegaderm
ADV
Permit constant observation
Minimizes pain
Reduce surface friction
Protect, moisture retentive, semipermeable, reduce infection
Secondary dressing to keep moist dressing for autolytic debridement

DISADV
Non absorptive
May damge new and fragile skin
Not suitable for deep cavity when used on tis own
Impregnated Gauze dressing
Characteristics: chemical compounds or agents added to gauze material, some medicated
and some non - medicated
Usage: for wound coverage and protection, initial dressing over skin grafts, donor sites in
plastic surgery
Examples: Jelonet, Paratulle (non medicated); Sofra tulle (anti infective with 1%
Framycetin Sulphate); Bactigras, Serotulle (antiseptic, 0.5% Chlorhexidine Acetate)
ADV
Low adherent
Moisture retentive
DISADV
Need secondary dressing
Permeable to air and bacteria
Non absorbent causing maceration of wound
Water vapour and exudates are trapped within the wound as they cannot pass through the
paraffin
Foam dressing
Characteristics: non adherent, highly absorbent
Usage: for Stage II to III surface to shallow wounds; heavily exudating wounds and
overgranulating tissue
Examples: Allevyn, Lyofoam, Tielle
ADV
Absorb excessive exudate
Non adherent
Moisture retentive
Protect from contaminant
May flatten overgranulating tissue
DISADV
Not suitable for dry wound
Hydrocolloid dressing
Characteristics: occlusive or semi occlusive, interacts with wound exudate to form a soft
gel like substance
Usage: Stage II or III pressure ulcers with moderate amount of exudates; has autolytic
debridement effect
Examples: Algoplaque, Comfeel, Duoderm, Hydrocoll, restore, Tegasorb
ADV
Minimal to moderately absorbent
Non traumatic on removal
Moisture retentive, thermal insulttion, water resistant
Bacterial barrier
Autolytic effect

DISADV
Not transparent
Melt out effect
Occlusive smell and gel resemble pus residue
Not recommended for infected wound or highly exudating wound
Lipido colloid dressing
Characteristics: vaseline and hydrocolloid dressing
Usage: For superficial burn wound, trauma wound, pressure ulcer, skin grafts and donor
sites
Examples: Urgotul
ADV
Moisture retentive
Allow drainage of exudate, prevent maceration
Non adherent, no pain
No penetration or granulation cells
No residue fiber
DISADV
Need secondary dressing
Hydrogel dressing
Characteristics: consists both absorption power and give moisture by its high water
content
Usage: Stage III or IV wound with no or minimal exudate, sloughor eschar, for autolytic
debridement
Examples: Duoderm gel, Hypergel, Intrasite gel, Nu gel, Suprasorb, Tegagel, Purilon Gel
ADV
Gel rinses off easily
Some with absorbent effect
Hydrate hard dry eschar
Autolytic effect
DISADV
Not suitable for highly exudating wound
Require secondary dressing
May macerate skin
Alginate dressing
Characteristics: composed of calcium and sodium to absorb excessive amount of exudate
and has hemostatic effect
Usage: highly exudating wounds, Stge II to IV wounds, wounds with slough, necrotic
tissue or bleeding, cancerous wounds
Examples: Fibracol, Kaltostat, Sorbalgon, Seasorb, Tegagen
ADV
Non toxic
Fiber biodegradable
Highly absorbent moisture
Autolytic effect
hemostatic
DISADV
Not suitable for dry wound
Require secondary dressing
Moisture Balance
Use of non irritant skin cleanser
Moisturizing cream
Protective skin barrier
Pressure ulcer preventive spray
Wound Irrigation
Wound irrigation
Promotes wound cleaning by creating hydraulic forces generated by the fluid stream.
In order for the irrigation to be effective in cleaning the wound, the force of the irrigation
stream must be greater than the adhesion forces that holds the debris to the surface of
the wound.
Bacterial burden
Amount of bacteria colonizing the wound bed
Wound irrigation
The process of washing debris, drainage or exudates out of the wound to promote healing
Wound Irrigation
Step 1: Assess patients pain and premedicate if needed 30 minutes prior to the procedure
Step 2: Place a waterproof pad on the bed. Assist the patient onto the pad and place in a
position that will allow fluid to flow through the wound.
Step 3: Clean hands and don clean gloves. Remove and discard old dressing.
Step 4: Assess the wound. Document findings.
Step 5: Prepare room temperature irrigating solution and syringe (20cc syringe and G23
needle).
Step 6: Change into clean gloves. Wear apron, gown or goggles if needed.
Step 7: Fill the syringe with irrigating solution and gently flush the wound. Hold the syringe
approximately 1 inch above the wound bed to irrigate.
Step 8: Refill the syringe and continue to flush the wound until the solution returns clear and
no exudates are noted.
Step 9: Dry the edges of the wound with sterile gauze.
Step 10: Assess the wound appearance and drainage and document.

Bandaging
OBJECTIVES
To learn principles of bandaging
To learn some bandaging techniques


Bandaging

Should be done neatly and carefully
Should be snug, but not too tight as to leave marks on the skin after it has been removed
Should remain firmly in place until it is time for the wound to be redressed
Amount of pressure should be merely sufficient to hold it in place
Bandage should be applied evenly without wrinkles
Use the widest bandage that will properly do the job
One inch for fingers
2 inch for hand and head
An elastic bandage should not be stretched to its limit before it is applied or its becomes, in
essence, a non elastic bandage.
When used to wrap an extremity, the elastic bandage should be tightest at the distal end and
looser as it is applied proximally.
An elastic bandage on the lower extremity must include the toes; otherwise the unbandaged
limb distal to the elastic bandage will swell.
If pressure over a wound is required, additional dressings should be applied and bandage
wrapped tighter.
Under such circumstances, the area must be examined at frequent intervals to ensure the
pressure is not injuring the tissues.
Methods of Bandaging
Circular Bandage
Used over a tubular area like the arm
Bandage is fixed by several turns about the part and it is then advanced by circular turns
in the direction desired.
Each successive turn overlaps the preceding one by to 1 inch
Figure of Eight
Used over joints, it is anchored at one end by making several turns about the limb below
the joint.
The bandage is then carried obliquely across the joint and is again anchored above the
joint by a complete turn.
The dressing is then carried obliquely across the joint to the lower part of the extremity
and anchored by a complete turn.
Recurrent bandage
This is used in distal stump.
It can be used as a bulky dressing over the hand, any distal area, such as the finger,
amputation stump or as ahead dressing.
The bandage is anchored by several circular turns and then, while one holds the bandage
at the point where it is anchored, the direction is changed 90 degrees and the bandage is
applied over the end and down to the other side of the anchoring bandage.
It is again anchored here and and the direction reversed back to the initial anchoring
point.
The dressing is continued back and forth until adequate covering is accomplished.
The bandage is locked by a circular turn.
Reversed spiral bandage
This bandage is used for tubular structures of changing diameter such as the leg or
forearm.
The bandage is fixed by two or three circular turns and then on each turn is rotated
counterclockwise 180 degrees, creating a reverse spiral as it is advanced along the
extremity.
This bandage is likely to slip and is unsuitable for use over joints.