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UNIT 4 Supporting Physiological Functioning
Procedure 32-5 ■ Removing and Applying Wet-to-Damp Dressings (continued)
17. Apply a secondary moist layer over the first layer. Repeat this pro- cess until the wound is filled with moistened sterile gauze—but do not tightly pack the gauze into the wound. Do not extend the moist dressing onto the surrounding skin. Packing the gauze tightly can restrict blood flow to the area. Moist dressings on the surrounding skin can cause maceration. 18.Cover the moistened gauze with a thick surgical pad. Protects the wound from external contaminants.
20. Dispose of gloves and materials in the biohazard waste receptacle. 21.Perform hand hygiene. Notes the date and time of the dressing. 22. Assist the patient to a comfort- able position. What if . . . ■ Gauze becomes dry between dressing changes? Moisten dressings with sterile saline before removing them; change dress- ing more frequently; consider using a semiocclusive dressing. A moistened dressing prevents debridement of granulating tissue, maintains a moist environment, and prevents tissue injury. Dressings that become too dry will injure healthy tissue and impair healing. ■ The patient has multiple wounds? The most infected wound should be treated last. Remember to always change your gloves in between wound dressing changes. The risk of cross-contamination is reduced when moving from clean to dirty and with fresh gloves.
gauze you use depends on the size of the wound. Maintains sterile field and supplies. 14. Moisten sterile gauze with saline solution or sterile water for irrigation. 15. Don clean nonsterile gloves. 16.Squeeze out excess moisture from the gauze.Apply a single layer of moist, fine-mesh gauze to the wound. Be sure to place gauze in all depres- sions or crevices of the wound.You may need to use forceps or a cot- ton applicator to ensure that you fill deep depressions or sinus tracts with gauze. “Fluff” the mesh gauze before placing in the wound so as it dries it acts as a wick for any drainage. Maintains a moist environment for the wound bed.
19. Secure the dressing with tape or Montgomery straps (see Fig. 32-16). Montgomery straps are useful when dressings must be frequently changed because they do not cause trauma to the skin.
Evaluation ■ Evaluate whether the patient feels pain with the procedure and afterward. ■ Note whether the patient verbalizes understanding of the procedure. Patient Teaching ■ Teach the patient about the expected healing process. ■ Inform the patient and caregiver about signs and symptoms of infection and the need to report these findings. Home Care ■ Help the patient store dressings appropriately to keep them clean, such as in a plastic container with a lid. ■ Teach the patient or caregivers to dispose of contaminated dressings and gloves by double-bagging them in mois- ture-proof bags (e.g., plastic grocery bags). ■ Advise the patient and family whether they can get the wound wet (e.g., during bathing). If it must be kept dry, demonstrate how to cover it with a waterproof barrier (e.g., a plastic bag).
Documentation Document the following information (many agencies use a wound/skin flow sheet): ■ Appearance and location of the wound, type and amount of exudate, and odor, if present, after cleansing ■ The patient’s pain level before and after the procedure ■ Pain medication given including the dose, time, your name, and the patient’s response ■ Method of cleansing the wound ■ Type of dressing applied to the wound ■ Education provided to the patient ■ Pressure relief measures, as applicable Practice Resources Baranoski & Ayello (2020); Bhimji (2021, March 15, reviewed); Bryant & Nix (2023,April);Wechter (2021, March);WOCN (2017, May/June). Thinking About the Procedure The video Removing and Applying Wet-to-Damp Dressings, along with questions and suggested responses, is available on the Davis’s Nursing Skills Videos Web site on FADavis.com.
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