Dressing Change and Wound Care

Basics

Wound

• Analysis: Assess the wound for necrosis, infection, debris, granulation, epithelialization, and scar maturation.
• Necrosis: Dead tissue in the wound (see p. 181).
• Infection: Presence of pathogens requiring therapeutic intervention (see p. 181).
• Debris: Accumulation of dead tissue or exudate.
• Debridement: Removal of dead tissue to promote wound healing (see p. 129).
• Antibiotic Therapy: Required for infected wounds (see p. 181).
• Cleansing: Preparing the wound for dressing (see p. 26).
• Moist Dressings: Necessary for promoting wound healing (see p. 31).
• Granulation: New tissue formation during healing (see p. 180).
• Surgical Wound Closure: Wound closure through surgical intervention (see p. 778).
• Epithelialization: The process of skin growing and closing the wound (see p. 180).
• Scar Maturation: The phase of scar formation and consolidation (see p. 182).

Indications for Dressing Change

Fresh Surgical Wound:

• Primary Sutured Wounds: The first dressing change should be on the 3rd postoperative day, except for high-risk sutures (e.g., after open injuries).
• Open Wound Treatment: For abscess incision, change the dressing on the first postoperative day.
• Skin Grafts: First dressing change of the recipient site no earlier than 3 days (with caution).

Contaminated or Saturated Dressing:

• Change immediately. For fresh wounds (0-2 days), strict adherence to sterility is required. Afterward, use “no-touch” technique.

Chronic Wounds:

• Moist Dressing Regime: Change the dressing daily, typically 2-3 times per day.
• Occlusive or Vacuum Sealing Dressings: Change according to need, usually every 3-4 days.

Photodocumentation:

• Especially important for chronic wounds to track healing progress.

Planning for Dressing Change

• Announce in Advance: Inform the responsible nursing staff ahead of time and request specific materials (e.g., vacuum pump materials).
• Pain Management: Ensure the patient receives pain relief well before the dressing change (at least 30 minutes before).
• Order of Treatment: Start with aseptic wounds, then treat contaminated, and finally septic wounds.

Hygiene and Procedure

• Work in Pairs: Always work with a second person (nursing staff or medical colleague). Use protective clothing if necessary.
• Materials: Bring all necessary items on a tray to the patient’s bedside, and leave the dressing cart within reach.

General Procedure

• Waste Disposal: Place a waste container next to the bed and a waterproof sheet under the body part to be dressed.
• Instrument Organization: Differentiate instruments for the “dirty phase” (removal of the old dressing) from those needed for sterile dressing application.
• No-Touch Technique: Avoid touching the wound itself. The packaging inside sterile gloves can be used as a practical tray for items.

Wound Cleansing

• Assess the Wound: Before and after cleaning, check for necrosis, infection, debris, granulation, and epithelialization.

Cleansing Methods:

• Dabbing: Use sterile Ringer’s solution-soaked swabs to clean lightly crusted surgical sites or minimally fibrin-covered granulating wounds.
• Irrigation: Use a sterile 20 or 50 ml syringe filled with warm Ringer’s solution to irrigate the wound under pressure.

Irrigation and Wound Care

• Aseptic Wounds: Irrigate with Ringer’s solution under pressure. If necessary, use a button cannula for wound pockets.
• Contaminated Wounds: Use Ringer’s solution or shower head for cleaning (check if tap water is adequately filtered).
• Septic Wounds: Irrigate with antiseptic solutions like Lavasept.

Special Wound Dressings

• Hydrogels and Occlusive Dressings: Help cleanse by loosening debris. After removal, rinse the wound with Ringer’s solution.
• Enzymatic Ointments: An alternative to surgical debridement for removing solid debris and minor necroses (e.g., Iruxol-N ointment).
• Maggot Therapy: Effective bio-surgical debridement with specially cultured maggots. They stay in the wound for 2 days under a closed dressing and usually cause minimal patient discomfort.

Debridement

• Surgical Debridement: The most thorough method for removing necrotic tissue. Anesthesia is usually required.
• Bedside Debridement: Necrosis removal outside the operating room, though the patient should receive adequate analgesia beforehand.

Amputation

• Indications for Amputation: If there is extensive necrotic tissue, and the tissue cannot be salvaged, amputation may be necessary.

Wound Coverage and Dressing

• Goal of Dressing: Protect the wound from harmful environmental, microbial, and physical influences while providing the optimal healing environment.
• Dry Wounds: Use Steristrips to support sutures for 7-14 days, or use sterile plaster after suture removal to protect the wound.

Dressing Selection Guide

• Dry Wounds: Steristrips applied without tension; change only if dirty.
• Moist Wounds: Use moist dressings to promote healing, especially for granulating wounds like skin graft donor sites or second-degree burns.

Special Wound Conditions:

• Septic Wounds: Focus on cleansing and possibly antibiotic therapy. Depending on pus development, more frequent irrigation and debridement may be required.
• Epithelializing Wounds: Transition from moist dressings to lipid-based, nourishing wound dressings (e.g., Jelonet gauze or Bepanthen compresses).