Dressing/ Wound management (wound healing)

What are the primary purposes of wound dressings?

To protect the wound, absorb exudate, maintain moisture, prevent infection, and promote healing.

Why is moisture balance important in wound care?

Moisture supports cell migration and collagen formation, while excess fluid causes maceration.

What is the nurse's role in wound dressing care?

Choose appropriate dressings, maintain sterile technique, and monitor wound progress.

What is a primary dressing?

The first layer applied directly to the wound surface.

What is a secondary dressing?

A layer placed over the primary dressing for absorption and protection.

What is an occlusive dressing?

A moisture-retaining barrier that prevents contamination and promotes autolytic debridement.

What are the benefits of occlusive dressings?

They speed epithelialization and protect against bacterial invasion.

What is a non-occlusive dressing?

A dressing that allows air flow and absorbs excess drainage.

What are examples of non-occlusive dressings?

Gauze pads or ABD pads.

What are transparent film dressings?

Clear, adhesive dressings that allow oxygen exchange and visualization of the wound.

What are transparent film dressings used for?

Covering superficial wounds, IV sites, or partial-thickness wounds with minimal drainage.

What are hydrocolloid dressings?

Occlusive dressings containing gel-forming agents that interact with exudate to promote moist healing.

When are hydrocolloid dressings indicated?

For shallow wounds, pressure injuries (Stage 2), and autolytic debridement.

What are contraindications for hydrocolloid dressings?

Heavily draining or infected wounds.

What are hydrogel dressings?

Water-based or glycerin-based gels that donate moisture to dry wounds.

When are hydrogels used?

For dry or painful wounds and burns that require gentle debridement.

What are foam dressings?

Highly absorbent dressings that cushion and protect wounds with moderate to heavy drainage.

When are foam dressings appropriate?

For Stage 2-4 pressure injuries and surgical wounds with exudate.

What are alginate dressings?

Highly absorbent dressings made from seaweed that form a gel on contact with wound fluid.

When are alginates used?

For wounds with heavy exudate or bleeding, such as venous ulcers.

What must be done before removing alginate dressings?

Moisten with saline to prevent tissue trauma.

What are composite dressings?

Multi-layer dressings combining absorbent and protective materials.

When are composite dressings used?

When multiple dressing functions (absorption, protection, adherence) are needed in one product.

What is a gauze dressing?

A woven or non-woven material used for cleansing, packing, and covering wounds.

Why must gauze be kept moist when used in wounds?

Dry gauze can adhere to the wound bed and cause trauma during removal.

What is a wet-to-dry dressing?

A form of mechanical debridement where dry gauze removes necrotic tissue when pulled off.

Why is wet-to-dry dressing used less often today?

It damages healthy tissue and delays healing.

What is negative pressure wound therapy (NPWT)?

A sealed wound VAC system that applies continuous suction to promote healing.

What are benefits of NPWT?

It removes exudate, reduces edema, improves perfusion, and stimulates granulation tissue.

What types of wounds benefit from NPWT?

Stage 3-4 pressure injuries, surgical wounds, and large exudative wounds.

What are key nursing responsibilities for NPWT?

Ensure airtight seal, measure drainage, assess surrounding skin, and monitor for infection.

What is the purpose of packing a wound?

To fill dead space and promote healing from the base up.

What should be used to pack wounds?

Moist (not wet) gauze or appropriate absorbent materials.

What is the goal of debridement?

To remove necrotic or infected tissue and promote healthy granulation.

What are the main types of debridement?

Mechanical, autolytic, enzymatic, and surgical (sharp).

What is autolytic debridement?

The use of moisture-retaining dressings to allow the body's enzymes to break down necrotic tissue.

What is enzymatic debridement?

The application of topical enzymes to dissolve dead tissue selectively.

What is surgical (sharp) debridement?

Removal of necrotic tissue with sterile instruments by a skilled provider.

When is sharp debridement necessary?

For extensive necrosis, eschar, or infection.

Why should hydrogen peroxide not be used for wound cleaning?

It is cytotoxic and damages healthy tissue.

What solution is most commonly used for wound cleansing?

0.9% normal saline.

Why should sterile technique be used in wound care?

To prevent contamination and infection.

What are the benefits of moisture-retentive dressings?

They promote faster epithelialization and reduce pain during dressing changes.

What must be documented after a dressing change?

Wound appearance, drainage type and amount, tissue color, odor, pain, and patient tolerance.

What teaching should be provided for patients with home dressings?

Hand hygiene, signs of infection, dressing change schedule, and when to contact the provider.