Applying dressings and bandages: Clinical skills notes
Notes
Integumentary
Applying Dressings and Bandages
Introduction
Some of the clients you care for will have dressings on their wounds, which are used to protect the wound; absorb wound drainage, or exudate; keep microorganisms from entering the wound; promote comfort; or keep the wound dry during bathing. Some dressings can even be used to apply pressure to control bleeding, while others can help remove dead or infected tissue; this process is called debridement. As a nurse, you will have the opportunity to apply dressings and bandages.
Types of Dressings
One of the most common types of dressings you will apply are gauze dressings, which are made of cotton or synthetic material. A dry gauze dressing is applied to protect a wound and absorb small amounts of exudate. Sometimes a moist-to-dry gauze dressing is applied, which means that the gauze is moistened before it’s applied to the wound, and then a dry gauze is layered on top. As the moist dressing dries, it helps with debridement and removal of exudate.
Gauze dressings are usually secured with tape, which can sometimes irritate the client’s skin, especially as it is peeled off for dressing changes. In cases where the dressing is large and needs to be changed frequently, it can be secured with Montgomery ties, or tape ties, which is when a wide strap is attached to the skin and then tied together over the wound. Whenever the dressing needs changing, the ties are untied and then tied again over the new dressing, so no peeling of tape is required! If a dressing needs to be secured over a joint, such as a wrist or knee, a bandage made of rolls of webbing, gauze, or stretchy elastic material is wrapped around the dressing.
Some small wounds, minor burns, or intravenous catheter insertion sites can be covered with a transparent dressing, which is a thin film with an adhesive coating on one side. Transparent dressings do not absorb exudate, but they allow you to see through the dressing, so you can observe the wound, and it allows the exchange of air at the wound site while preventing water or bacteria from entering. This dressing also creates a moist healing environment for the wound.
Gauze dressings are usually secured with tape, which can sometimes irritate the client’s skin, especially as it is peeled off for dressing changes. In cases where the dressing is large and needs to be changed frequently, it can be secured with Montgomery ties, or tape ties, which is when a wide strap is attached to the skin and then tied together over the wound. Whenever the dressing needs changing, the ties are untied and then tied again over the new dressing, so no peeling of tape is required! If a dressing needs to be secured over a joint, such as a wrist or knee, a bandage made of rolls of webbing, gauze, or stretchy elastic material is wrapped around the dressing.
Some small wounds, minor burns, or intravenous catheter insertion sites can be covered with a transparent dressing, which is a thin film with an adhesive coating on one side. Transparent dressings do not absorb exudate, but they allow you to see through the dressing, so you can observe the wound, and it allows the exchange of air at the wound site while preventing water or bacteria from entering. This dressing also creates a moist healing environment for the wound.
Figure 1: Types of dressings and items used to secure them. A. Gauze. B. Tape. C. Montgomery ties. D. Stretchy elastic. E. transparent dressing.
Common Care Tips
- Check the client’s plan of care to confirm what type of wound the client has, what type and size of dressing and tape to use, how often the dressing needs to be changed, and if the wound needs to be cleaned (Fig. 2a).
- Applying dressings can be uncomfortable and even painful; if you plan on administering pain medication beforehand, wait until the medication takes effect before you start the procedure (Fig. 2b).
- As you apply the dressing, avoid reaching over the wound or your work area; this will help prevent contamination (Fig. 2c).
- If you are removing an old dressing first and need to remove any tape, do so slowly and gently, pulling toward the wound (Fig. 2d).
- Some clients are allergic to tape, so check for allergies in the client’s plan of care.
- If you are wrapping a bandage over a dressing, be sure to check back frequently to provide range of motion and observe the color and temperature of the extremity (Fig. 2e).
- The dressing can stick to the wound; you may need to moisten the dressing with a saline solution before removing it (Fig. 2f).
Figure 2: Common care tips for applying dressings. A. Check the client's plan of care. B. Wait until pain medication takes effect before you start the procedure. C. Avoid reaching over the wound. D. Remove any tape slowly and gently. E. Check back frequently to provide range of motion and observe color and temperature. F. Moisten the dressing with a saline solution before removal.
Applying Gauze and Transparent Dressings
Supplies
When applying a dressing, first gather the supplies you need:
- clean gloves and other personal protective equipment (PPE) like a mask or gown if needed
- a towel or similar item to protect the client’s bed linen, like a bed protector
- appropriate dressings
- tape or bandages to secure the dressing
- sterile 4x4 gauze squares or cotton balls and saline solution if needed
- forceps
- paper towels
- a biohazard bag for disposal of soiled materials
Figure 3: Supplies that you may need to apply dressings. A. Gloves. B. PPE. C. Towel or bed protector. D. Appropriate dressings. E. Tape or bandages. F. Sterile gauze. G. Cotton balls. H. Saline solution. I. Forceps. J. Paper towels. K. Biohazard bag.
Procedure
- Cover the bedside table with paper towels and arrange your supplies. Place the biohazard bag where you can easily reach it.
- Perform hand hygiene.
- Put on clean gloves and other PPE as needed.
- Raise the bed to a height that’s comfortable to work with. Make sure the wheels on the bed are locked, and lower the bed rail on the side you’ll be working on.
- Assist the client into a comfortable position, and place the towel as needed to protect the bed linen under the area you’ll be working on.
- Expose the wound while keeping the rest of the client covered.
- If you need to remove the existing gauze dressing,
- Gently peel the tape by holding down the skin and pulling the tape toward the wound or, if Montgomery ties are present, untie the straps and fold them away from the wound.
- Remove the old dressing, one layer at a time. If it sticks a little, moisten it with saline.
- To remove a transparent dressing, it’s most helpful to break the seal by stretching it parallel to the wound, then peel it off.
- Place the soiled dressing in the biohazard bag while being careful to prevent the dressing from touching the outside of the bag. Dispose of the bag in a facility-approved waste container.
- Remove and dispose of your soiled gloves, practice hand hygiene, and put on a pair of clean gloves.
- If you will be cleaning the wound,
- Use forceps to clean the wound with 4x4 gauze or a cotton ball moistened in saline solution.
- Gently wipe from the wound center towards the outer edges, using a different piece of gauze or cotton ball with each wipe.
- After cleansing, blot the wound and the surrounding skin dry with gauze as needed.
- Apply the clean dressing and secure it with tape or tie the Montgomery ties.
- Avoid applying tape over irritated skin.
- For a transparent dressing,
- Peel away the paper backing and, starting about one inch, or two cm, from the edge of the wound, place the film over the wound.
- Avoid wrinkles but do not stretch the dressing; this can cause it to come loose.
- If applying a bandage over a dressing,
- Hold the end of the roll with one hand as you unroll the bandage and wind it around the extremity and around the wound.
- Begin at the distal part of the extremity and work your way up proximally; for example, if wrapping the ankle, start slightly above the toes and move up and a little bit past the ankle. Each layer should overlap the previous layer by about ½ – ⅓ of the bandage width.
- When you have finished wrapping, secure the end of the bandage with tape if needed. Be sure the bandage holds the dressing in place but is not too tight. A tight bandage can cut off circulation and put pressure on the nerves, so it’s a good idea to ask the client how the bandage feels to them.
- Remove the towel, remove and dispose of your gloves, and practice hand hygiene.
- Assist the client to a comfortable position, lower the bed, and put the side rails up.
- Return supplies to their proper place.
Documentation
When applying a dressing or bandage, you should report the following to the healthcare provider:
For a wound secured by a bandage, let the healthcare provider know:
Document:
- if the client develops a fever
- if you notice an increase in drainage from the wound
- if you notice a worsening in the appearance of the wound or the skin around the wound
For a wound secured by a bandage, let the healthcare provider know:
- if you notice any color change in the skin
- if the client reports numbness or tingling
Document:
- the type of dressing you applied
- how you secured the dressing
- the appearance of the wound and exudate
- any unusual observations about the wound
- the date and time of your observations