Dressings

Before memorizing the steps of a dressing or a bandage, you must understand the underlying physiology of tissue repair and vascular dynamics. Nursing is not just completing tasks; it is applied physiology. If you understand why a wound heals or how a bone dies from lack of blood, the procedures will make perfect logical sense.

Every wound, from a tiny paper cut to a massive surgical incision, heals through four distinct, overlapping phases. Aseptic dressing techniques are designed to protect these fragile stages:

1. Hemostasis (Minutes): Blood vessels constrict, and platelets aggregate to form a fibrin clot to stop bleeding.
2. Inflammation (Days 1-4): White blood cells (neutrophils and macrophages) flood the area to eat dead tissue and kill bacteria. The wound is red, warm, and swollen.
3. Proliferation (Days 4-21): New blood vessels form (angiogenesis), and fibroblasts lay down collagen. Bright red, bumpy Granulation Tissue fills the wound bed. (Rough bandaging or peeling off a dry dressing rips this new, fragile tissue away!)
4. Maturation/Remodeling (Months to Years): Collagen cross-links and strengthens, forming a scar.

Veins have one-way valves to push blood back to the heart against gravity. When you bandage a limb, you must always bandage from below, upwards (distal to proximal). This physically squeezes the blood back toward the heart. If you bandage downwards, you trap blood in the extremity, causing massive, painful swelling.

The skin is heavily colonized with normal flora (like Staphylococcus epidermidis). When the skin breaks, these bacteria become deadly pathogens. Aseptic technique utilizes a strict clean-to-dirty workflow to ensure that zero bacteria are pushed from the outside skin into the sterile wound bed.

• A Dressing is a sterile pad or compress applied directly to a wound to promote healing, protect it, and/or absorb exudate (fluids).
• Wound Dressing is the systematic, aseptic procedure of cleaning a wound and applying a sterile covering using strict sterile technique and sterile equipment.

Why do we dress wounds? As a nurse, you must know these indications for your OSCEs:

1. To protect the wound from further mechanical injury or external bacterial infection.
2. To absorb exudates such as pus, blood, or serum (preventing the skin from macerating).
3. To immobilise and support the injured part, reducing pain.
4. To apply pressure on the wound to control bleeding (hemostasis) or to approximate (bring together) the wound edges.
5. To provide psychological and physical comfort for the patient (hiding a severe, traumatic wound drastically reduces patient anxiety).
6. To keep the wound environment moist for optimal healing (dry cells die!) and to allow for regular inspection/monitoring of the wound bed.

• Surgical wounds: Sutured incisions directly from the operating theatre. These are usually clean, primary-intention wounds.
• Traumatic wounds: Abrasions, lacerations, and deep punctures from accidents (high risk for tetanus and gross contamination).
• Infected wounds: Wounds actively discharging foul-smelling fluids or pus ("dirty wounds").
• Burn wounds: Requiring highly specialized, sterile, non-adherent care to prevent peeling off massive sheets of skin.
• Chronic wounds: Pressure sores (bedsores from ischemia), diabetic foot ulcers (neuropathy), and venous leg ulcers.

Aseptic technique is the absolute foundation of wound care. The core principles are to:

• Prevent cross-infection (spreading nosocomial germs like MRSA from one patient to another) and wound sepsis.
• Protect both the patient and the nurse by following Universal Precautions (treating all blood/body fluids as potentially infectious for HIV, Hepatitis B, and C).
• Ensure that ONLY sterile articles touch the wound bed.
• Maintain a strict clean-to-dirty workflow, performing rigorous hand hygiene before and after the procedure.

Before you clean a wound, you must scientifically observe and document its status:

• Anatomy: Site, exact size (length x width), depth, and shape of the wound.
• Exudate: Type and amount of discharge: Serous (clear fluid), Sanguineous (fresh blood), Serosanguineous (pinkish), or Purulent (thick, foul-smelling pus).
• Wound Edges: Are they approximated (closed nicely) or gaping open? Check the integrity of any stitches, clips, or surgical drains.
• Signs of Infection: Redness (erythema), heat, localized swelling, severe pain out of proportion, fever, or dangerous red streaks tracking up the limb (lymphangitis).
• Periwound: The condition of the surrounding skin (is it macerated/soggy?) and the patient's general systemic vital signs.

If a nurse is sloppy with asepsis or aggressive with cleaning, it leads to severe wound sepsis, system-wide bacteremia, drastically delayed healing, wound dehiscence (a horrific complication where a surgical wound bursts completely open), excessive bleeding, or the destruction of fragile new granulation tissue from rough handling. Always respect the sterile field!

Examiner Objectives:
1. Mention the indications for wound dressing.
2. Mention the general rules of wound dressing.
3. Identify requirements for wound dressing.
4. Prepare requirements for wound dressing.
5. Perform the wound dressing flawlessly.

You must memorize this exact layout for your practical exams to avoid failing on safety protocols:

If the examiner verbally tells you or the scenario dictates that the wound is dirty, necrotic, or infected, you MUST dynamically add these specific items to your trolley setup:

1. Probe: To assess the depth of sinuses/fistulas.
2. Hydrogen peroxide (H₂O₂): For effervescent lifting of dead slough and necrotic debris.
3. Pedal bin: For immediate disposal of highly infectious waste.
4. Sinus forceps: For packing deep cavities.
5. Pus swab + Laboratory form: For collecting a vital microbiology Culture & Sensitivity (C&S) sample before giving antibiotics.
6. Hypotonic/Hypertonic saline: Based on osmotic requirements for the slough.

• Use surgical spirit or alcohol for easy, painless removal of sticky adhesive marks from previous strapping.
• If the inner strapping/gauze is stuck and adherent to the raw skin, do not rip it! Soften it by soaking it with warm normal saline or antiseptic lotion.
• For a dirty wound, Hydrogen Peroxide is used specifically to bubble out hidden debris from deep crevices.
• Avoid excessive, aggressive surgical toilet. Scrubbing too hard destroys the delicate, new angiogenesis (blood vessels) required for wound healing and causes unnecessary bleeding.

Always clean in ONE direction only, from the cleanest part to the dirtiest part.

• 1st swab: Straight down the centre of the surgical incision. (Discard)
• 2nd swab: Down one side of the wound, moving slightly outward. (Discard)
• 3rd swab: Down the other side of the wound, moving slightly outward. (Discard)

Physiological Rule: Each swab is discarded after a single continuous stroke. Never return a used swab to the wound bed; doing so carries the patient's own skin flora (bacteria) back into the open tissues, causing iatrogenic infection.

Objectives:
1. Identify the exact requirements for the safe removal of sutures/clips.
2. Demonstrate the correct removal of sutures/clips without causing dehiscence.

Requirements: Same trolley setup as standard wound dressing, plus stitch scissors or a specialized clip remover.

• Stitches or clips are normally removed between the 5th and 10th day post-operatively, depending on the tissue vascularity (face/neck heal fast in 5 days; joints/abdomens take 10-14 days).
• Sometimes the stitches or clips are removed alternatively (every other stitch) on day 7, and the rest on day 9. This prevents the nightmare complication of the wound bursting open (dehiscence) prematurely if it hasn't gained enough tensile strength.
• On some occasions, absorbable sutures (like Vicryl or Monocryl) may be used internally or subcuticularly, in which case they dissolve and are not removed.

For advanced exams, know the difference:

• Non-absorbable: Silk, nylon, polypropylene, stainless steel clips. The body cannot digest these; they retain strength indefinitely and must be physically cut and removed.
• Absorbable: Catgut, Vicryl, Dexon. Broken down via enzymatic digestion or hydrolysis naturally inside the body. Used for deep tissues.

• First Intention: Clean, neatly sutured edges that heal quickly with minimal scar tissue.
• Second Intention: A dirty, infected, or gaping wound that is intentionally left open. It heals slowly by massive granulation tissue filling the defect from the base upwards. Leaves a prominent, large scar.

• A Bandage is a continuous strip of material used to bind, support, cover, or immobilise a specific part of the body.
• Bandaging is the clinical technique of applying these bandages firmly, evenly, and safely to hold dressings in place, support muscular injuries, or apply hemostatic pressure.

1. To keep a sterile dressing securely in position on a wound without using skin-damaging adhesive tape.
2. To apply direct mechanical pressure and control severe bleeding (e.g., a pressure bandage for arterial hemorrhage).
3. To support and immobilise an injured musculoskeletal part (sprains, strains, or undisplaced fractures).
4. To prevent or rapidly reduce swelling (using compression combined with elevation).
5. To secure rigid splints firmly in place against a broken limb.
6. To correct or prevent physical deformity (e.g., clubfoot strapping) and to provide thermal warmth to a joint.
7. To mechanically assist in venous blood return and reduce dependent oedema in the lower limbs.

1. Roller bandages: Long strips rolled tightly on themselves. Made of Cotton (breathable), Crepe (highly elastic for compression), Domette, or Flannel.
2. Triangular bandages: Extremely versatile First Aid staples! Made by cutting a large square of cloth diagonally. Used for arm slings, tourniquets, and securing massive dressings.
3. Tubular bandages: E.g., stockinet, tube gauze, or elastic tubing. Slipped seamlessly over fingers, arms, and legs.
4. Adhesive strapping (plaster): Sticky tape for exact fixation of dressings or strapping joints (e.g., sports taping).
5. Plaster of Paris (POP) bandage: Gauze infused with dry calcium sulfate dihydrate. When soaked in water, it undergoes an exothermic reaction and hardens into rigid splints/casts for broken bones.

• Too tight (The Ischemic Threat): Obstructs arterial blood flow and venous return, causing severe distal swelling, excruciating throbbing pain, numbness, a cold/blue (cyanotic) limb, and eventual tissue death (gangrene) requiring amputation.
• Too loose: Slips off instantly as the patient moves, completely failing to support the injury or apply life-saving pressure to bleeding.
• Too much tension on fragile skin: Causes severe friction blisters, shear tears, and pressure sores over bony prominences.
• THE GOLDEN RULE - ALWAYS CHECK CSM: After applying ANY bandage, immediately check the Circulation (capillary refill < 2 secs), Sensation (can they feel you touching?), and Movement (can they wiggle their toes/fingers?) of the part beyond the bandage. Recheck rigorously after 15–30 minutes!

Objectives:
1. Mention the general physiological principles of bandaging.
2. Outline indications for bandaging.
3. Identify requirements for bandaging.
4. Prepare materials for bandaging.
5. Perform bandaging of various body parts flawlessly.

Used when simple circular turns would leave gaping gaps due to anatomy.

1. Make a fixing (anchor) turn firmly around the forehead/head.
2. Bring the bandage diagonally under the affected ear, pulling it straight over the head and down the back, deliberately leaving the normal, healthy ear un-bandaged for hearing and comfort.
3. Repeat these diagonal turns three or four times, overlapping each by 2/3, until the thick dressing on the affected ear is gradually and completely covered.
4. Finish with a final circular fixing turn and secure the bandage at the centre of the forehead (where the patient isn't resting their head) using a safety pin, clip, or medical tape.

This pattern weaves away from the centre, accommodating extreme angles.

1. Make two locking anchor turns directly over the exact centre (apex) of the bent joint (e.g., right over the point of the elbow or kneecap). (Rationale: To instantly stabilize the dressing at the point of highest tension).
2. Now make alternate figure-of-8 turns spreading outwards: one turn above the joint, then the next turn below the joint, diverging further outward each time. This forms a perfect, snug basket-weave pattern at each side of the joint without bunching up in the crease.

The ultimate first-aid tool for stabilizing upper extremity fractures.

1. Place the injured arm gently across the patient's chest so that the fingers are elevated and almost touching the opposite (healthy) shoulder. (Rationale: To physically mobilise the fracture, reduce muscle spasm, and relieve severe pain).
2. Slide the unfolded triangular bandage between the chest and the injured arm. Place one upper corner over the uninjured shoulder, letting the right-angled corner (the point) stick out just beyond the elbow on the injured side.
3. Bring the bottom corner up over the injured forearm, carrying it over the injured shoulder.
4. Carry both corner ends around the back of the neck and tie the ends securely with a reef knot (square knot). The knot MUST lie in the fleshy hollow just above the clavicle on the UNINJURED side. (Rationale: Never tie a knot directly on the cervical spine/neck bone; the weight of the arm will cause excruciating pressure and nerve damage).
5. The protruding right-angle point at the elbow is neatly folded forward and pinned securely to the front of the sling to enclose the elbow tightly in a pocket. (Rationale: To prevent the elbow from sliding out and prevent raw edge skin irritation).

1. Facing the patient, hold the sterile eye pad firmly in position over the affected eye until the first turn of the bandage locks it. (Rationale: To secure the dressing and maintain gentle pressure).
2. Begin from the affected side, pulling toward the normal side. Go across the forehead and round the head in a circular fixing turn.
3. From the back of the head, bring the bandage under the ear on the affected side, diagonally up across the cheek, covering the lower (nasal) side of the eye pad, and pull it straight over the top of the head and down the back.
4. The next turn repeats this, but comes slightly higher, overlapping the first eye turn by 2/3. It crosses the fixing turn at the exact same point above the ear, covers the rest of the pad, and comes round to the front.
5. Fix a safety pin or tape safely in the centre of the forehead.

1. Position the patient comfortably in a sitting up position and stand directly behind them.
2. Place the centre of the outer surface of the bandage precisely in the centre of the forehead/head.
3. Bring both heads of the bandage round the sides, over the temples, and strictly above the ears to the nape of the neck where the ends cross over each other. (Rationale: Ensure that the delicate cartilage of the ear is not caught or folded over).
4. Bring one bandage horizontally around the head (the locking band), while the other bandage is pulled vertically over the centre of the top of the scalp (the dome) down to the root of the nose.
5. Bring the horizontal locking bandage over the forehead, pinning down the vertical bandage. The vertical bandage is then flipped back over the head to the nape of the neck.
6. Ensure that each vertical turn across the scalp overlaps 2/3 of the previous turn. (Rationale: Ensures the bandage adheres snugly to the spherical shape of the skull without slipping).
7. Cross it again at the back, lock it with the horizontal bandage, and bring it forward over the scalp to the opposite side of the midline.
8. Repeat these alternating backward and forward turns to the left and right of the centre until the entire scalp is completely woven and covered.
9. Take two final, tight circular turns entirely around the head with the horizontal bandage to lock all the pleats, and secure with a safety pin or tape.

1. Apply longitudinal strips back and forth over the end of the stump. Overlap each layer by half to two-thirds the width. Wrap firmly to shape the stump, but not tightly enough to cause ischemia. Ask the patient frequently if they feel any numbness, tingling, loose skin rubbing, tightening, aching, or throbbing pain.
2. Stand directly facing the patient and take a circular fixing turn around the base of the stump. (Rationale: To constantly observe their facial expression for signs of hidden pain).
3. Fold the bandage forward across the front of the stump at a 45° angle, fold it over the blind end, and bring it backwards. Lock it in place by crossing the first circular turn at a right angle.
4. Repeat these recurrent, folding turns—locking each one with a circular turn—until the stump is fully enclosed and protected.

You must know the specific indications for each sling type for clinical scenarios:

• Triangular arm sling (Broad Arm Sling): Supports the entire weight of the forearm and the wrist horizontally. Used primarily for fractures of the radius/ulna (forearm) or wrist sprains.
• High arm (Elevation) sling: The arm is folded tightly and elevated high against the opposite chest wall, with the fingers pointing to the collarbone. Used to drastically reduce severe swelling of the hand/wrist post-injury, and to use gravity to control severe arterial bleeding from the arm.
• Collar-and-cuff sling: A simple loop of material forming a clove hitch around the wrist, suspended from the neck. It supports ONLY the wrist. Used specifically for fractures of the upper arm (humerus), shoulder, or clavicle. Rationale: It allows the heavy humerus bone to hang vertically by gravity, pulling the broken bone ends into perfect, natural alignment without needing a heavy cast.

• A Splint is any rigid or flexible device used to immobilise, structurally support, and protect an injured part of the musculoskeletal system (such as a bone fracture, joint dislocation, or severe tendon/ligament sprain) or to forcefully maintain a body part in correct anatomical alignment during the long healing process.
• Splinting is the precise clinical act of applying this device safely.

Why is splinting a life-saving first aid skill?

1. To strictly immobilise unstable fractures and dislocations. Rationale: Broken bone ends are as sharp as razor blades. If they move, they will slice through nearby major nerves and deadly arteries (converting a closed fracture into a massive internal hemorrhage).
2. To drastically relieve excruciating pain and instantly reduce severe, damaging muscle spasms around the break.
3. To prevent or mechanically correct severe deformity, maintaining proper alignment during bone healing (callus formation).
4. To support massively injured soft tissues (severe Grade III sprains and muscle tears).
5. To secure and protect life-saving dressings and IV lines inserted on agitated patients' limbs.
6. To allow the safe, pain-free, and shock-preventing transport of the injured casualty from the field to the hospital.

• Rigid splints: Made of wood, solid metal, hard plastic, or stiff cardboard. Rule: They must be physically long enough to completely immobilise the joint ABOVE and the joint BELOW the fracture.
• Soft splints: Using a thick pillow wrapped around an ankle, a heavy blanket roll, or a simple arm sling tied to the torso. Used for minor/stable injuries.
• Traction splints (e.g., The Thomas Splint): Used specifically and exclusively for mid-shaft Femur (thigh) fractures. The thigh muscles are massive; when the femur breaks, the muscles spasm and pull the bone ends over each other, causing massive internal bleeding (up to 1.5 Liters!). The traction splint applies continuous, powerful mechanical pulling (traction) to realign the massive bone, stopping the spasm and saving the leg.
• Plaster of Paris (POP) casts / slabs: Used definitively in hospitals for long-term (6-8 weeks) rigid immobilisation while the bone fuses.
• Air (pneumatic) splints: Inflatable, clear plastic sleeves commonly used in modern ambulance/field rescue. They provide uniform 360-degree compression to stop bleeding and immobilize simultaneously.

If you fail to follow these golden rules in the field, you can cause permanent paralysis, massive bleeding, or forced amputation:

1. Always assess the casualty's ABCs first (DRABC) and definitively control severe, spurting arterial bleeding before attempting to apply a splint.
2. Splint the limb in the EXACT position it was found. NEVER, ever attempt to forcefully straighten or realign a severe fracture or dislocation in the field. You will sever the artery. Let the ER doctors do it under X-ray.
3. Always immobilise the joint strictly above and the joint strictly below the fracture site. (e.g., For a shin/tibia fracture, you must lock both the knee and the ankle).
4. Pad the rigid splint extremely well with cotton or clothing, especially around bony prominences (ankles, knees). Secure it with bandages tightly above and below the fracture site — never tie a constricting knot directly over the broken bone.
5. Always expose the tips of the fingers or toes. Check CSM (Circulation, Sensation, Movement) before applying the splint, AND immediately after tying it. Recheck every 15 minutes!
6. The splint must be mechanically snug, but never tight enough to act as a tourniquet and cut off blood flow.
7. Elevate the shattered limb after splinting, treat the patient for systemic hemorrhagic shock (keep them warm, lie them flat), and arrange urgent surgical referral.

This is an absolute orthopaedic emergency. It occurs when a bone breaks, causing massive internal bleeding and swelling inside a rigid, non-expanding muscle compartment (or inside a tight POP cast/bandage). The pressure builds until it crushes and collapses the arteries and veins. Muscle tissue and nerves begin to die (necrosis) within 4-6 hours, leading to irreversible paralysis and amputation.

You must continuously check the "6 Ps" of arterial ischemia:

• 1. Pain: Severe, relentless, out of proportion to the injury, and agonizingly worse on passive stretching of the toes/fingers.
• 2. Pallor: The skin becomes pale, white, and completely drained of blood.
• 3. Paresthesia: Numbness, tingling, or "pins and needles" (the nerves are screaming as they die).
• 4. Paralysis: The patient is completely unable to move the fingers/toes.
• 5. Pulselessness: No palpable pulse beyond the cast (a very late, ominous sign).
• 6. Poikilothermia: The limb feels ice cold to the touch compared to the rest of the body.

Action: This is a massive EMERGENCY. The cast or tight bandage must be split down the middle (bivalved) or removed entirely immediately! If pressure doesn't drop, the surgeon must perform an emergency fasciotomy (slicing the leg open to relieve pressure).

• While the plaster dries (The critical first 24–48 hours): A wet cast is fragile. Handle it using the flat palms of your hands only! Using your fingertips will create inward dents in the wet plaster; when it dries hard as rock, these dents will press into the patient's skin, cutting off blood supply and causing deep, rotting pressure sores. Support the wet cast on soft, plastic-covered pillows. Keep it completely uncovered and exposed to room air to facilitate rapid drying. Use a bed cradle (a metal cage) to keep the heavy weight of bedclothes off a wet leg plaster.
• After drying: Keep the plaster strictly clean and dry. (Cover it with a plastic bag when washing/sponging the patient, but do not leave the plastic enclosed long-term, or the trapped sweat will macerate the skin). Keep the hard edges of the cast smooth and heavily padded with adhesive tape (petaling) to prevent it from slicing into the skin.
• Neurovascular observations (CSM): As the nurse, you must constantly, obsessively check the colour, warmth, capillary refill, pulses, sensation, and movement of the exposed fingers/toes. Always compare them directly with the uninjured, normal limb. Report coldness, blueness (cyanosis), massive swelling, numbness, or severe unremitting pain immediately!
• Elevate: Keep the casted limb elevated high on pillows above the level of the heart for the first 24–48 hours. Gravity is your best friend to drastically reduce massive inflammatory swelling.
• Exercises: Forcefully encourage the patient to actively and frequently move their fingers/toes and the joints that are NOT locked inside the cast. Rationale: This prevents severe joint stiffness, muscle atrophy, and promotes venous return, preventing deadly Deep Vein Thrombosis (DVT) blood clots.
• The "Itch" Warning: Warn the patient to never, ever insert foreign objects (like rulers, knitting needles, or pens) deep inside a cast to scratch a maddening itch. It breaks the fragile, unseen skin, introduces bacteria, and causes horrific hidden, rotting staph infections under the plaster.

Objectives:
1. Identify the exact clinical requirements used for preparing and applying orthopaedic POP splints.
2. Demonstrate the application of an orthopaedic splint correctly and safely.

1. Understand the chemistry: Plaster sets (hardens) in just a few minutes due to an exothermic chemical reaction (it gets very warm), but it takes several hours to up to 48 hours to dry completely and reach maximum structural strength.
2. To assist the splint in maintaining the exact correct anatomical position, allow absolutely nothing hard to press against a wet plaster (e.g., resting it on the metal bed frame, a chair edge, or a cradle). Keep the rest of the patient's body warm with blankets to prevent systemic chilling from the wet, evaporating cast.
3. Leave the new plaster completely exposed to the circulating room air, supported gently on soft, yielding pillows if necessary.
4. For a massive leg plaster, a bed cradle should be used to suspend the heavy, warm bed clothes off the wet cast, allowing air flow and preventing deformation.

1. The patient should receive a thorough, soapy bath of the limb before the plaster is applied to remove oils and dead skin; fingernails should also be cut very short to prevent the patient from blindly scratching inside the cast and causing infection.
2. The fingernails must be completely clean, and absolutely no plaster splash should be left dried on them. (Rationale: Plaster stuck on nails makes it physically impossible for nurses to accurately check capillary refill and assess life-saving circulation).
3. The fingers and toes should feel subjectively warm to the patient and be completely free to move voluntarily.
4. REPORT IMMEDIATELY to the surgeon if the fingers become ice cold, pale, or blue (cyanotic) in colour! This is an active compartment syndrome.
5. The patient should be able to move their fingers and toes freely without agony, and neurological sensation (sharp vs dull touch) should be tested regularly to ascertain that the neurovascular circulation is perfectly satisfactory and the cast is not crushing a major nerve (like the radial or peroneal nerve).

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