Observe the dressing and wound site:
Do not change the dressing if it is clean and dry.
- If the wound dressing has exudates soaked through it should be replaced. Consideration should be given to a suitable dressing for the absorption of exudate by referring to local wound guidelines. The wound should be observed and nursing interventions recorded in the nursing documentation.
Clean, dry wounds:
Dry wounds should be treated dry.
The wound should be irrigated and cleaned with non-woven sterile gauze. The wound should be irrigated with sterile saline solution. A wound swab should then be taken and sent for culture and sensitivity.
Important questions to consider when observing surgical wounds:
- Bleeding – check if it is seeping or trickling, what should be done?
- Is there tenderness or pain around the wound edges, what should be done?
- Swelling could be a haematoma. What should be done in such cases?
- Redness around the wound edges. If the redness is over 2cm, an infection is indicated.
- Pyrexia can be a clear sign of infection in combination with redness and swelling around the wound edges.
- Does the suture line seem swollen?
- Exudate, colour, amount and odour?
Symptoms of infected surgical wounds are redness, pyrexia, pain, swelling and excessive exudates.