Nursing Component Task
Nursing procedures & clinical learning

General Nursing (RGN)

DRESSING OF COMPLICATED WOUND (WITH ASSISTANT)

A complicated wound dressing is a planned aseptic intervention for a large, deep, draining, undermined, infected, or otherwise complex wound. Two nurses coordinate positioning, pain relief, equipment, observation, and documentation while maintaining asepsis and patient safety.

Purpose

  • Remove exudate and non-viable material as prescribed
  • Protect the wound and surrounding skin
  • Promote healing and reduce infection risk
  • Assess wound progress and identify complications
  • Support the patient during a procedure that may require assistance

Indications

  • A complex wound requiring aseptic dressing
  • Heavy exudate, cavities, drains, multiple wound sites, or difficult positioning
  • A prescribed dressing plan or wound-care review

Equipment

  • Sterile dressing pack and sterile gloves
  • Prescribed cleansing solution and irrigation equipment
  • Sterile gauze, packing material, and appropriate dressing
  • Forceps, scissors, probe, kidney dishes, and gallipots as indicated
  • PPE including apron, mask, and eye protection when splash is possible
  • Mackintosh and clean towels
  • Waste bags and sharps container
  • Pain assessment tool and documentation record

Preparation

  • Check analgesia effectiveness, nutrition and pressure-area needs, and the patient’s ability to tolerate the required position.
  • Review the previous dressing, wound photographs or measurements, and prescribed products before opening sterile supplies.

Procedure steps

  • Review the wound-care plan, allergies, analgesia prescription, isolation status, and need for a second trained nurse.
  • Identify the patient with two identifiers, explain the procedure and roles, obtain consent, assess pain, and provide prescribed analgesia in time to work.
  • Prepare a clean trolley, perform hand hygiene, provide privacy, and position the patient with the assistant while protecting alignment and dignity.
  • Inspect the existing dressing for strike-through, odour, leakage, and displacement; remove it gently with clean gloves and dispose of it safely.
  • Remove gloves, perform hand hygiene, and establish the sterile field without reaching over it or allowing non-sterile items to touch it.
  • The assistant maintains the patient’s position, light, privacy, and safety while the primary nurse performs the aseptic wound care.
  • Assess wound bed, edges, surrounding skin, exudate, odour, pain, drains, and signs of infection; compare with prior documentation.
  • Clean from the least contaminated area to the most contaminated area using one sterile swab per stroke, or irrigate as prescribed; avoid trauma to granulation tissue.
  • Apply prescribed packing or dressing without overpacking, secure it comfortably, and label the dressing or wound record when required.
  • Reposition the patient, dispose of equipment, decontaminate reusable items, perform hand hygiene, reassess comfort, and document findings and escalation.

Precautions

  • Use aseptic non-touch technique and change gloves when moving from contaminated to clean tasks.
  • Stop and escalate uncontrolled bleeding, wound dehiscence, exposed organs, severe pain, rapidly spreading erythema, or systemic deterioration.
  • Do not probe a wound, remove packing, or apply topical products unless prescribed or included in the wound plan.
  • Use an assistant who understands the role; the assistant must not compromise the sterile field.

Aftercare

  • Ensure the dressing is secure but not constrictive and that circulation, sensation, and comfort are maintained.
  • Give the patient advice about keeping the dressing clean and reporting increased pain, bleeding, odour, fever, or leakage.

Documentation

  • Record wound location, measurements, tissue type, exudate amount and character, odour, edges, surrounding skin, pain, dressing products, and tolerance.
  • Record the names or roles of staff assisting and any specimen, referral, or urgent escalation.

Educational resource only. Follow current Nursing and Midwifery Council guidance, local institutional protocols, scope of practice, and clinical supervision.

Open Component Task app