SELF/Perioperative Nursing/Wound Management

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▼This page is a part of the Perioperative Nursing Curriculum by ECSACONM and SELFPlease see the Intuitive Foundation Terms of Use and do not edit without permission.

This module trains learners to perform wound cleaning and dressing using sterile technique. It includes all steps from preparation and assessment to dressing application and post-procedure documentation. The learner is expected to maintain sterility throughout the procedure, ensure patient comfort, and perform a clinical evaluation of the wound. The skill is essential for infection prevention and effective wound healing, particularly in inpatient, surgical recovery, or outpatient wound care settings.

• Identify the essential supplies for wound care and explain how preparation and organization support sterility and patient comfort.
• Explain the principles, benefits, and appropriate situations for using the forceps method in wound dressing.  
• Differentiate between dressing types and explain how wound characteristics and resource availability influence selection.
• Identify appropriate indications and contraindications for performing wound cleaning and sterile dressing.
• Recognize unexpected wound findings, explain why they require reassessment, and describe appropriate next steps.
• Explain strategies to adapt wound care practices in low-resource environments, including equipment improvisation and task-shifting.

Before beginning wound care, the nurse should ensure all necessary supplies are collected and arranged to avoid contamination or interruptions. Essential items include:

• sterile dressing packs
• sterile gauze, forceps
• sterile gloves
• a sterile drape
• wound cleaning solution (such as normal saline)
• adhesive or bandaging materials
• waste disposal bags

In some cases, additional items like topical antimicrobials or specialized dressings may be needed, depending on the wound characteristics and availability of resources.

Equally important as the items themselves is the organization of the working environment. The nurse should prepare a clean surface where sterile items can be placed, ensure adequate lighting for wound visualization, and confirm that the patient is comfortably positioned to minimize movement during the procedure. Collecting all supplies beforehand prevents unnecessary interruptions, which may risk breaking sterility if the nurse has to leave the sterile field to search for missing items. In low-resource settings, improvisation may be necessary, but sterility should be prioritized whenever possible—for example, by using boiled and cooled instruments if sterile packs are unavailable.

Self-Assessment

Please complete the following: Quiz: Supplies to Gather - ECSACONM

The selection of the appropriate dressing is a critical clinical decision that directly influences wound healing outcomes. The nurse should begin by assessing wound size, depth, and exudate level, as well as considering the overall health of the patient and the availability of materials.

For wounds with minimal exudate, simple sterile gauze is often sufficient and remains the most accessible option in low-resource environments.

For dry wounds, however, moist dressings such as saline-soaked gauze are strongly preferred because they create a favorable environment for cellular migration, prevent tissue desiccation, and reduce local tissue damage.

In contrast, wounds producing moderate to heavy exudate require absorbent materials that prevent pooling and maceration of surrounding tissue. Layered gauze is commonly used for this purpose, though when available, foam or alginate dressings provide superior absorbency and may reduce the frequency of dressing changes.

For wounds with signs of infection or contamination, antimicrobial dressings may be beneficial, though access to such materials is often limited in low-resource settings.

The nurse’s decision should also factor in patient comfort and practical realities such as how often the dressing can be feasibly changed. Even the best dressing choice will fail if it cannot be maintained appropriately. In practice, many low-resource facilities rely on frequent dressing changes with sterile gauze, which, while resource intensive, can still support healing if performed with rigorous adherence to sterile technique and good clinical judgment.

Self-Assessment

Please complete the following: Quiz: Deciding on Dressing Type - ECSACONM

The forceps method is a sterile dressing technique in which the nurse handles all dressings and wound-contacting materials exclusively with sterile forceps rather than with gloved hands. This technique is especially valuable in low-resource settings where sterile gloves may be limited or must be conserved. By avoiding direct contact, the forceps method minimizes the potential for cross-contamination and maintains a strict “no-touch” principle, allowing the nurse to deliver safe wound care with fewer consumables.

The nurse should consider the forceps method particularly in situations where wound surfaces are small, localized, and can be effectively managed with precision handling. It is most appropriate for surgical incisions, clean traumatic wounds, and wounds with delicate new tissue such as granulation beds. Additionally, it is the preferred method when gloves may be available only in non-sterile form or must be reserved for other invasive procedures.

However, the forceps method requires a high level of technical precision and awareness. Nurses must ensure that the sterile tips of the forceps are the only surfaces that touch dressings or the wound, and that the rest of the instrument does not come into contact with non-sterile fields. Continuous vigilance in technique is necessary, as accidental contamination can easily occur if the forceps touch unsterile surfaces or if dressings are not manipulated carefully.

Self-Assessment

Please complete the following: Quiz: Using the Foreceps - ECSACONM

The use of sterile technique, including the forceps method, is indicated in small, clean wounds that are expected to heal without complications. Examples include minor surgical incisions, superficial lacerations that have been cleaned, and wounds showing healthy granulation tissue without signs of infection. These wounds benefit from careful cleaning and sterile dressing as they are at a stage where the preservation of sterility directly enhances healing outcomes.

Such wounds typically require less complex dressing approaches and can be managed effectively with minimal materials, making them ideal for the forceps method in low-resource settings. By applying a sterile dressing, the nurse protects the wound from external contaminants, maintains a moist healing environment, and reduces patient discomfort. This approach is also particularly suited for perioperative settings, where patients are already vulnerable to infection risks.

The nurse should confirm that the wound has clean edges, controlled exudate, and no evidence of necrosis or infection before proceeding. By adhering to these indications, the nurse ensures that resources are being applied where they are most effective and that wound care interventions are matched to the clinical condition of the patient.

Self-Assessment

Please complete the following: Quiz: When to Perform Wound Cleaning and Dressing - ECSACONM

Sterile dressing with the forceps method is contraindicated for extensive wounds, large burns, or wounds that are heavily contaminated. Such wounds often require advanced wound care interventions such as surgical debridement, skin grafting, or the use of specialized dressings that provide more than basic coverage. Attempting to manage them with simple sterile gauze and the forceps method risks inadequate care, delayed healing, and increased infection.

Nurses should also avoid using this method when wounds involve deep tissue structures, uncontrolled bleeding, or systemic signs of infection such as fever, spreading cellulitis, or sepsis. In such situations, wound care becomes a higher-level intervention requiring surgical or medical management beyond the scope of routine sterile dressing. Continuing with simple dressing in these cases may give a false sense of security while the patient’s condition deteriorates.

Recognition of these contraindications is crucial. By identifying when not to apply the forceps method, the nurse can advocate for appropriate referral, escalate care where possible, and avoid wasting limited resources on interventions unlikely to succeed.

Self-Assessment

Please complete the following: Quiz: Contraindications for Wound Cleaning and Dressing - ECSACONM

During the procedure, the nurse must be alert to unexpected findings. These may include an increase in exudate, the presence of foul odor, necrotic tissue, spreading erythema, or signs of systemic infection. If such findings are present, continuing with a routine dressing is not appropriate, as the underlying wound pathology may require more intensive intervention. The nurse should instead pause, reassess the wound, and consider alternative approaches or referral to higher care.

In resource-limited environments, where advanced wound care options may not be immediately available, the nurse may need to adapt while still prioritizing patient safety. For example, applying a temporary protective dressing, maintaining documentation of the wound’s changes, and initiating infection prevention measures such as cleansing with saline may serve as interim steps. Importantly, any changes should be carefully recorded in the patient’s notes to guide continuity of care and referral decisions.

Ultimately, the decision to continue or withhold further dressing depends on a balance between clinical judgment, available resources, and patient safety. Nurses must rely on their theoretical knowledge of wound healing, combined with careful bedside evaluation, to determine the best course of action.

Self-Assessment

Please complete the following: Quiz: When the Wound is Not as Expected - ECSACONM

In low-resource environments, shortages of personnel or equipment may require adaptation without compromising safety.

When sterile gloves are unavailable, for example, the nurse can use a forceps-only technique to avoid direct wound contact, ensuring that instruments remain sterile throughout. Boiling instruments or using chemical sterilization may be necessary when pre-packaged sterile supplies are not available. Nurses should also prioritize the use of limited resources for patients at greatest risk of complications.

When personnel are limited, task-shifting strategies can be used—such as assigning supportive staff or family caregivers to assist with non-sterile tasks like preparing the patient or managing waste, leaving sterile procedures to the nurse. Careful planning, clear role division, and strict adherence to infection prevention principles allow wound care to remain safe and effective even under constrained conditions.

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Wound Management - Cumulative Assessment

Please complete the following before proceeding to the next section of this module:

Module Test: Wound Management - ECSACONM

• Lesson 1 - to be created after completing Section 4.3 in the worksheet
• Lesson 2 - to be created after completing Section 4.3 in the worksheet
• Lesson 3 - to be created after completing Section 4.3 in the worksheet

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