17. CCA Study Notes: Wound Dressings, Dressing Changes, and Support Worker Responsibilities

The Big Picture

A wound is a break in the skin or a mucous membrane. A dressing covers a wound for reasons such as protection, drainage absorption, comfort, and healing support.

CCA responsibilities depend on the dressing, the client’s care plan, workplace directions, and whether the task falls within the worker’s role. An important part of wound care is noticing changes, following directions, protecting the client, and reporting and recording observations.

Dressing changes also require careful attention to cleanliness, comfort, privacy, and infection prevention.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

What Wound Dressings Do

Wound dressings serve several purposes. They:

• protect a wound from injury and microbes
• absorb drainage
• remove dead tissue
• promote comfort
• cover wounds that the client finds unpleasant to see
• provide a moist environment for wound healing
• help control bleeding when a pressure dressing is used

Who Chooses the Dressing

The type and size of dressing depend on several factors:

• the type of wound
• the wound’s size and location
• the amount of drainage
• whether infection is present
• the purpose of the dressing
• how often the dressing changes

The physician and nurse choose the most suitable dressing.

A CCA might assist with the application of a sterile dressing. Choosing the type of dressing falls outside the support worker’s role.

Role limit: The CCA is not responsible for sterile dressing changes or skin assessment. Those responsibilities belong to the nurse.

The CCA still has an important observation role. Watch the dressing and report important details to the nurse.

Overall Responsibilities When a Client Has a Wound

The CCA should:

• follow the client’s care plan
• document wound care and observations made
• work with the rest of the health care team
• practise proper hand hygiene
• follow asepsis rules
• report and document wound-related observations

Reporting and documentation should include a description of the wound and a measurement of its size. This information helps the health care team determine whether the wound is healing, worsening, or becoming infected.

Preventing Pressure Injuries

A pressure injury is an injury caused by unrelieved pressure. Other names include pressure ulcer, pressure sore, bedsore, and decubitus ulcer.

A bony prominence is an area where the underlying bone seems to stick out. These areas need close observation because pressure against a surface increases concern for skin damage.

Observe the client’s skin, especially over bony prominences. Report reddened areas.

Other supported prevention measures include:

• Remove restrictive clothing, such as socks that are too tight and interfere with circulation.
• Reposition the client at least every 2 hours, or more often when the care plan directs it.
• Inspect bony prominences that have been compressed against a surface.
• Make sure the client uses a gel pad seat cushion correctly when one is provided to reduce pressure.
• Keep bony prominences and skin folds clean and dry.
• Wash the skin after soiling, rinse it, and pat it dry.
• Place padding between body parts when directed to reduce pressure and irritation.
• Avoid oily soaps that trap bacteria.
• Avoid drying antiperspirant soaps that contribute to dry, cracked skin.
• Use peri-wash when possible. Peri-wash is a gentle, pH-balanced cleanser that leaves no residue on the skin.
• Massage around reddened areas only. Never massage directly on a reddened area.
• Never perform nail care when the client has diabetes or when the care plan says to avoid it. For some clients, nail care should be performed only by a professional with specialized training in foot care. Report reddened areas and ingrown toenails.
• Report and record findings according to workplace policy.

Pain and Comfort

Pain affects more than comfort. A client in pain might eat less or avoid participating in care. Pain also affects breathing, movement, turning, repositioning, and walking. It is exhausting and might contribute to depression or irritability.

Look for signs of pain such as:

• grimacing
• holding one body part for a long time
• tensing during repositioning

When the client is in pain, identify the location, amount, intensity, aggravating factors ⓘ, and cause so the information is available for reporting and recording.

The CCA should:

• handle the client gently
• report pain and its details to the appropriate nurse
• allow pain medication to take effect before care, at least 1 hour as directed in this section
• help the client into a comfortable position
• turn the client according to the care plan
• avoid pressure on compromised areas
• massage around bony prominences only when the care plan directs it
• support proper body alignment
• use pillows for positioning
• keep the bed surface wrinkle-free

The nurse gives ordered pain medication when appropriate.

Movement and Ambulation

Movement encourages deeper breathing and better circulation. It also reduces pressure-injury risk, increases metabolism, promotes peristalsis, and improves digestion.

Pain might make a client reluctant to move or walk. A foul-smelling wound might also make the client feel self-conscious about leaving the room.

Support movement by:

• encouraging the client to move in bed
• encouraging deep breathing
• encouraging independent turning as much as possible
• assisting the client into a chair or wheelchair according to the care plan
• assisting with walking as often as the care plan states
• turning a client who cannot walk as frequently as the care plan directs
• scheduling activity at least 1 hour after pain medication so the client is more comfortable
• having another worker nearby in case the client feels light-headed or faint
• encouraging the client to rise slowly
• encouraging a few deep breaths before standing

Caring for and Observing Dressings

Dressing appearance and maintenance differ by dressing type. All dressings should stay clean.

Dressing application might be a task delegated ⓘ by a nurse in some parts of Canada.

Observe whether the dressing is:

• clean
• free from urine, feces, and other bodily fluids

Report relevant findings.

When required, assist the nurse during a dressing change. Control facial expressions when a wound has an unpleasant appearance. Your reaction should not alarm or embarrass the client.

Nutrition and Hydration

Wound healing requires adequate nutrition and fluid.

A diet low in protein or vitamin C does not support wound healing. The client also needs enough fluid to replace fluid lost through wound drainage.

A client with anemia does not have enough hemoglobin to bind with oxygen. An iron-rich diet is therefore included in the supported nutrition information.

Follow the care plan, dietary needs, and client preferences when preparing food. Supported food priorities include protein, vitamin C, and iron.

For a client with diabetes, make sure caloric restrictions ⓘ are not exceeded.

Offer liquids frequently during the day. Observe and report urine output that is low or dark in colour.

Oxygen and Healing

Oxygen is required for healing. Oxygen binds to hemoglobin, which forms part of a red blood cell, and travels through the body.

The CCA should:

• help the client maintain positions that support maximum lung expansion
• remind the client gently to take several deep breaths at least every hour

Managing Wound Odour Respectfully

Wounds containing necrotic tissue, meaning localized dead tissue caused by disease or injury, might have a strong unpleasant smell.

Odour might embarrass the client and affect appetite.

Support the client by:

• keeping drainage containers out of sight
• opening windows for fresh air when possible
• removing used dressing materials promptly
• putting used dressing materials in a plastic bag
• tying the bag to contain the odour
• using room air freshener discreetly when possible
• moving the client to another room for meals when possible

Temperature and Signs of Infection

Fever is one way the body responds to infection by increasing white blood cells and blood flow to the affected area.

A client with an infection does not always have a fever. Older people and people with immune challenges might have an infection without a noticeable fever.

Follow the care plan for taking the client’s temperature. Report a fever.

Report: Report abnormal findings at once.

Older people often have a lower normal body temperature. Watch for other supported signs of infection around a wound, including:

• redness
• swelling
• tenderness
• warmth

Skin Care

Clean, dry skin is less likely to harbour pathogens than moist, soiled skin. Pathogens contribute to skin infections, injury, and breakdown.

The CCA should:

• keep the client’s skin clean and dry
• avoid powders that dry the skin too much or irritate the airway
• rinse the skin thoroughly after washing
• pat the skin dry
• avoid rough towel drying, especially with fragile skin
• report and record edema, bruising, swelling, and other abnormal findings

Edema means swelling in tissues caused by accumulated fluid.

Maintaining Skin Integrity

Intact skin provides the body’s first line of defence against pathogens.

Protect the skin by:

• transferring and positioning the client gently
• using equipment correctly
• using friction-reducing equipment such as sliding boards
• never placing straps or boards directly against the skin
• keeping the skin clean and dry
• avoiding tight or restrictive clothing

Direct contact between straps or boards and skin increases the risk of scratches and bruising.

Physical and Emotional Concerns Related to Wounds

Delayed healing is a concern for clients who are older, obese, or poorly nourished. Poor circulation and diabetes also affect healing.

Wounds affect more than the skin. A wound might change the client’s body image and self-esteem. A client might worry about scarring, disfigurement, delayed healing, infection, or the wound opening.

An amputation involving a finger, hand, arm, toe, foot, or leg might affect function, daily activities, and employment.

Eye injuries might affect vision. A wound might also affect sexual performance or the client’s sense of sexual attractiveness.

Clients with serious or disfiguring wounds might need added love and acceptance. They might feel sad, tearful, angry, or hostile.

CCA support includes:

• showing empathy
• handling the client gently
• giving compassionate care
• communicating well
• cooperating with other health care team members involved in the client’s care

Those team members might include social workers, psychiatrists, therapists, and spiritual advisors.

Survivors of violence might fear another attack, worry about the attacker being found or convicted, or fear for family members. Survivors of abuse sometimes hide the true source of their injuries.

After surgery, anaesthesia and pain medication might affect eating and elimination.

Common Types of Dressings

Dressings differ by material and application method. They include dry, moist, and hydrocolloid dressings.

A hydrocolloid is described here as a substance that forms a gel when water is present.

Gauze

Gauze comes in:

• squares
• rectangles
• pads
• rolls

Gauze absorbs moisture.

Non-Adherent Gauze

Non-adherent gauze has a nonstick surface. It does not stick to the wound and comes away more easily without injuring the tissue.

Vapour-Permeable Transparent Adhesive Film

This transparent film allows air to reach the wound while blocking fluid and microbes.

It:

• keeps the wound moist
• does not absorb drainage
• allows the wound to remain visible for observation

Some dressings contain special agents that promote wound healing.

When assisting with a dressing change within the worker’s role, follow the supervisor’s explanation and directions about the dressing used for that client.

Securing a Dressing

A dressing must stay secure over the wound. Secure placement helps keep microbes out and drainage contained.

Types of Tape

Common tapes include:

• adhesive tape
• paper tape
• plastic tape
• elastic tape

Adhesive tape sticks well. Its adhesive residue might be difficult to remove and might irritate the skin. Skin might come off with the tape and cause an abrasion.

An abrasion is a partial-thickness wound caused when skin is scraped or rubbed away.

Paper and plastic tapes are used for clients who are allergic to adhesive tape because these tapes do not usually cause allergic reactions.

Elastic tape supports easier movement of the body part.

How Tape Is Placed

Tape secures the top, middle, and bottom of a dressing. It extends several centimetres past both sides.

Avoid: Tape must not circle the entire body part. Swelling might then impair circulation.

A picture-frame dressing has tape along all four edges. It is less likely to wrinkle or fall off when the client tolerates this method.

Some simple bandages already have adhesive on all four edges. Others are transparent and allow vapour and oxygen exchange.

Children and Dressing Changes

Children often fear dressing changes. Removing tape might hurt, and the wound’s appearance might frighten the child.

It is important to keep the child calm and cooperative so the sterile field does not become contaminated.

Supported approaches include:

• having a parent or caregiver hold the child so the wound remains accessible
• letting the child hold or play with a favourite toy
• suggesting that the child practise applying and removing a dressing on a doll

Older People and Tape Removal

Skin becomes thinner and more fragile with age. Skin tears are therefore more common in older people.

A skin tear is a break or rip in the skin where the epidermis separates from underlying tissue.

Use extreme care when removing tape. One supported method involves folding the edge of the tape back and peeling it along the skin instead of lifting it upward. This reduces lifting of the skin.

Home Care Dressing Changes

In home care, the supervisor might direct the worker to telephone after removing the old dressing.

During the call:

1. Report observations.
2. Receive the supervisor’s directions about what to do next.

Follow employer policy for dressing disposal.

The usual disposal process described here is:

1. Put the used dressing in a plastic bag.
2. Fasten the bag securely.
3. Put the bag in the household garbage.

Before Applying a Nonsterile Dressing

Some employers allow support workers to apply simple, dry, nonsterile dressings to simple wounds.

Before performing this task:

• Make sure the province or territory permits the procedure.
• Make sure the procedure appears in the worker’s job description.
• Apply the dressing only under a nurse’s direction and supervision.
• Review the procedure with the nurse.
• Allow pain medication time to work. The nurse gives the medication and tells you how long to wait.
• Meet the client’s fluid and elimination needs before starting.
• Gather equipment and supplies before beginning.
• Watch your facial expressions and other nonverbal reactions to wound appearance, odour, and drainage.
• Follow Standard Practices.
• Wear personal protective equipment when needed.
• Never touch a wound with ungloved hands.
• Keep the soiled side of a removed dressing out of the client’s view.
• Do not force the client to look at the wound.
• The nurse addresses the client’s concerns about the wound.
• Pull tape toward the wound and fold it back on itself during removal.
• Remove the dressing gently.
• When a dressing sticks, ask the supervisor whether the wound should be dampened, such as with sterile normal saline, to loosen it.
• Observe the wound.
• Report and record observations according to employer policy.

Applying a Dry Nonsterile Dressing

This procedure includes pre-procedure, procedure, and post-procedure steps. Keep the sequence in order.

Promote the client’s dignity, independence, individualized care, preferences, privacy, and safety throughout the procedure.

Pre-Procedure

1. Review the procedure with your supervisor. Knowing the procedure reduces your anxiety and, in turn, the client’s anxiety.
2. Identify the client according to employer policy. Correct identification prevents confusing one client with another.
3. Explain the procedure to the client.
4. Allow pain medication time to take effect. Injectable medication might start working within minutes. Oral pain medication might require at least 1 hour. Waiting supports the client’s comfort.
5. Meet the client’s fluid and elimination needs. This helps the client remain comfortable during the procedure.
6. Practise proper hand hygiene.
7. Collect the required supplies:
   • gloves
   • personal protective equipment as needed
   • tape
   • dressing directed by the care plan
   • dressing tray directed by the care plan
   • small clean gauze squares for wiping the wound area as directed
   • normal saline for cleaning the wound as directed
   • adhesive remover
   • scissors
   • leak-proof plastic bag
   • bath blanket or clean sheet

Gathering equipment before starting avoids leaving the client’s side unnecessarily. It also saves time and avoids tiring the client while missing items are collected.

8. Provide privacy.
9. Arrange the items on the work area.
10. Raise the bed to a comfortable working height. Follow the care plan for bed rail use. Raising the bed reduces back strain. Lowering the head of the bed makes repositioning the client upward easier when needed.

Procedure

11. Lower the bed rail nearest you if it is raised.
12. Help the client into a comfortable position.
13. Cover the client with a bath blanket or clean sheet. Fan-fold the top linen toward the foot of the bed. The folded sheet is easier for the client to grasp when it is time to cover up.
14. Expose only the affected body part. Keep the rest of the client covered to protect privacy and prevent unnecessary chilling.
15. Make a cuff on the plastic bag. Keep the bag within reach and place it so you do not cross over the wound with soiled wipes.
16. Put on a gown and mask when the care plan directs them. These measures reduce pathogen spread.
17. Put on gloves.
18. Remove the tape carefully. Hold the skin down and gently pull the tape toward the wound. Peel the tape close to the skin instead of lifting it upward. This approach improves comfort and reduces the chance of reopening a wound that has not fully healed.
19. Remove adhesive from the skin. Wet a 10 × 10 cm, or 4 × 4 in., gauze dressing with adhesive remover. Clean away from the wound. Remove any remaining adhesive because it irritates the skin. Cleaning away from the wound reduces the chance of introducing pathogens or adhesive into the wound.
20. Remove the gauze dressing. Start with the top dressing. Keep its soiled side out of the client’s sight to reduce anxiety.
21. Put the removed dressing into the leak-proof bag. Do not let it touch the outside of the bag. Keeping the outside clean reduces pathogen spread.
22. Gently remove the dressing directly over the wound. A stuck dressing might reopen tissue that has not fully healed if handled roughly.
23. Observe the wound and drainage. Keep the drainage out of the client’s view because seeing it might upset the client.
24. Remove your gloves and put them in the bag. Practise proper hand hygiene. If a bed rail was in use, raise it before leaving the bedside and lower it when you return.
25. Open the dressing tray. Unfold the clean or sterile wrapper and keep it open. Open the new tray after removing the soiled dressing to reduce contamination risk.
26. Pour normal saline into the dressing tray. Avoid splashing it onto the wrapper because splashing contaminates the wrapper.
27. Prepare five or six small gauze squares. Open their package and use the supplied forceps to place the squares on the dressing tray or clean wrapper. Keep them near the centre of the wrapper or tray. These squares are used to remove old drainage and dried blood. The outer 2.5 cm of the wrapper is considered contaminated.
28. Cut the required length of tape.
29. Put on clean gloves.
30. Pick up a small gauze square. Use the supplied forceps or a clean, gloved hand. Dip the gauze into the normal saline.
31. Clean the middle of the wound with one long stroke from top to bottom. Discard the gauze square into the leak-proof bag after the stroke. When using a cleaning cloth, use a fresh corner for every stroke. Never touch the wound again with a soiled gauze square or used part of the cloth. This method reduces pathogen spread.
32. Clean the wound again down the middle and then along both sides. Work from the centre toward the outside to reduce contamination of the wound.
33. Apply the dressing according to the care plan.
34. Secure the dressing with tape. Tape keeps the dressing from falling off.
35. Remove your gloves and place them in the bag. Practise proper hand hygiene. These steps reduce pathogen spread.

Post-Procedure

36. Provide for the client’s safety and comfort.
37. Cover the client and remove the bath blanket or clean sheet.
38. Place the call bell within reach. This gives the client a safe, easy way to contact staff when needed.
39. Return the bed to its lowest position. Follow the care plan for bed rail use.
40. Remove the privacy measures.
41. Discard the supplies in the leak-proof bag. Tie the bag closed and dispose of it according to employer policy.
42. Clean the work surface according to employer policy. Cleaning reduces pathogen contamination of items later placed on the surface.
43. Practise proper hand hygiene.

After the procedure, report and record your actions, observations, and basic assessments according to employer policy. Reporting and recording keep the health care team informed and are required for legal reasons.

Steps involving bed height, the call bell, and returning the bed to its lowest position do not always apply in community settings.

Common Mix-Ups

Wrong Idea	Better Idea
The CCA chooses the dressing.	The physician and nurse choose the dressing.
Observing the client’s skin means performing a skin assessment.	The CCA observes and reports. Skin assessment is the nurse’s responsibility.
Gauze and transparent film handle drainage the same way.	Gauze absorbs moisture. Transparent film does not absorb drainage.
Tape should wrap fully around a body part to hold a dressing firmly.	Tape must not encircle the whole body part because swelling could impair circulation.
A CCA always performs a nonsterile dressing change when asked.	The procedure must be permitted, included in the job description, and performed under nursing direction and supervision.