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25.2 Dressing a malignant fungating wound

After the nurse has assessed the wound and decided on the clinical management plan as outlined previously, the malignant fungating wound is redressed. In practice, this is a continuation of Procedure guideline 25.1. Please refer to this for the pre‐procedure steps.

Procedure

ActionRationale

  1. 1.
    Clean hands and put on sterile gloves.
    To reduce the risk of cross‐contamination of micro‐organisms to staff and patients. Aseptic technique required to prevent hospital‐acquired infection when the body's natural defence mechanisms are compromised by an open wound (Loveday et al. [84]). C
    Gloves provide greater sensitivity than forceps and are less likely to traumatize the wound or the patient's skin. E
  2. 2.
    If necessary, gently irrigate the wound with 0.9% sodium chloride warmed to body temperature, unless another solution is indicated (warm saline solution in tap water).
    To reduce the possibility of physical and chemical trauma to granulation and epithelial tissue (Hess [67]). C
    When wound temperature drops below body temperature cellular activity decreases, slowing the healing process (Naylor et al. [103], E).
  3. 3.
    Apply skin barrier if required (see periwound skin, Table 25.5)
    To protect skin from damage due to excessive exudate (Benbow [15], E).
  4. 4.
    Apply the dressing that is most suitable for the wound using the criteria for dressings (see section for relevant symptom).
    To promote healing and/or reduce symptoms. E
  5. 5.
    Secure dressing in place with atraumatic tape/netting or tubular bandage.
    To reduce the risk of trauma to surrounding tissue (Davis et al. [26], E).
  6. 6.
    Make sure the patient is comfortable and the dressing is secure.
    A dressing may slip or feel uncomfortable as the patient changes position. E

Post‐procedure

  1. 7.
    Dispose of waste in orange plastic clinical waste bags and sharps into a sharps bin. Remove gloves and wash hands.
    To prevent environmental contamination and sharps injury. Orange is the recognized colour for clinical waste (DOH [30], C).
  2. 8.
    Ensure the patient is comfortable and draw back the curtains.
    To promote well‐being and maintain dignity and comfort. E
  3. 9.
    Clean hands with bactericidal alcohol rub. Wipe trolley with detergent wipe and return to storage.
    To prevent the risk of cross‐contamination from previous episode of care (Fraise and Bradley [43]). C
  4. 10.
    Record assessment in relevant documentation at the end of the procedure.
    To maintain an accurate record of wound‐healing progress (NMC [107], C). See Figure 25.5.
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