Performing Irrigation of a Wound

Goal: The wound is cleaned without contamination or trauma and without causing the patient to experience pain or discomfort.

1. Review the medical orders for wound care or the nursing plan of care related to wound care.

2. Gather the necessary supplies and bring to the bedside stand or overbed table.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed and close door to room if possible. Explain what you are going to do and why you are going to do it to the patient.

6. Assess the patient for possible need for nonpharmacologic pain-reducing interventions or analgesic medication before wound care and/or dressing change. Administer appropriate prescribed analgesic. Allow enough time for analgesic to achieve its effectiveness before beginning procedure.

7. Place a waste receptacle or bag at a convenient location for use during the procedure.

8. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8, 2009).

9. Assist the patient to a comfortable position that provides easy access to the wound area. Position the patient so the irrigation solution will flow from the clean end of the wound toward the dirtier end. Use the bath blanket to cover any exposed area other than the wound. Place a waterproof pad under the wound site.

10. Put on a gown, mask, and eye protection.

11. Put on clean gloves. Carefully and gently remove the soiled dressings. If there is resistance, use a silicone-based adhesive remover to help remove the tape. If any part of the dressing sticks to the underlying skin, use small amounts of sterile saline to help loosen and remove.

12. After removing the dressing, note the presence, amount, type, color, and odor of any drainage on the dressings. Place soiled dressings in the appropriate waste receptacle.

13. Assess the wound for appearance, stage, the presence of eschar, granulation tissue, epithelialization, undermining, tunneling, necrosis, sinus tract, and drainage. Assess the appearance of the surrounding tissue. Measure the wound. Refer to Fundamentals Review 8-3.

14. Remove your gloves and put them in the receptacle.

15. Set up a sterile field, if indicated, and wound cleaning supplies. Pour warmed sterile irrigating solution into the sterile container. Put on the sterile gloves. Alternately, clean gloves (clean technique) may be used when irrigating a chronic wound.

16. Position the sterile basin below the wound to collect the irrigation fluid.

17. Fill the irrigation syringe with solution. Using your nondominant hand, gently apply pressure to the basin against the skin below the wound to form a seal with
the skin.

18. Gently direct a stream of solution into the wound. Keep the tip of the syringe at least 1 above the upper tip of the wound. When using a catheter tip, insert it gently into the wound until it meets resistance. Gently flush all wound areas.

19. Watch for the solution to flow smoothly and evenly. When the solution from the wound flows out clear, discontinue irrigation.

20. Dry the surrounding skin with gauze dressings.

21. Apply a skin protectant to the surrounding skin.

22. Apply a new dressing to the wound (see Skills 8-1, 8-2, 8-3).

23. Remove and discard gloves. Apply tape, Montgomery straps, or roller gauze to secure the dressings. Alternately, many commercial wound products are self adhesive and do not require additional tape.

24. After securing the dressing, label dressing with date and time. Remove all remaining equipment; place the patient in a comfortable position, with side rails up and bed in the lowest position.

25. Remove remaining PPE. Perform hand hygiene.

26. Check all wound dressings every shift. More frequent checks may be needed if the wound is more complex or dressings become saturated quickly.