Performing Sterile Wound Irrigation

Performing Sterile Wound Irrigation

Equipment
■ Clean gloves.
■ Sterile gloves.
■ Gown and face shield.
■ Water-resistant, disposable drapes.
■ Tepid (body temperature) irrigation solution.
■ Sterile gauze.
■ Dressing supplies.
■ Biohazard waste container.
■ Sterile impermeable barrier.
■ Sterile bowl.
■ Sterile piston syringe or commercial irrigation kit (if irrigating with a syringe).
■ If using an angiocatheter:
• Sterile emesis basin.
• 35-mL syringe.
• 19-gauge angiocatheter (with needle removed).

Assessment
■ If the wound is covered when you begin, you will make these assessments when you remove the soiled dressing and after cleansing the wound:
■ Amount and type of tissue present in the wound bed.
■ Whether the wound requires sterile, modified sterile, or clean technique for irrigation.
■ Assess the wound for:
• Signs of infection (erythema, induration, amount and type of drainage).
• Odor.
• Periwound tissue.
• Patient pain.

Post-Procedure Reassessment
■ Determine whether the patient remains comfortable. If not, medicate according to prescriptions.
■ Reassess the wound at regular intervals.

Key Points
■ Administer pain medication 30 minutes before the procedure, if necessary.
■ Position the patient for easy access to the wound and in a manner that will allow the irrigation solution to flow freely from the wound with the assistance of gravity.
■ Be Safe! Don protective equipment: gown, face shield, and clean gloves.
■ Remove the soiled dressing, and dispose of gloves.
■ Set up a sterile field with a sterile irrigation kit or a 35-mL syringe and a 19-gauge angiocatheter (needle removed), dressing supplies, and irrigation solution.
■ Wearing sterile gloves, fill either the syringe and angiocatheter or the piston-tip syringe with irrigation solution.
■ Be Smart! Holding the syringe tip 2 cm (3/4 to 1 in.) from the wound bed, gently irrigate the wound with a back-and-forth motion, moving from the superior aspect to the inferior aspect.
■ Dry the tissue surrounding the wound with sterile gauze.
■ Apply a new dressing as prescribed.
■ Dispose of used equipment and soiled dressings in a biohazard waste container.
■ Reposition the patient.

Documentation
■ Document:
■ Appearance and location of the wound, size, tissue in wound base, periwound tissue, type and amount of exudate, and odor, after irrigation.
■ Patient’s pain level.
■ If the patient was medicated for pain, document the drug and dose used, time given, and patient response.
■ Record:
■ Method by which the wound was cleansed.
■ Dressing reapplied to the wound, if applicable.
■ Education provided to the patient.

Performing a sterile wound irrigation using a syringe