Wound and Pressure Ulcer Care
Irrigating Wounds
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Take the Review Test:
Safety
- Perform meticulous hand hygiene, and follow proper infection control procedures before and after removing soiled dressings. Wear clean gloves during wound care.
- Use sterile irrigation solution for postoperative wounds. Use clean solution for chronic wounds.
- Irrigate so that the solution flows from the least contaminated area (healthy tissue) toward the most contaminated area (infected tissue), and from the area being cleansed to a lower, distal area.
- Consider using a handheld shower technique for wound cleansing in an ambulatory patient, keeping the shower head about 12 inches from the wound.
- Never substitute a skin cleanser for a wound cleanser; they are not the same.
- Do not force a catheter into the wound. Place the syringe carefully to keep the pressure of the flowing solution from becoming too high.
- Consider culturing a wound if it has a foul odor, becomes inflamed, or begins to drain, or if the patient becomes febrile.
- If bleeding occurs, serosanguineous drainage appears, or the suture line on a surgical wound opens or extends, flush with less pressure during the next irrigation. Notify the health care provider of the bleeding.
Equipment
(Roll cursor over items to see labels)
Irrigant/cleansing solution
Emesis basin
Sterile irrigation 30-mL syringe with sterile soft angiocatheter
Personal protective equipment:
- Clean gloves
- Sterile gloves
- Gown
- Goggles (if needed)
Waterproof pad
ABD dressing
Metapore tape
4x4 gauze
Disposable biohazard bag
Measuring gauge
Cotton tipped applicators
Basin
Towels
PrintableDelegation
The skill of sterile wound irrigation may not be delegated to nursing assistive personnel (NAP). You may, however, delegate the cleansing of chronic wounds using clean technique. It remains your responsibility as the nurse to assess and document the wound characteristics. Be sure to inform NAP of the following:
- Instruct NAP to notify you when the wound is exposed, so that an assessment can be completed.
- Instruct NAP to report any patient complaints of wound pain.
Preparation
- Review the order to irrigate an open wound, and note the type of solution to be used.
- Review the most recently charted wound assessment for comparison.
- Determine if the patient has a history of allergies to any medication, antiseptic, latex, tape, or other dressing material.
- If needed, administer an analgesic 30 minutes to 45 minutes before wound irrigation.
- Educate the patient and family members about the procedure.
Follow-up
- Have the patient rate his or her level of pain on a scale of 0 to 10.
- Monitor the type of tissue in the wound bed.
- Inspect the dressing periodically, according to your agency’s policy.
- Evaluate the integrity of the skin surrounding the wound.
- Look for irrigant retained in the wound.
Documentation
- Record your wound assessment before and after irrigation, including the following:
- Amount, color, and odor of any drainage on the removed dressing
- Amount and type of solution used
- Irrigation device used
- Patient’s tolerance of the procedure
- Type of dressing applied after the irrigation
- Immediately report to the health care provider any evidence of fresh bleeding, sharp pain, or increased pain, as well as any irrigant retention, or signs of shock.
Review Questions
1. When irrigating a wound, how would the nurse know the right amount of pressure to apply?
Calculate the wound size.
Follow the general rule of keeping the pressure between 4 and 15 psi.- Keep the pressure strong enough to cause moderate pain.
- Gentle enough that it does not create a splash off of the wound.
INCORRECT. The amount of irrigant, not the pressure, is dictated by the wound size.
CORRECT. Less than 4 psi would not be effective. More than 15 psi is likely to cause tissue damage.
INCORRECT. Irrigation will cause different amounts of pain with different patients. This is not a good gauge by which to determine the correct amount of pressure to apply.
INCORRECT. The amount of pressure is gauged with PSI, not with splash off the wound.
2. Which action should the nurse avoid before irrigating a patient’s foot wound?
- Assess the patient for a history of allergies to tape and irrigating solution.
- Review the provider’s orders for the type of irrigating solution to be used.
- Assess the patient’s pain on a scale of 0 to 10.
- Warm the irrigant to body temperature in the microwave.
INCORRECT. The nurse would assess the patient’s allergy history before beginning the irrigation.
INCORRECT. The nurse must review the provider’s order before initiating the intervention in order to select the correct irrigating solution.
INCORRECT. It is appropriate to assess the patient’s pain before initiating the intervention.
CORRECT. Although the nurse must warm the solution before irrigating the wound, using the microwave can create hotspots and make the fluid unsafe.
3. Which device is used for wound irrigation?
- 19-gauge needle attached to a 10-mL syringe
- 19-gauge needle attached to a 35-mL syringe
- Sterile container held 30.5 cm (12 inches) above the wound
- Foley irrigating syringe
INCORRECT. A 19-gauge needle attached to a 10-mL syringe will not supply enough solution for wound irrigation, nor will it release it at the recommended pressure.
CORRECT. A 19-gauge needle attached to a 35-mL syringe will release a sufficient quantity of solution at the correct pressure for wound irrigation.
INCORRECT. Holding a container of solution above the wound would yield an unpredictable result and would probably be ineffective for wound irrigation.
INCORRECT. A Foley irrigating syringe will not release a sufficient quantity of solution at the right pressure for wound irrigation.
4. Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient’s left heel is infected?
INCORRECT. Although an elevated white blood cell count indicates infection, it would not be specific to the pressure ulcer in question.
INCORRECT. The complete blood count cannot indicate or rule out infection.
INCORRECT. The nurse would not consult an imaging study to determine whether the patient’s pressure ulcer is infected.
CORRECT. A wound culture and sensitivity test will indicate whether the pressure ulcer is infected, identify the pathogen responsible (if any), and determine which antibiotic the pathogen is most vulnerable to.
5. A nurse is irrigating a patient’s abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider?
- Drainage that was not present previously
- Redness at the abdominal suture line
- Granulation tissue in the wound bed
- The patient reports less pain
CORRECT. The appearance of new drainage indicates possible wound infection.
INCORRECT. Redness at the incision site does not necessarily indicate a postsurgical complication.
INCORRECT. The appearance of granulation tissue indicates wound healing.
INCORRECT. Pain is expected during wound care at this time.
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