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UNIT 4 Supporting Physiological Functioning
Procedure 32-2 ■ Performing a Sterile Wound Irrigation ➤ For steps to follow in all procedures, refer to the Universal Steps for All Procedures on the inside back cover.
tissue. Pale pink tissue may indicate a delay in wound healing because of compromised blood supply to the wound bed or lack of proper nutrition. Necrotic tissue, which is black, brown, or yellow in appearance, is nonviable and inhibits healing and is a source of bacterial growth. Wound irrigation should not be performed if the wound is actively bleeding, as irrigation may dislodge any clots that are forming. ■ Determine whether the wound requires sterile, modified sterile, or clean technique for irrigation. Irrigation helps wounds to heal because it removes bacteria, old drainage, and necrotic tissue from the wound bed. Sterile technique is used for acute surgical wounds, for wounds that have undergone recent sharp debridement, or when the health- care provider has ordered it. Chronic wounds are colonized with bacteria and may be irrigated with clean technique. Irrigation using clean technique is presented in steps 1 through 8 of Procedure 32-1. ■ Assess the wound for signs of infection (erythema, indura- tion, amount and type of drainage). Exudate may be a sign of infection. Infected wounds require higher flow pressures for irrigation. ■ Assess the wound for odor. A foul odor may indicate infection. Cleanse wounds before you assess for odor, because some dressings interact with wound drain- age to produce an odor. ■ Assess the tissue surrounding the wound edge. Surrounding tissue that is red, warm, and/or edematous may indi- cate infection.Tissue that is macerated (white and moist) indicates too much fluid is being held against the skin, usually from saturated dressings. ■ Assess for pain and the need to premedicate. Wound irrigation may be painful.
Equipment ■ Nonsterile gloves ■ Sterile gloves ■ Gown and face shield ■ Water-resistant disposable drapes ■ Tepid (body temperature) irrigation solution ■ Sterile gauze ■ Dressing supplies
■ Biohazardous waste container ■ Sterile impermeable barrier ■ Sterile bowl For Step 10A Variation: ■ Sterile emesis basin ■ 35-mL syringe ■ 19-gauge angiocatheter (needle removed) For Step 10B Variation: ■ Sterile commercial irrigation kit containing a sterile basin and piston-tip syringe Delegation This is an invasive, sterile procedure that requires nursing assessment, judgment, evaluation, and teaching during the pro- cedure. It requires knowledge of wound healing and should be performed by a registered nurse. Do not delegate this skill to nursing assistive personnel (UAP). Preprocedure Assessments NOTE: If the wound is covered when you begin, you will make these assessments when you remove the soiled dressing and after cleansing the wound. ■ Assess the amount and type of tissue present in the wound bed. Granulating tissue is beefy red with a velvety appearance. It appears with the growth of new blood vessels and connective
➤ When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation.
Procedure Steps 1.Administer pain medication 30 minutes before the treatment, if necessary. 2. Place the patient for easy access to the wound and in a position that will allow the irrigation solution to
flow freely from the wound with the assistance of gravity. 3. After performing hand hygiene, apply a gown, face shield, and clean nonsterile gloves. Personal protective equipment provides a barrier against splattering that commonly
occurs during wound irrigation. For splash- ing, a face shield, mask, and protection over scrubs are advised. 4. Remove the soiled dressing. Dis- pose of gloves and soiled dressing in a biohazard bag. Soiled dressings contain body fluids and other contaminants and should be treated as biohazardous waste.
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