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UNIT 4 Supporting Physiological Functioning
Procedure 32-2 ■ Performing a Sterile Wound Irrigation (continued)
18. Remove your gloves,face shield, and gown . Dispose of these items in a biohazard collection container. Contaminants from the irrigation may be present on these items, and they should also be considered biohazardous. 19. Reposition the patient to a com- fortable position. Change any linen that may have become wet during the procedure. Hand hygiene prevents cross-contam- ination and transmission of infectious organisms. What if . . . ■ The patient has a wound covering a large area of the body? 20. Perform hand hygiene. A general rule is that the larger the wound, the more solution is needed to clean it.
The purpose of cleansing a wound is to remove bacteria and debris by flushing the wound. ■ Peroxide or another antiseptic solution is prescribed? First, identify the reason that the solution was ordered for the wound type.Then identify the length of time it is to be used. Weigh the benefit of using the solution with the potential risks to healing tissues. Finally, discuss any concerns with the healthcare provider. Peroxide is indicated more for acute, trau- matic wounds to remove dirt and other debris. Peroxide and other commercial anti- septics can damage fibroblasts and cause air embolism if used to forcefully irrigate or pack a tunneling wound. Fibroblasts pro- duce collagen, the major structural protein of skin and healing tissues.
■ All I have available for irrigation fluid is tap water?
Tap water has been proven to be as effective as sterile water irrigation. Make sure the source of tap water is clean (sink, tub, etc.). Tap water has now been shown to have same results as sterile saline in both wound infection rate and wound healing (Burch & Köpke, 2018; Chan et al., 2016). With the cheaper cost and more availability, tap water will become more of a standard for irrigation fluid.
Evaluation ■ Determine whether the patient remains comfortable. If not, medicate according to prescriptions. ■ Reassess the wound at regular intervals.
■ Method by which the wound was cleansed. ■ Dressing reapplied to the wound, if applicable. ■ Education provided to the patient. Sample Documentation 00/00/0000 0800 Dressing change to sacral wound using modified sterile technique due to saturation of old dressing with serious drainage. Patient premedicated with Lortab 5 mg PO 30 minutes before dressing change. Wound irrigated with normal saline using 19-gauge needleless angiocatheter and 35-cc syringe.Wound repacked with saline-moistened fluffed gauze and ABD pad to cover. Healing stage 4 pressure injury with 100% granulation tissue to the wound bed; 4 × 3.5 cm, with 1 cm of undermining at 6:00; copious serous drainage though no odor was noted. Periwound is slightly macerated; therefore, zinc-based barrier cream applied for protection. Patient reported no pain with procedure.Will continue to monitor and change dressing as needed. —L. Syzmanski, RN Practice Resources Burch & Köpke (2018); Chan et al. (2016); Lewis & Pay (2022, July 25, updated); Gabriel & Schraga (2021,August 27, updated);WOCN (2010, updated 2017, May/June).
Patient Teaching ■ Answer any questions the patient may have.
■ Teach the patient about the expected healing process. ■ Inform the patient and caregiver about signs and symptoms of infection and the need to report these findings. Home Care ■ Wound irrigation is commonly done in the home. In most cases, clean technique is used in the home setting. ■ Irrigation solutions, such as saline, can be made and stored up to 7 days if refrigerated. ■ Review with the family proper disposal of contaminated supplies. Documentation Document the following information (many agencies use a wound/skin flow sheet): ■ Appearance and location of the wound, size, tissue in wound base, periwound tissue, type and amount of exudate, and odor, if present, after irrigation. ■ The patient’s pain level. If the patient has been medicated for pain, document the drug and dose used, time given, and patient response.
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