Irrigation is a directed flow of solution over tissues. Wound irrigations are ordered to clean the area of pathogens and other debris and to promote wound healing.
Irrigation procedures may also be ordered to apply heat or antiseptics locally. If the wound edges are approximated, clean technique may be used.
if the wound edges are not approximated, sterile equipment and solutions are used for irrigation.
Normal saline is often the solution of choice when irrigating wounds.
EQUIPMENT
• A sterile irrigation set, including a basin, irrigant container,and irrigation syringe
• Sterile irrigation solution as ordered, warmed to body temperature, commonly 0.9% normal saline solution
• Plastic bag or other waste container to dispose of soiled dressings
• Sterile gloves
• Sterile drape (may be optional)
• Clean, disposable gloves
• Moisture-proof gown, mask, and eye protection
• Sterile dressing set or suture set (for the sterile scissors and forceps)
• Waterproof pad and bath blanket, as needed
• Sterile gauze dressings
• Sterile packing gauze, as needed
• Tape or ties
• Skin protectant wipes
NURSING DIAGNOSIS
• Risk for Infection
• Acute Pain
• Impaired Skin Integrity
• Impaired Tissue Integrity
IMPLEMENTATION
1. Review the medical orders for wound care.
2. Perform hand hygiene and put on PPE.
3. Identify the patient.
4. Provide privacy to patient.
5. Explain Procedure to the patient.
6. Provide Analgesic to pain controle.
7. Place a waste receptacle at a near location for use during the procedure.
8. 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.
9. Put on a gown, mask, and eye protection.
10. Put on clean gloves. Carefully and gently remove these oiled 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 it.
11. 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.
12. Assess the wound for appearance, stage, presence of eschar, granulation tissue, epithelialization, undermining, tunneling, necrosis, sinus tract, and drainage.
Assess the appearance of the surrounding tissue. Measure the wound.
13. Remove your gloves and put them in the receptacle.
14. Set up a sterile field, 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 or pressure ulcer.
15. Position the sterile basin below the wound to collect the irrigation fluid.
16. 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.
17. Gently direct a stream of solution into the wound.
Keep the tip of the syringe at least 1 inch 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.
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High-pressure irrigation flow may cause patient discomfort as well as damage granulation tissue.
18. Dry the surrounding skin with gauze dressings.
19. Apply a new dressing to the wound.
20. 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.
21.Perform hand hygiene.
EVALUATION
• Wound irrigation is completed without contamination and trauma.
• Patient verbalizes little to no pain or discomfort.
• Patient verbalizes understanding of the need for irrigation.
• Patient’s wound continues to show signs of progression of healing.
DOCUMENTATION
-Document the location of the wound and that the dressing was removed. Record your assessment of the wound, including evidence
of granulation tissue, presence of necrotic tissue, stage and characteristics of drainage. Include the appearance of the surrounding skin.
-Document the irrigation of the wound and solution used. Record the type of dressing that was applied.
Note pertinent patient and family education and any patient reaction to this procedure, including patient’s pain level and effectiveness of nonpharmacologic interventions or analgesia if administered.
of granulation tissue, presence of necrotic tissue, stage and characteristics of drainage. Include the appearance of the surrounding skin.
-Document the irrigation of the wound and solution used. Record the type of dressing that was applied.
Note pertinent patient and family education and any patient reaction to this procedure, including patient’s pain level and effectiveness of nonpharmacologic interventions or analgesia if administered.
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