Definition
Performing wound irrigation is a vital nursing procedure used to cleanse a wound, reduce infection risk, and promote optimal healing. It involves flushing the wound with a sterile solution to remove debris, exudate, and contaminants.
Purposes
- To clean the area from pathogens and debris
- To apply local heat.
- To irrigate with antiseptic solution.
Articles
- Irrigate/cleansing solution as ordered, usually 200-500 mL depending on the size of wound.
- Asepto syringe for large wound or 40 ml syringe with 19 G needle or sterile soft
- Angiocather.
- Clean gloves.
- Sterile gloves.
- Waterproof under pad.
- Dressing supplies.
- Disposable waterproof bag.
- Gown
- Goggles
- Sterile soft catheter.
- Sterile dressing set.
- Sterile basin.
Procedure
| Nursing action | Rationale | |
| 1 | Before procedure Check physician’s order for wound irrigation type of solution to be used | Physician’s order clarifies procedure and type of supplies required. Open wound irrigation requires medical order including type of solutions to be used. |
| 2 | Explain procedure to patient. | Explanation facilitates patient’s cooperation. |
| 3 | Assest patient’s level of pain. Administer prescribed analgesic 30-45 minutes before starting wound irrigation procedure | Reduces pain and permits patient to tolerate the procedure better. |
| 4 | Assess recent recording of signs and symptoms related to patient’s open wound: (Mnemonic for wound assessment). CODES a. Condition of skin and wound. | Data used as baseline to identify change in condition of wound. May Indicate response to infection. Drainage amount will decrease as healing take place. |
| b. Odor | Strong odor indicates infection process. Leukocytes produce thick drainage. | |
| c. Drainage from wound and consistency of drainage. | Determines stage of healing. | |
| d. Elevation of body temperature. | ||
| e. Size of wound including depth, length and width. | ||
| 5 | During procedure Perform hand washing. | Reduces transmission of microorganisms. |
| 6 | Position patient comfortably to permit gravitational flow of irrigating solution through wound and into collection receptacle. | Gravity directs flow of fluid from least contaminated to more contaminated area. Waterproof pad protects patient and bed linen. |
| 7 | Warm irrigation solution to approximate body temperature. | Warm solution increases comfort and reduces vasoconstriction response in tissues. |
| 8 | Form a cuff of waterproof bag and place it near bed. | Cuffing helps to maintain large opening, thereby permitting placement of contaminated dressing without touching refuse bag itself. |
| 9 | Close room door and pull curtains. | Maintains privacy. |
| 10 | Apply gown and goggles, if needed. | Protects nurse from splashes or sprays of blood and body fluids. |
| 11 | Put on clean gloves and remove soiled dressings and discard in waterproof bag. Discard gloves. | Reduces transmission of microorganisms. |
| 12 | Open sterile dressings and supplies on work area using aseptic technique. | Supplies are within easy reach and sterility is maintained. |
| 13 | Put on sterile gloves. | Maintains surgical asepsis |
| 14 | Position the sterile basin below the wound to collect irrigation fluid with dominant hand. | Irrigation is facilitated and patient and bed linen are protected from contaminated fluid. |
| 15 | Irrigated wound | |
| a. Wound with wide opening: Fill 35 ml syringe with irrigation solution. Attach 19-gauze needle or Angio catheter Hold syringe tip 2.5 cm above upper end of wound and over area being cleansed. Using continuous pressure, flush wound: repeat steps until solution draining into basin is clear. | Irrigating wound helps remove debris and facilitates healing by secondary intention. Provides ideal pressure for cleansing and removal of debris. Prevents syringe contamination. Careful placement of solution the syringe prevents unsafe pressure of the flowing solution. Clear solution indicates that all debris have been removed. | |
| b. Deep wound with very small opening; Attach soft Angio catheter to a filled irrigation Syringe. Lubricate tip of catheter with irrigating solution then gently insert tip of catheter and pull out about 1 cm (0.39 inch). Use slow continuous pressure to flush Wound. Pinch off catheter just below syringe while keeping catheter in place. Remove and refill syringe. Reconnect to catheter and repeat until solution draining into basin clear | Catheter permits direct flow of irrigant into wound. Expect wound to take longer time to empty when opening is small. Helps in easy entry of catheter. Removes tip from fragile inner wall of wound. Avoids contamination of sterile solution. | |
| 16 | Dry wound edges with gauze. | Prevents maceration of surrounding tissues caused by excess moisture. |
| 17 | Apply appropriate dressing. | Maintains protective barrier and healing environment for wound. |
| 18 | After procedure Remove gloves, mask, goggles and gown | Prevents transfer of microorganisms. |
| 19 | Dispose off soiled equipment and soiled supplies. Perform hand washing. | Reduces transmission of microorganism. |
| 20 | Assist patient to comfortable position. | |
| 21 | Assess type of tissue in the wound bed. | Identifies wound healing progress and determines type of wound cleansing. |
| 22 | Inspect dressing periodically. | Determines patient’s response to wound irrigation and need to modify plan of care. |
| 23 | Evaluate skin integrity. | Determines if extension of wound has occurred. |
| 24 | Observe for presence of retained irrigant. | Retained irrigant is a medium for bacterial growth and subsequent infection. |
| 25 | Record wound irrigation and patient responses in progress notes. | |
| 26 | Report any evidence of fresh bleeding, sharp increases |
Special Consideration
- Consider culturing a wound if it has foul odor, inflammation surrounding the wound, purulent drainage from wound or fever
- if insertion of packing is ordered:
- Use sterile forceps to insert sterile packing into wound gently.
- Be careful not to pack wound excessively because this may impede blood flow and delay healing.
- Cut packing material with sterile scissors.
- Allow a small strip of packing to protrude from small and deep wounds to facilitate removal.
- The wound may be anesthetized first if the patient cannot tolerate the wound irrigation and cleansing.
- A catheter tip syringe may be used to create a hydraulic action
- Devitalized tissue and foreign matter are removed. Devitalized tissue inhibits wound healing and enhances chance of bacterial infection.
- Obtain culture if needed before cleansing the wound.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
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