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Wound Irrigation (102.153)

Wound Irrigation (102.153) - Policies, Clinical, UWMF Clinical, UWMF-wide, Clinical Policies and Procedures, Wound and Skin

102.153

1
UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE

TITLE: WOUND IRRIGATION

Effective Date: April, 2002 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education

Reviewed October, 2003 April, 2005 February, 2008 May 2010
October 2011

PURPOSE: To provide guidelines for wound irrigation for patients at UWMF Clinics.

DEFINITION: The purpose of wound irrigation is to remove exudate and debris from
slow-healing wounds. It requires sterile technique and is particularly useful for open deep
wounds, when access to all wound surfaces is limited. Wound irrigation can deliver a
cleansing or medicated solution to an affected area to promote healing or facilitate the
application of local medications.

POLICY: Clinical staff who has been proper trained in aseptic technique will utilize the
following guidelines to properly irrigate a wound for UWMF patients.

EQUIPMENT:
Sterile basin, waterproof pad, disposable gloves
Irrigating solution; ie normal or ½ strength normal saline-warmed to body
temperature (32°-37°C or 90°- 98.6° F)
30ml Sterile irrigating syringe with 18 or 19 Gauge sterile catheter attachment for
deep wounds
Clean basin to receive solution, sterile dressing tray, supplies for dressing change
Gown, mask, goggles (required if risk of splash of secretions from wound exists)

PROCEDURE:

1. Wash hands and gather equipment.

2. Check provider’s order and clarify any inconsistencies.

3. Introduce yourself, identify the patient by verifying complete name and date of birth
and provide privacy.

4. Explain procedure and need for wound irrigation.

5. Position patient so irrigating solution will flow from upper end of wound into basin
held below wound.

6. Place waterproof pad under client.

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7. Put clean disposable gloves.

8. Remove tape, loosen end and pull gently, parallel with skin and toward dressing.
 If adhesive remains on the skin, it may be removed with acetone.

9. With gloved hand or forceps, lift dressings off, one dressing layer at a time.
 If dressing sticks to wound, apply sterile saline or water.
10. Observe character and amount of drainage on dressings and wound character.
11. Dispose of soiled dressings in proper container
12. Remove and dispose of gloves than wash hands.
13. Prepare sterile supplies, maintaining sterile technique.
 Open basin.
 Pour in solution (amount may depend on size of wound and drainage).
 Open syringe and sterile catheter tip if needed.
 Prepare dressing tray.
 Put on sterile gloves.

14. Place clean basin against client's skin below incision or wound site.
15. Draw up 30ml of solution into syringe.
16. Gently instill a slow, steady stream (with18-19-gauge angiocatheter if needed) over
the wound.
 Make sure the solution meets all areas of the wound.
 Avoid sudden spurts or splashing of fluid.
 Avoid touching syringe to inside wound edges, irrigate pockets in wound.
17. Use sterile gauze to gently absorb or remove fluid and debris.
 Clean from least contaminated to most contaminated area.
 Move in progressive strokes away from incision line or wound edges.
18. Irrigate wound until solution returns clean.
19. Keep the patient positioned to allow further wound drainage.
20. Dispose of waterproof pads and other disposable supplies in garbage.
 If saturated with blood dispose of in ‘biohazard container’.

21. Apply sterile dressing and secure with tape, Montgomery ties, bandage, or binder.
22. Remove gloves, protective gear and dispose of them properly.

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23. Documentation: Record in the medical record
 Date and time
 the wounds condition: color of drainage, odor, depth, width and margins or
 placement of drain(s) (if applicable),
 integrity of suture or skin closure,
 additional procedures: packing wound, irrigating wound, or application
of topical medication.. Amount and type of irrigant
 Type of dressing applied after irrigation; sterile

24. Assist the patient to a comfortable position.
REVISED BY:

LaVay Morrison, RN, BSN, Clinical Staff Educator

WRITTEN BY:

Ronnie Peterson, R.N., M.S., Manager of Clinical Support


REFERENCES:

1. Perry, A.G. & Potter, P.A. (2002). Clinical nursing skills & techniques. (5
th
ed.). St.
Louis, MO: Mosby.
2. Perry, A.G. & Potter, P.A. (2009). Fundamentals of nursing. (7
th
ed.). Hall, A. &
Stockert, P.A. (Eds.). St. Louis, MO: Mosby Elsevier.
3. Kowalak, J. P. (Ed.). (2009). Lippincott’s nursing procedures (5
th
ed.). Ambler, PA:
Lippincott Williams & Wilkins.

AUTHORIZATION:



Medical Director Date