Skill 8-3

Performing Irrigation of a Wound

Irrigation is a directed flow of solution over tissues. Wound irrigations are prescribed to clean the area of pathogens and other debris and to promote wound healing. Irrigation procedures may also be prescribed to apply heat or antiseptics locally. An ideal pressure for wound cleansing is 5 to 15 psi (Baranoski & Ayello, 2020). A needle or angiocath and syringe are often used to deliver fluid for irrigation of a wound. The size of the syringe and the needle/angiocath gauge determine the amount of pressure of the fluid stream, with larger syringes providing less force and needles/angiocaths with larger lumen diameters providing greater flow and greater pressures (Baranoski & Ayello, 2020). An 18- to 19-gauge needle/angiocath and a 30- to 35-mL syringe is an inexpensive and easy-to-use method for irrigation (Baranoski & Ayello, 2020, p. 152; McLain et al., 2021). If the wound edges are approximated, nonsterile solutions and clean technique may be used; if the wound edges are not approximated, sterile equipment and solutions are used for irrigation (Taylor et al., 2023). Normal saline (0.9% sodium chloride) is often the solution of choice when irrigating wounds, but sterile water, commercially prepared wound cleansers containing an antimicrobial, or potable tap water may be used (Baranoski & Ayello, 2020; Mahoney, 2020b; Taylor et al., 2023; WOCN, 2016).

Delegation Considerations

Irrigation of a wound and procedures requiring the use of a sterile field and other sterile items are not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, these procedures may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

An 18- to 19-gauge needle/angiocath and 30- to 35-mL syringe or a commercial cleanser packaged in a pressurized container (Baranoski & Ayello, 2020, p. 152; McLain et al., 2021; WOCN, 2016)
Sterile irrigation solution as prescribed, warmed to body temperature, commonly 0.9% normal saline solution or other solution as prescribed
Alternatively, irrigation solution may be packaged in individual, single-use syringe
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 or face shield
Waterproof pad and bath blanket
Bath blanket or other linens for draping patient
Additional PPE, as indicated
Additional dressings and supplies needed or required based on the wound dressing/care prescribed for the patient

Assessment

Assess the situation to determine the need for wound irrigation. Confirm any prescribed interventions relevant to wound care and any wound care included in the plan of care. Assess the current dressing to determine if it is intact. Assess the patient's level of comfort and the need for analgesics before wound care. Assess if the patient experienced any pain related to previous dressing changes and the effectiveness of interventions employed to minimize the patient's pain. Assess for excess drainage or bleeding or saturation of the dressing. Inspect the wound and the surrounding tissue. Assess the location, appearance of the wound, stage (if appropriate), drainage, and types of tissue present in the wound. Measure the wound. Note the stage of the healing process and characteristics of any drainage. Also assess the surrounding skin for color, temperature, and edema, ecchymosis, or maceration.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Altered skin integrity
Infection risk
Knowledge deficiency

Outcome Identification and Planning

The expected outcome to achieve when irrigating a wound is that the irrigation is performed without contamination or trauma, without damaging proliferative cells and newly formed tissues, and without causing the patient to experience pain or discomfort. Other outcomes that might be appropriate include: the wound continues to show signs of progression of healing, and the patient demonstrates an understanding of the wound care.

Implementation

Action	Rationale
1. Review the patient's health record for prescribed wound care or the plan of care related to wound care. Gather necessary supplies.	Reviewing the health record and care plan validates the correct patient and correct procedure. Preparation promotes efficient time management and an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Assemble equipment on the overbed table or other surface within reach.	Organization facilitates performance of the task.
5. Close the curtains around the bed and close the door to the room if possible. Explain what you are going to do and why you are going to do it to the patient.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement.
6. Assess the patient for possible need for nonpharmacologic pain-reducing interventions or analgesic medication before wound care and/or dressing change. Administer appropriate prescribed analgesic. Allow enough time for the analgesic to achieve its effectiveness before beginning the procedure.	Pain is a subjective experience influenced by past experience. Wound care and dressing changes may cause pain for some patients.
7. Place a waste receptacle or bag at a convenient location for use during the procedure.	Having a waste container handy means the soiled dressing may be discarded easily, without the spread of microorganisms.
8. Adjust the bed to a comfortable working height (VHACEOSH, 2016).	Having the bed at the proper height prevents back and muscle strain.
9. 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 or top to bottom. Use the bath blanket to cover any exposed area other than the wound. Place a waterproof pad under the wound site.	Patient positioning and the use of a bath blanket provide for comfort and warmth. Gravity directs the flow of liquid from the least contaminated to the most contaminated area. Waterproof pad protects underlying surfaces.
10. Put on a gown, mask, and eye protection or face shield.	Using PPE, such as gowns, masks, and eye protection, is part of Standard Precautions. A gown protects clothes from contamination should splashing occur. Appropriate personal protective equipment, including a mask and eye protection or face shield is essential when irrigating a wound with any degree of pressure (WOCN, 2016).
11. Check the position of drains, tubes, or other adjuncts before removing the dressing. Put on clean, disposable gloves and loosen the tape on the old dressings by removing in the direction of hair growth and the use of a push-pull method (see Figure 1, Skill 8-2) (Fumarola et al., 2020). Push-pull method: lift a corner of the dressing away from the skin, then gently push the skin away from the dressing/adhesive (Fumarola et al., 2020). Continue moving the fingers of the opposite hand to support the skin as the product is removed (Fumarola et al., 2020). Once all adhesive is loosened from the skin, carefully lift the dressing from the surrounding skin to prevent medical adhesive-related skin injury (MARSI). Remove the sides/edges first, then the center. If the patient is at increased risk for MARSI (see Box 8-2 in Skill 8-2), requires repeated application or removal of adhesive devices, or there is resistance, use an adhesive remover (Barton, 2020; Fumarola et al., 2020; Kelly-O'Flynn et al., 2020).	Checking ensures that a drain is not removed accidentally if one is present. Gloves protect the nurse from contaminated dressings and prevent the spread of microorganisms. Removal of the tape in the direction of hair growth minimizes trauma to the skin (Fumarola et al., 2020). The use of adhesive remover allows for the easy, rapid, and painless removal without the associated problems of skin stripping and helps reduce patient discomfort (Barton, 2020; Fumarola et al., 2020; Kelly-O'Flynn et al., 2020).
12. Carefully remove the soiled dressings. If any part of the dressing sticks to the underlying skin, use small amounts of sterile saline to help loosen and remove it.	Cautious removal of the dressing is more comfortable for the patient and ensures that any drain present is not removed. Sterile saline moistens the dressing for easier removal and minimizes damage and pain.
13. 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.	The presence of drainage should be documented. Proper disposal of soiled dressings and used gloves prevents the spread of microorganisms.
14. 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. Refer to Fundamentals Review 8-2.	This information provides evidence about the wound healing process and/or the presence of infection.
15. Remove your gloves and put them in the receptacle. Perform hand hygiene.	Discarding gloves prevents the spread of microorganisms. Hand hygiene prevents the spread of microorganisms.
16. Set up a sterile field, if indicated, and wound cleaning and irrigation supplies. Pour warmed sterile irrigating solution into the sterile container (based on supplies in use). Moisten gauze for cleaning the periwound skin. Put on the sterile gloves. Alternatively, clean gloves (clean technique) may be used when cleaning a chronic wound or pressure injury.	Using warmed solution prevents chilling the patient and may minimize patient discomfort. Aseptic technique should be used to change dressings for surgical wounds and in the acute clinical setting, to reduce the risk of transfer of pathogens, likely to be present in an acute care setting, to the wound (Brown, 2018). Clean technique is appropriate for cleaning chronic wounds, wounds in the home, or pressure injuries (Baranoski & Ayello, 2020; EPUAP, NPIAP, & PPPIA, 2019a; Taylor et al., 2023).
17. Position the sterile basin below the wound to collect the irrigation fluid.	Patient and bed linens are protected from contaminated fluid.
18. Fill the irrigation syringe with solution (Figure 1). Alternatively, irrigation solution may be packaged in individual, single-use syringe; remove cap on syringe. Using your nondominant hand, gently apply pressure to the basin against the skin below the wound to form a seal with the skin (Figure 2).	The solution will collect in the basin and prevent the irrigant from running down the skin. Patient and bed linens are protected from contaminated fluid.
19. Using either a pulsatile or continuous flow pattern, direct a stream of solution into the wound from top to bottom (Figure 3). Flush all wound areas.	The wound irrigating fluid stream can be delivered in either a pulsatile or continuous flow pattern (Baranoski & Ayello, 2020). Directing flow from top to bottom ensures that a previously cleaned area is not contaminated again.
20. Watch for the solution to flow smoothly and evenly. When the solution from the wound flows out clear, discontinue irrigation.	Irrigation removes exudate and debris.
21. Once the wound is cleaned, clean the skin surrounding the wound and then dry the skin surrounding the wound (Figure 4). (Refer to Steps 18 and 19, Skill 8-2).	Excess moisture on healthy skin increases risk for moisture-associated skin damage and interferes with proper adhesion of securement of dressings.
22. If a drain is in use at the wound location, clean around the drain. Refer to Skills 8-6, 8-7, 8-8, and 8-9.	Cleaning the insertion site helps prevent infection.
23. Remove gloves and perform hand hygiene.	Proper disposal of used gloves and hand hygiene prevent the spread of microorganisms.
24. Redress the wound, applying any topical medications, foams, gels, and/or gauze to the wound (Figure 5) and based on type of dressing prescribed or in use. (Refer to Skill 8-2 for general guidelines.)	Provides appropriate wound care to support plan of care.
25. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
26. Check all wound dressings at least every shift. More frequent checks may be needed if the wound is more complex.	Checking dressings ensures the assessment of changes in patient condition and timely intervention to prevent complications.

Evaluation

The expected outcomes have been met when the irrigation was completed without contamination or trauma, without damaging proliferative cells and newly formed tissues, and without causing the patient to experience pain or discomfort; the wound has continued to show signs of progression of healing; and the patient has demonstrated an understanding of the wound care and dressing.

Documentation

Guidelines

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 (if pressure injury), 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/caregiver education and any patient reaction to this procedure, including patient's pain level and effectiveness of nonpharmacologic interventions or analgesia if administered.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient experiences pain when the wound irrigation is begun: Stop the procedure and administer an analgesic, as prescribed. Obtain new sterile supplies and begin the procedure after an appropriate amount of time has elapsed to allow the analgesic to begin working. Note the patient's pain on the plan of care so that pain medication can be given before future wound treatments.
During the wound irrigation, the nurse notes bleeding from the wound. This has not been documented as happening with previous irrigations: Stop the procedure. Assess the patient for other symptoms. Obtain vital signs. Report the findings to the health care team and document the event in the patient's record.

Special Considerations

Optimum and timely wound healing are supported by adequate nutrition and hydration (Dudek, 2018; EPUAP, NPIAP, & PPPIA, 2019a; Stuart, 2020). Collaborate with the registered dietician and dietary staff to develop an individualized nutrition intervention plan for the patient.
A whirlpool bath may be prescribed as an alternative to irrigation for some chronic wounds (Baranoski & Ayello, 2020). The wound should not come in close contact with the water jets in the whirlpool to avoid tissue injury.

EVIDENCE FOR PRACTICE

Prevention of Medical Adhesive-Related Skin Injuries

Fumarola, S., Allaway, R., Callaghan, R., Collier, M., Downie, F., Geraghty, J., Kiernan, S., & Spratt, F. (2020). Overlooked and underestimated: Medical adhesive-related skin injuries. Best practice consensus document on prevention. Journal of Wound Care, 29(Suppl 3c), S1-S24. https://doi.org/10.12968/jowc.2020.29.Sup3c.S1

This consensus document is the result of a review of the literature on medical adhesive-related skin injury (MARSI) by a panel of wound care experts, educators, and researchers. This best practice guideline provides recommendations for the assessment and prevention of MARSI, with the goal of standardizing care across all health care settings.

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Skill 8-3

EVIDENCE FOR PRACTICE