Skill 85

Wound Irrigation

Wound irrigation cleanses and irrigates surgical or chronic wounds such as pressure ulcers (Table 85-1). Introduce the cleansing solution directly into the wound with a syringe, syringe and catheter, or pulsed lavage device. When using a syringe, the tip remains 2.5 cm (1 inch) above the wound. If a patient has a deep wound with a narrow opening, attach a soft catheter to the syringe to permit the fluid to enter the wound. Irrigation should not cause tissue injury or discomfort. Avoid fluid retention in the wound by positioning patient on his or her side to encourage the flow of the irrigant away from the wound.

TABLE 85-1

Wound Cleansing Considerations

	Mechanical Force
	High Pressure	Low Pressure
Wound base characteristics	Presence of necrotic tissue (eschar, fibrin slough), debris, or other particulate matter Significant bacterial burden Moderate/large amount of exudates	Presence of granulation tissue or new epithelial cells Nonserous or minimally serous or serosanguineous exudate
Clinical outcomes	Loosen, soften, and remove devitalized tissue from wound Separate eschar from fibrotic tissue/fibrotic tissue from granulating base	Prevent trauma to viable wound tissue Remove wound care product residue
Solutions	Normal saline Volume of solution depends on size of wound	Normal saline Volume of solution depends on size of wound
Delivery systems	35-mL syringe/19-gauge angiocatheter	Pouring saline directly from a bottle Bulb syringe Piston syringe

Adapted from Spear M: Wound cleansing: solutions and techniques, Plast Surg Nurs 31(1):29, 2011.

Delegation Considerations

The skill of sterile wound irrigation cannot be delegated to nursing assistive personnel (NAP). However, you can delegate the cleansing of chronic wounds using clean technique. It is the nurse’s responsibility to assess and document wound characteristics. The nurse directs the NAP to: