Irrigating a Wound and Applying a Sterile Wet to Dry Dressing Rationale: Wound irrigation may be ordered to rid the

area of pathogens and other debris in order to promote wound healing. The goal of wound irrigation is to the clean the wound without contamination or trauma and without causing discomfort to the patient. Supplies needed: Clean gloves Emesis basin Measuring tape Sterile bowl Goggles

Sterile Drape Cotton tip applicator 4x4 gauze (2-3) Chux pad Gown

Sterile gloves Irrigation solution Paper tape Bulb syringe

Preparation for procedure: 1. Checks physicians order for type of irrigation solution and type of dressing to be applied. 2. Introduce yourself to the patient, identify the patient and explain the procedure. 3. Assesses for pain. Medicate if necessary allowing 30 minutes before beginning procedure. 4. Gather all necessary supplies and equipment. 5. Provide for privacy by closing doors or curtains. Removing old dressing: 6. Place patient in a comfortable position that provides easy access to the wound. 7. Wash hands. 8. Apply clean gloves & put on personal protective equipment if necessary (goggles/gown). 9. Loosen the edges of the tape of the old dressing. Stabilize the skin with the other hand while pulling the tape in the opposite direction. 10. Beginning with the top layer, lift the dressing from the corner toward the center of the wound. 11. Continue to remove layers until the entire dressing is removed. 12. Assess the type and amount of drainage present on the removed dressing. 13. Dispose of soiled dressing in the trash. 14. Assess the wound for location, amount of tissue present, exudate and odor. 15. Measure wound dimensions (in cm or mm) using measuring tape or cotton tipped applicator noting margins, tunneling or undermining. 16. Reposition patient (if necessary) to a position that will allow for irrigation solution to flow freely from the wound and allow wound to be cleansed from most clean to contaminated. 17. Position chux pad underneath patient to protect bedding. Position emesis basin under wound area to collect irrigation solution run off. 18. Remove gloves and discard in trash. 19. Wash hands.

Preparing a sterile field: 20. Place sterile drape package on a clean, dry work surface that is above waist level. 21. Hold the edge of the package flap down toward the table and grasp the top edge of the package and peel back. 21. Pick up the sterile drape by the corner and allow it to fall open without touching unsterile surfaces. 23. Open drape onto surface touching only the edge of the drape. Adding items to a sterile field: 24. Open sterile item packaging by peeling paper down and apart to expose sterile item. 25. Holding item several inches above the field, allow the item to drop onto sterile field. Do not let arms pass over the field and do not touch item with nonsterile hands. 26. Dispose of the wrapper and continue opening any needed supplies for the procedure onto the sterile field, including the sterile bowl and bulb syringe. 27. Check that the irrigation solution is correct and not expired. If bottle has been previously opened check time and date it was opened. If older than 24 hours, discard and get new bottle of solution. 28. Remove the cap off the solution bottle by lifting directly up. If cap is to be reused, set it upside down on a clean area. 29. If bottle has been previously used, then pour out a small amount into the trash. 30. Hold the bottle 4-6 inches above the bowl and pour needed amount into the bowl. Applying sterile gloves: 31. Determine correct glove size. 32. Create a clean space for opening the package. 33. Open the outer wrapper and place the glove package on a clean, dry surface. 34. Open the inner package so that the glove cuffs are nearest to the nurse. 35. Fully open the package flaps so that they do not fold back over and contaminate the gloves. 36. With the thumb and first two fingers of nondominant hand, grasp the glove for the dominant hand and insert fingers. Pull glove completely over dominant hand. 37. With gloved dominant hand, slip four fingers underneath second gloves cuff and carefully pull second glove over nondominant hand. 38. Adjust both gloves to fit the fingers. 39. Keep hands between shoulder and waist level. Irrigating a wound: 40. Fill bulb syringe with irrigation solution. 41. Hold syringe tip 2cm from the wound bed and gently irrigate the wound with a back and forth motion, moving from superior aspect to the inferior aspect. 42. Repeat the irrigation until the solution returns clear. 43. Dry wound edges and surrounding skin with sterile 4x4 gauze. Do not touch skin with sterile gloved hands. 44. Discard gauze in the trash.

Applying a wet-to-dry dressing: 45. Moisten remaining sterile 4x4 gauze in solution in the sterile bowl. 46. Wring out excess moisture from the gauze. 47. Fluff and pull apart gauze to create a single layer of fine-mesh. 48. Apply gauze to the wound being careful to not touch gauze to surrounding skin. 49. Use cotton tipped applicator to apply gauze to deep depressions or sinus tracts. 50. Apply a secondary moist layer over the first layer. Repeat this process until the wound is completely filled with moistened sterile gauze. 51. Do not pack the gauze tightly into skin or allow the moist dressing to extend onto surrounding skin. 52. Cover the moistened gauze with a surgipad (ABD pad). 53. Place paper tape strips around surgipad that extend inch beyond the dressing. 54. Apply tape without tension or pulling. 55. Smooth tape in place by gently stroking the surface to maximize adhesion. Removing sterile gloves: 56. Grasp outside of one cuff with the other hand; avoid touching the wrist. 57. Pull glove off, turning it inside out and place it in gloved hand. 58. Take fingers of bare hand and peel glove off inside out and over the previously removed glove. 59. Discard both gloves in the trash. 60. Wash hands. Documentation: 61. In patients medical record document the following: time and date of dressing procedure, wound size, location, stage, appearance, presence of drainage or odor, amount of gauze used to pack wound and patients tolerance of procedure.