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Wound Irrigations

Nursing Policy & Procedure Manual

Wound Irrigations Policy 

Purpose: 

To remove materials on the wound surface such as foreign bodies, residual topical agents, dressing residue, wound exudates, and metabolic waste that are inflammatory and prevent optimal healing without causing trauma to the wound bed. 

Policy: 

The licensed nurse will perform wound irrigation only when specifically ordered by the physician. 

Equipment: 

  • Irrigating solution as ordered by the physician or wound wash saline (normal saline preferred choice) 

  • Piston syringe (35 ml syringe recommended by AHCPR) 

  • Sterile container 

  • 4x4 gauze and dressing materials 

  • Gloves (3 pairs) 

  • Protective padding 

  • Goggles in anticipation of splashing from the wound 

  • Material for clean surface 

  • Trash receptacle 

Procedure: 

I. Preparation: 

  • 1. Verify patient’s name, type of irrigation ordered, and correct solution. 

  • Open sterile container if using a piston syringe and pour the irrigating solution into it. 

  • Open dressing materials using aseptic technique and place them on a clean barrier. 

  • Remove old dressing; assess drainage and discard waste in trash receptacle. 

II. Initial Cleanliness: 

  • Remove gloves. 

  • Wash hands. 

  • Don gloves. 

III. Irrigation: 

  • Hold syringe above the top edge of the wound and push the irrigant into the wound slowly without stopping until you have used the prescribed amount. 

  • Irrigate the wound, reaching all areas of the wound bed, including undermining and tunneling. 

  • Keep the resident positioned to allow further wound drainage. 

  • Dry the surrounding skin with 4x4 gauze. 

IV. Redressing: 

  • Remove gloves and discard them into a plastic bag. 

  • Wash hands and don new gloves. 

  • Redress the wound using clean technique. 

  • Reposition the patient onto a clean surface. 

V. Post-Procedure: 

  • Discard gloves into a plastic bag. 

  • Wash hands. 

  • Discard the bag in the Soiled Utility room trash. 

Documentation: 

  • Document treatment on the treatment kardex. 

  • Document any adverse reactions and the condition of the wound and surrounding skin on the Pressure/Non-Pressure Sore Record or in the Narrative Nursing Note. 

References: 

  • Centers for Medicare & Medicaid Services (CMS), Requirements of Participation for Long-Term Care Facilities. 

  • State Operations Manual (SOM), CMS. 

Tags
wound irrigation
Wound Care
sterile technique
licensed nurse
CMS Guidelines
SOM compliance
Long-Term Care Facility
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